Torkel Richert

Diversion of methadone and buprenorphine by patients in opioid substitution treatment in Sweden: Prevalence estimates and risk factors

BACKGROUND Diversion--patients who sell or share their medication--is a hotly debated but relatively unresearched phenomenon. We have investigated the prevalence of self-reported diversion of methadone and buprenorphine at OST programs in Sweden. We have also examined if demographic, treatment, and social factors can be associated with an increased risk of diversion. METHODS Structured interviews were conducted with 411 patients from eleven OST programs. A standardized questionnaire with 106 close- and five open-ended questions were used. 280 interviews were done on site, by the researchers, while 131 interviews were conducted by specially trained patients through privileged access interviewing. The data were analyzed through frequency- and averages-calculations, cross-tabulations, and logistic regression analysis. RESULTS In total, 24.1% (n=99) of the patients reported diversion in the past month. 67.6% (n=277) stated that they had diverted at some point. The peer interviews showed significantly higher levels of diversion (37.4% past month) compared with the researcher interviews (17.2%). Neither demographic factors, dosages, nor collection routines were associated with diversion. The likelihood of diversion was higher for patients on mono-buprenorphine (OR=5.64) and buprenorphine-naloxone (OR=2.10), than among methadone patients. Other factors which increased the likelihood of diversion were current illicit drug use (OR=5.60), having had patients as a primary source of illicit methadone or buprenorphine prior to treatment (OR=3.39), and mainly socializing with active drug users (OR=2.12). CONCLUSION Self-reported diversion was considerably higher than in previous studies. This is most likely due to the new methodological strategy we used, but may also partly be explained by low availability of OST in Sweden, leading to a high demand for the substances by heroin users outside treatment. Efforts to decrease diversion should primarily focus on psychosocial and lifestyle-changing interventions, and expanded access to treatment, rather than on control measures.

Illicit use of methadone and buprenorphine among adolescents and young adults in Sweden

BackgroundIllicit use of methadone and buprenorphine has been described as a growing problem in Sweden in recent years, and has been associated with an increased drug-related mortality. Critics claim that the substances have become popular among adolescents and that they function as a gateway to heroin use. The aim of this study is to investigate, firstly, the extent to which illicit use of methadone and buprenorphine occurs among adolescents and young adults in Sweden, and secondly, at what stage in a user’s drug career these substances tend to appear.MethodsThe study is based on surveys and structured interviews on drug use among various populations of young people, in addition to qualitative interviews with 86 informants who, in their professional capacity, encounter adolescents or young adults who are using illicit drugs.ResultsIllicit use of methadone and buprenorphine is rare among young people in Sweden. According to high school surveys, less than 0.1% have tried these substances. Among young drug users in general, few have tried the substances, and there is nothing to indicate that they act as gateway drugs. Among adolescents and young adults with severe drug problems, however, the illicit use of methadone and buprenorphine is more common (54% in a compulsory care sample). These substances normally enter the drug career late, and few use them as their main drug of choice. Other prescription drugs, like benzodiazepines and tramadol, are used by adolescents to a far greater extent. Diversion and illicit use of methadone and buprenorphine is not seen as a serious problem by the professionals interviewed. A general view is that the substances are mainly used by people with a heroin or polydrug addiction, often for “self-medication” purposes. However, several informants express concern that methadone and buprenorphine may cause fatalities among young drug users without an opioid tolerance.ConclusionsIllicit use of methadone and buprenorphine among young drug users is not a widespread problem in Sweden. Harm-reduction measures should target drug users with more severe problems, among whom illicit use of methadone and buprenorphine is more common and pose a medical risk. Illicit use of other prescription drugs, which are less controlled and more widely used by young people, is an important issue for further research.

Wasted, overdosed, or beyond saving – To act or not to act? Heroin users’ views, assessments, and responses to witnessed overdoses in Malmö, Sweden

BACKGROUND Overdose is a significant cause of death among heroin users. Frequently, other heroin users are present when an overdose occurs, which means the victims life could be saved. There is a lack of studies that, based on heroin users own stories, examine their views, assessments, and responses to witnessed overdoses. METHODS The study is based on qualitative interviews with thirty-five heroin users who witnessed someone elses overdose. RESULTS The heroin users generally had a positive attitude towards assisting peers who had overdosed. A number of factors and circumstances, however, contribute to witnesses often experiencing resistance to or ambivalence about responding. The witnesss own high, the difficulty in assessing the seriousness of the situation, an unwillingness to disturb someone elses high, uncertainty about the motive behind the overdose and whether the victim does or does not want assistance as well as fear of police involvement, were common factors that acted as barriers to adequate responses in overdose situations. CONCLUSION The fact that being high makes it difficult to respond to overdoses, using traditional methods, argues for simpler and more effective response techniques. This can include intranasal naloxone programs for heroin users. The findings regarding the uncertainty about the intention of the overdose victim and the sensitivity to the experience of a good high argue for more up-front communication and discussion amongst using peers so that they can make their intentions clear to each other. Issues like this can be addressed in overdose education interventions. Overdose prevention measures also need to address the fact that fear of the police acts as a barrier to call emergency services.

