Healthcare staff's perspectives on long-acting injectable buprenorphine treatment: a qualitative interview study.

BACKGROUND: Long-acting injectable buprenorphine (LAIB) formulations are a novel treatment approach in opioid agonist treatment (OAT), which provide patients with a steady dose administered weekly or monthly and thus reduce the need for frequent clinic visits. Several studies have analyzed patient experiences of LAIB but the perspective of OAT staff is unknown. This study aimed to explore how healthcare staff working in OAT clinics in Sweden perceive and manage treatment with LAIB. METHODS: Individual qualitative interviews were conducted with OAT physicians (n = 10) in tandem with nine focus group sessions with OAT nurses and other staff categories (n = 41). The data was analyzed with thematic text analysis. RESULTS: Five central themes were identified in the data: (1) advantages and disadvantages of LAIB, (2) patient categories that may or may not need LAIB, (3) patients' degrees of medication choice, (4) keeping tabs, control and treatment alliance, and (5) LAIB's impact on risk and enabling environments in OAT. Overall staff found more advantages than disadvantages with LAIB and considered that patients with ongoing substance use and low adherence were most likely to benefit from LAIB. However, less frequent visits were viewed as problematic in terms of developing a treatment alliance and being able to keep tabs on patients' clinical status. Clinics differed regarding patients' degrees of choice in medication, which varied from limited to extensive. LAIB affected both risk and enabling environments in OAT. CONCLUSIONS: LAIB may strengthen the enabling environment in OAT for some patients by reducing clinic visits, exposure to risk environments, and the pressure to divert medication. A continued discussion about the prerequisites and rationale for LAIB implementation is needed in policy and practice.

Long-acting injectable depot buprenorphine from a harm reduction perspective in patients with ongoing substance use and multiple psychiatric comorbidities: a qualitative interview study.

BACKGROUND: Long-acting injectable depot buprenorphine may increase access to opioid agonist treatment (OAT) for patients with opioid use disorder in different treatment phases. The aim of this study was to explore the experiences of depot buprenorphine among Swedish patients with ongoing substance use and multiple psychiatric comorbidities. METHOD: Semi-structured qualitative interviews were conducted with OAT patients with experience of depot buprenorphine. Recruitment took place at two OAT clinics with a harm reduction focus, specializing in the treatment of patients with ongoing substance use and multiple comorbidities. Nineteen participants were included, 12 men and seven women, with a mean age of 41 years (range 24-56 years), and a mean of 21 years (5-35 years) of experience with illicit substance use. All participants had ongoing substance use and psychiatric comorbidities such as ADHD, anxiety, mood, psychotic and eating disorders. Interviews were transcribed verbatim. Thematic content analysis was conducted both manually and using qualitative data analysis software. RESULTS: Participants reported social benefits and positive changes in self-perception and identity. In particular, depot buprenorphine contributed to a realization that it was possible to make life changes and engage in activities not related to substance use. Another positive aspect that emerged from the interviews was a noticeable relief from perceived pressure to divert OAT medication, while some expressed the lack of income from diverted oral/sublingual OAT medication as a negative, but still acceptable, consequence of the depot buprenorphine. Many participants considered that the information provided prior to starting depot buprenorphine was insufficient. Also, not all patients found depot buprenorphine suitable, and those who experienced coercion exhibited particularly negative attitudes towards the medication. CONCLUSIONS: OAT patients with ongoing substance use and multiple psychiatric comorbidities reported clear benefits of depot buprenorphine, including changes in self-perception which has been theorized to play an important role in recovery. Clinicians should consider the specific information needs of this population and the extensive diversion of traditional OAT medications in this population to improve the treatment experience and outcomes. Overall, depot buprenorphine is a valuable treatment option for a population in need of harm reduction and may also contribute to psychological changes that may facilitate recovery in those with the greatest need.

Drug prescriptions preceding opioid-related deaths-a register study in forensic autopsy patients.

BACKGROUND/AIM: Opioid overdose deaths have increased in Sweden and other developed countries in recent decades, despite increased treatment efforts and harm-reduction interventions. Further knowledge in this field is needed if this trend is to be reversed. Previous research suggests that mental health and patterns of prescription of opioids and other prescription drugs are associated with increased opioid-related mortality. The present study therefore aimed to investigate what drugs were prescribed during the last six months of life to individuals with a history of illicit substance use who died with opioids present in their blood, the relationship between drugs prescribed and drugs found in blood at time of death, and if prescription of specific drugs was temporally associated with death. METHODS: This was a retrospective, register-based observational study that utilized data from the National Board of Forensic Medicine, the Prescribed Drug Registry, regional health care services, and municipal social services. We used conditional logistic regression to find temporal associations between the prescription and dispensing of drugs and time of death. RESULTS: Prescription and dispensing of alprazolam and diazepam were temporally associated with death. The most frequently dispensed drugs were zopiclone, pregabalin, methylphenidate, diazepam and oxycodone. Methadone, alprazolam, and buprenorphine were the drugs most often found in the blood. Opioids and tranquilizers in combination were found in a vast majority of deaths, and prescription data suggested that the use of these drugs was illicit in a majority of cases. CONCLUSION: Prescription of certain drugs, especially alprazolam and diazepam, should be made with great caution to patients with a history of illicit substance use or concurrent use of opioids.

