En dyster parentes – opiatregeln i svensk LARO-behandling 2010–2016

Sammanfattning: Opioids are well documented to arouse euphoria, relieve pain, and to have a high dependency potential. Opioid dependence is a serious chronic condition with a high risk of extensive worsened health, relapse and premature death.Opioid maintenance treatment (OMT) is well researched and has strong scientific support. In Sweden, OMT over time was subjected to polarised and infected political debate and has been strictly regulated by the National Board of Health and Welfare (NBHW). During 2010–2016 NBHW redefined the diagnostic concept of “opiate dependence” in the regulation SOSFS 2009:27. Dependence to only three opioids: heroin, opium or morphine, could give eligibility to OMT (here called the “opiate rule”). The purpose stated was to prevent those dependent to other opioides, e.g. buprenorphine,from receiving OMT. Applicants with severe opioid dependence were thereby divided into two subgroups: those with “opiate” dependence related to heroin, morphine or opium, and those with opioid dependence who lacked documentation in relation to the three opiates. The question is whether there were differences between these groups concerning problem severity or substance-related diagnostics that could justify differences in access to OMT?A population (n = 127) actualised for OMT during 2005-2011 in Jönköping County is studied regarding severity of problems, diagnostics and trajectories in and out of treatment. In order to provide precise drug use data, a cognitive tool for taking anamnestic information, called the Drug List, was developed.In Study I, using the Addiction Severity Index, the two groups were found to be quite similar in severity of health problems, social situation and drug problems, including overdoses and injections.In Study II, the Drug List was found to be superior to a traditional way of taking anamnestic data, more sensitive and giving more precise data, without taking more time. Validity was shown in relation to faked drugs.In Study III, using a structured diagnostic interview, ADDIS, with the Drug List, showed that both two groups qualified for severe opioid dependence, that opiates and other opioids had contributed equally to the development of opioid dependency, and that the two groups also had similar additional substance dependence problems.Study IV investigated how “the opiate rule” affected practice by interviewing representatives of OMT clinics as well as a representative of a users’ association. The regulation created dilemmas for clinics as well as for users. Users developed a strategy of getting "negative merits" for being eligible to OMT. Clinicians developed strategies to find ways “around” the regulation in order to admit patients in OMT.Study V followed those who had applied for OMT and found four trajectory subgroups – those denied OMT, those discharged, those readmitted, and those who remained in treatment. The study provides evidence for a more positive development being related to more involvment in OMT concerning health, social situation as well as substance use problems. Being denied or discharged is related to increased risks of a negative development.The thesis conclude that there was no support for dividing applicants according to “the opiate rule”. The purpose of top-down control using regulations, is to guarantee uniform and knowledge-based care. In this case the regulation had negative effects in these respects, increasing risks for the applicants, and lost credibility from the profession. The opiate rule in SOSFS 2009:27 is therefore a dismal parenthesis in the history of OMT in Sweden, and could be studied to prevent similar mistakes in the future.