Diversion of Methadone and Buprenorphine from Opioid Substitution Treatment: A Staff Perspective

Abstract Opioid substitution treatment (OST) is still controversial, despite positive results. The issue of diversion to the illicit drug market is a cornerstone in the criticism typically voiced against the treatment. Little research is available concerning how professionals who work in OST view the issue of diversion. In this article, we discuss existing ideas and attitudes toward diversion of methadone and buprenorphine among OST staff in Sweden. The article is based on semi-structured interviews with 25 professionals working in eight OST-programs in southern Sweden. Diversion was seen as a deleterious phenomenon by the interviewees. Three problematic aspects were highlighted: medical risks in the form of overdose fatalities and the recruitment of new opiate/opioid users; negative consequences for the legitimacy of OST; and moral objections, since diversion means that the patients remain in a criminal environment. However, positive aspects were also highlighted. Illicit methadone or buprenorphine is perceived as safer than heroin. In this way, diversion can fulfill a positive function; for instance, if there is a shortage of access to regular treatment. Patients who share their medication with opioid-dependent friends are seen as less culpable than those who sell to anyone for money.

Gambling with life - injection drug use, risk taking and overdoses

Aims: This article describes experiences of overdose among a group of long time heroin users. The main aim is to seek understanding for circumstances, motives and actions concerning the phenomena o ...

Parents as victims of property crime committed by their adult children with drug problems : Results from a self-report study

Parents who are subjected to crime by adult children with drug problems have been neglected in victimological research. We have examined how common it is for parents to fall victim to theft and burglary committed by their children and how the risk varies depending on the parents’ and children’s circumstances. A self-report questionnaire on victimisation was distributed to parents of adult children with drug problems (n = 687). The data were collected by means of a postal survey sent to members of the Swedish organisation Parents Against Drugs (Föräldraföreningen mot narkotika) (n=411) and through an online questionnaire that was disseminated on social media and among treatment facilities and other support associations for family members (n=276). Half (50.7%) of the parents declared that they had at one point or another been victims of theft or burglary committed by their children. The level was higher among older parents, among those whose children had more severe drug problems and among parents of children with attention deficit hyperactivity disorder. Of the respondents, 9.9% had been exposed to property crime during the past year. The level was higher among parents of children who were currently taking drugs, among parents of younger children and among parents whose children were living at home. Parents of adult children with drug problems run a high risk of being subjected to property crime by their children. The risk appears to be mostly related to the children’s drug problems and certain other circumstances pertaining to the children. Further research is needed on the extent and nature of this type of crime and about risk prevention for the parents.

Being a Parent to an Adult Child With Drug Problems: Negative Impacts on Life Situation, Health, and Emotions:

This study is about the vulnerability of parents to adult children with drug problems. The study is based on a self-reporting questionnaire (n = 687) distributed to parents in Sweden via family member organizations, treatment centers, and online communities. Most parents reported extensive negative consequences on relationships, social life, and mental health due to their children’s drug problems. Most parents also experienced strong feelings of powerlessness, grief, guilt, and shame. Many parents reported a negative impact on their economy and work ability. In general, fathers claimed to feel less of a negative impact than mothers. A more severe drug problem and life situation for the child was associated with a greater negative impact for the parents. Many parents experienced difficulties in securing adequate help both for their child and for themselves. The study shows the need for increased support efforts for this parent group.

A comparison of privileged access interviewing and traditional interviewing methods when studying drug users in treatment

Abstract Aims: Privileged access interviewing (PAI) has traditionally been used to reach illicit drug users and other ‘hidden’ populations. How PAI data compare to other self-reported data have seldom been discussed. We compare data from patients in opioid substitution treatment (OST), gathered through PAI and researcher interviews, respectively, to investigate whether PAIs and researchers are reaching comparable populations, and whether differences in answers are due to the sensitive nature of the questions. Methods: Structured interviews were conducted with 368 patients from nine OST clinics in three Swedish cities. 237 interviews were carried out by researchers, and 131 by nine PAIs (OST patients). Data were analyzed with χ2 test, Fisher’s exact test, t-test and logistic regression analysis. Results: PAIs and researchers recruited comparable populations, with few differences in terms of individual, treatment and social factors. However, self-reported behaviors revealed several significant differences. Alcohol consumption and drinking to intoxication was more commonly reported among patients interviewed through PAI (p < 0.001 and p = 0.001, respectively). Furthermore, the PAI group reported selling medication (p < 0.001 last month, p < 0.001 during treatment episode) and snorting buprenorphine (p = 0.010 last month, p = 0.001 during treatment episode) more frequently. Conclusions: PAI is a useful method in studies of illicit drug use and a valuable complement to more traditional interviewing methods. Specifically as regards revelations of a sensitive or controversial nature, PAI seems to produce different results than researcher interviews, and possibly also more truthful responses. PAI may have considerable potential as a data-gathering method also when studying other, more easily accessible populations.