Patient perspectives on depot buprenorphine treatment for opioid addiction - a qualitative interview study.

BACKGROUND: Recently developed buprenorphine depot injections have the potential to reduce risk for diversion and misuse, and to increase adherence with fewer visits for supervised intake. However, it is unclear how patients perceive this new form of medication. The purpose of this study was to explore patients' experiences of depot injections and their reasons for continuing, discontinuing, or declining depot injection treatment. METHODS: We conducted semi-structured qualitative interviews with 32 people, 14 of whom had ongoing depot injection treatment, 11 who had discontinued depot-injections and switched to other medication and seven who had declined treatment with depot formulations. Interviews were transcribed, coded, and analysed using NVivo, based on this overall stratification into three participant groups. RESULTS: The main categories relate to the effects and side effects of the depot formulation, social and practical factors, psychological benefits and disadvantages, and interactions with treatment staff. Social and practical factors were of importance for choosing depot formulations, such as increased freedom and their making it easier to combine treatment with work and family life, as well as psychological advantages including "feeling normal". Initial withdrawal symptoms that resolved themselves after a number of injections were reported by most participants. Reliable information and patient-staff relationships characterized by trust helped patients to cope with these initial problems. Those who discontinued treatment often did so near the beginning of the treatment, reporting withdrawal symptoms and insufficient effects as the main reasons. Coercion and insufficient information contributed to a negative pharmaceutical atmosphere at one of the clinics, which may have adversely influenced perceptions of depot formulations and decreased willingness to accept and continue treatment. CONCLUSIONS: Buprenorphine depot injections may have social, practical, and psychological benefits compared to other formulations. However, depot injections are not perceived as an attractive option by all patients. Trust, consistent and adequate information, and awareness of the implications of the pharmaceutical atmosphere should be considered when introducing new medications.

Does it matter in what family constellations adolescents live? Reconsidering the relationship between family structure and delinquent behaviour.

OBJECTIVES: This study examines the associations between ten family structure types and delinquency, including four groups of symmetrical and asymmetrical living arrangements. We also adjust for attachment to parents and parental monitoring. METHODS: Data are drawn from four cross-sectional surveys conducted between 2016 and 2019 in southern Sweden. The sample consists of 3,838 adolescents, aged 14-15. Negative binomial models were used to calculate the associations between family structure and delinquency. RESULTS: The results show that those living in single-father, single-mother, father-stepmother, mother-stepfather families report significantly more delinquency than adolescents living with both their parents. Adolescents living in "symmetrical" family arrangements, i.e. both parents are single or have a new partner, reported lower levels of delinquency, whereas adolescents living in "asymmetrical" family arrangements, i.e. where either the mother or the father, but not both, have a new partner, reported higher levels of delinquency. Most of the associations between family structure and delinquency decline when adjusted for attachment to parents and parental monitoring. DISCUSSION: This study shows that it is important to move on to the use of more detailed categorisations of family structure in relation to delinquency. We need to increase our knowledge about the group of adolescents that moves between parents and especially about the different constellations of asymmetrical and symmetrical living arrangements.

Does gender matter? The association between different digital media activities and adolescent well-being.

BACKGROUND: Previous research on the relationship between social media use and well-being in adolescents has yielded inconsistent results. We addressed this issue by examining the association between various digital media activities, including a new and differentiated measure of social media use, and well-being (internalizing symptoms) in adolescent boys and girls. METHOD: The sample was drawn from the four cross-sectional surveys from the Öckerö project (2016-2019) in eight municipalities in southern Sweden, consisting of 3957 adolescents in year 7 of compulsory education, aged 12-13. We measured the following digital media activities: playing games and three different activities of social media use (chatting, online sociability, and self-presentation). Our outcome measure was internalizing symptoms. Hypotheses were tested with linear regression analysis. RESULTS: Social media use and playing games were positively associated with internalizing symptoms. The effect of social media use was conditional on gender, indicating that social media use was only associated with internalizing symptoms for girls. Of the social media activities, only chatting and self-presentation (posting information about themselves) were positively associated with internalizing symptoms. Self-presentation was associated with internalizing symptoms only for girls. CONCLUSION: Our study shows the importance of research going beyond studying the time spent on social media to examine how different kinds of social media activities are associated with well-being. Consistent with research in psychology, our results suggest that young girls posting information about themselves (i.e. self-presentation) might be especially vulnerable to display internalizing symptoms.

[Fatal opioid overdoses usually occur without anyone being present and able to intervene. Knowledge of the presence of witnesses is important for how naloxone programs should be designed]. / Dödlig överdos skedde ofta utan person nära som kunde ingripa.

Drug mortality has increased in Sweden during the 2000s. The vast majority of deaths are opioid overdoses. The National Board of Health and Welfare recommends that the antidote naloxone and a brief overdose education should be offered to people who are at risk of opioid overdose. A retrospective registry study of 193 forensically examined fatal opioid overdoses in Skåne showed that over 80 percent occurred in private residences, most often the deceased's own home. Other people were present in just over 40 percent of the 193 deaths, but usually in another room or asleep. In most cases, the witnesses were friends, partners, parents, or other people close to the deceased. Naloxone programs should be expanded to include family members and other persons who are close to opioid users, and who therefore may witness or be present early in case of an overdose.

A community intervention to reduce alcohol consumption and drunkenness among adolescents in Sweden: a quasi-experiment.

BACKGROUND: Several studies have examined the effect of community interventions on youth alcohol consumption, and the results have often been mixed. The aim of this study is to evaluate the effectiveness of a community intervention known as the Öckerö Method on adolescent alcohol consumption and perceived parental attitudes towards adolescent drinking. METHOD: The study is based on a quasi-experimental design, using matched controls. Self-report studies were conducted among adolescents in grades 7-9 of compulsory education in four control and four intervention communities in the south of Sweden in 2016-2018. Baseline measures were collected in autumn 2016 before the intervention was implemented in the intervention communities. Outcomes were the adolescents' alcohol consumption, past-year drunkenness, past-month drunkenness and perceived parental attitudes towards alcohol. RESULTS: Estimating Difference-in-Difference models using Linear Probability Models, we found no empirical evidence that the intervention has any effect on adolescents' drinking habits, or on their perceptions of their parents' attitudes towards adolescent drinking. CONCLUSION: This is the first evaluation of this method, and we found no evidence that the intervention had any effect on the level of either young people's alcohol consumption or their past-year or past-month drunkenness, nor on their parents' perceived attitudes toward adolescent drinking. A further improvement would be to employ a follow-up period that is longer than the three-year period employed in this study. TRIAL REGISTRATION: ISRCTN registry: Study ID: 51635778 , 31th March 2021 (Retrospectively registered).

Changes in opioid-related deaths following increased access to opioid substitution treatment.

BACKGROUND: Opioid-related mortality is high and increasing in the Western world, and interventions aimed at reducing opioid-related deaths represent an important area of study. In Skåne County, Sweden, a patient choice reform resulted in increased access to opioid substitution treatment (OST). In addition, a gradual shift towards less restrictive terms for exclusion from OST has been implemented. The aim of this study was to assess the impact of these policy changes on opioid-related deaths. METHODS: Detailed data on opioid-related deaths in Skåne during the 2 years prior to and following the policy change were obtained from forensic records and from health care services. Data on overdose deaths for Skåne and the rest of Sweden were obtained using publicly available national register data. Time periods were used as the predictor for opioid-related deaths in the forensic data. The national level data were used in a natural experiment design in which rates of overdose deaths were compared between Skåne and the rest of Sweden before and after the intervention. RESULTS: There was no significant difference in the number of deaths in Skåne between the data collection periods (RR: 1.18 95% CI:0.89-1.57, p= 0.251). The proportion of deaths among patients enrolled in OST increased between the two periods (2.61, 1.12-6.10, p= 0.026). There was no change in deaths related to methadone or buprenorphine in relation to deaths due to the other opioids included in the study (0.92, 0.51-1.63, p= 0.764). An analysis of national mortality data showed an annual relative decrease in unintentional drug deaths in Skåne compared to the rest of Sweden following the onset of the reform (0.90, 0.84-0,97, p= 0.004). CONCLUSIONS: Opioid-related deaths, as assessed using forensic data, has not changed significantly in Skåne following a change to lower-threshold OST. By contrast, national level data indicate that the policy change has been associated with decreased overdose deaths. The discrepancy between these results highlights the need for more research to elucidate this issue. The result that more patients die during ongoing OST following an increase in access to treatment underlines the need for further preventive interventions within the OST treatment setting.

Parents' experiences of abuse by their adult children with drug problems.

AIMS: To examine parents' experiences of abuse directed at them by their adult children with drug problems. MATERIAL AND METHOD: The material consists of 32 qualitative interviews on child-to-parent abuse with 24 mothers and eight fathers. The interviewees had experienced verbal abuse (insults), emotional abuse (threats), financial abuse (damage to property and possessions) and physical abuse (physical violence). FINDINGS: In the parents' narratives, the parent-child interaction is dominated by the child's destructive drug use, which the parents are trying to stop. This gives rise to conflicts and ambivalence. The parents' accounts seem to function as explaining and justifying their children's disruptive behavior in view of the drug use. The fact that an external factor - drugs - is blamed seems to make it easier to repair the parent-child bonds. The parents differentiate between the child who is sober and the child who is under the influence of drugs, that is, between the genuine child and the fake, unreal child. The sober child is a person that the parent likes and makes an effort for. The child who is on drugs is erratic, at times aggressive and self-destructive. CONCLUSIONS: The interviewed parents' well-being is perceived as directly related to how their children's lives turn out. The single most important factor in improving the parents' situation is to find a way for their adult child to live their lives without drug problems.

Internet use and adolescent drinking: Does it matter what young people do online?

BACKGROUND: In this study we examine whether the association between internet use and drinking could be different for different types of internet activities among adolescents. We also adjust for a number of theoretically relevant factors such as peer influence, unstructured activities, impulsivity and parental monitoring. METHOD: The data are drawn from four cross-sectional surveys from the years 2016-2019 in eight municipalities in southern Sweden. The sample consist of 3733 adolescents in year 9 of compulsory education, aged 14-15. RESULTS: The results show that there is an association between internet activities and drinking and that there are differences depending on what young people do online. Self-presentation and online sociality are both positively associated with drinking, whereas news consumption and playing games are negatively associated with drinking. The results also show that the association between the different internet activities and drinking becomes weaker when adjusting for the control variables. CONCLUSION: This study suggests that more research is needed to examine the correlations between different forms of internet activities and drinking among adolescents in more detail.

Investigating opioid-related fatalities in southern Sweden: contact with care-providing authorities and comparison of substances.

BACKGROUND: Opioid-related deaths have increased in Western countries over recent decades. Despite numerous studies investigating opioid-related mortality, only a few have focused on the lives of the deceased individuals prior to their deaths, specifically regarding contact with care-providing authorities such as health, social and correctional services. Furthermore, a change has been noted in the last two decades as to which opioids cause most deaths, from heroin to prescription opioids. However, studies comparing fatalities caused by different substances are rare. The aim of this study was to investigate contact with care-providing authorities during the year prior to death among individuals who died as a result of opioid intoxication and to analyse differences relating to which opioids caused their deaths. METHODS: The study is based on retrospective register data and includes 180 individuals with a history of illicit drug use, who died from opioid intoxication in Skåne, Sweden, between 1 January 2012 to 31 December 2013 and 1 July 2014 to 30 June 2016. Intoxications caused by heroin, methadone, buprenorphine and fentanyl were included. Data were collected from the National Board of Forensic Medicine, regional health care services, municipal social services and the Prison and Probation Service. Statistical testing was performed using Pearson's chi-square test, Fisher's exact test and the Mann-Whitney U test to analyse group differences. RESULTS: A total of 89% of the deceased individuals had been in contact with one or more of the care-providing authorities during the year prior to death; 75% had been in contact with health care, 69% with the social services, 28% with the Prison and Probation Service, and 23% had been enrolled in opioid substitution treatment at some point during their final year of life. Few differences appeared between the substance groups with regard to which opioid contributed to the death. In addition to opioids, sedatives were present in more than 80% of the cases. Individuals whose deaths were buprenorphine-related had been in contact with the social services to a significantly lesser extent during the year prior to death. CONCLUSIONS: The studied population is characterised by extensive contact with care-providing authorities, thus providing numerous opportunities for authorities to reach this group with preventive and other interventions. Few differences emerged between groups with regard to which opioid had contributed to the death.

Non-prescribed use of methadone and buprenorphine prior to opioid substitution treatment: lifetime prevalence, motives, and drug sources among people with opioid dependence in five Swedish cities.

BACKGROUND: Opioid substitution treatment (OST) with methadone or buprenorphine is the most effective means of treating opioid dependence. If these substances are used by people who are not undergoing OST, they can however carry serious risks. This article examines the lifetime prevalence, motives, and drug sources for such use, as well as geographical differences in these variables. METHODS: Structured interviews were conducted with 411 patients from 11 OST clinics in five Swedish cities. The researchers carried out 280 interviews on-site, while 131 interviews were conducted by specially trained patients through privileged access interviewing. Data were analyzed by frequency and average calculations, cross-tabulations, and χ2 tests. RESULTS: The lifetime prevalence of non-prescribed use was 87.8% for methadone, 80.5% for buprenorphine, and 50.6% for buprenorphine/naloxone. Pseudo-therapeutic motives-avoiding withdrawal symptoms, staying clean from heroin, detoxification, or taking care of one's own OST-were commonly cited as driving the use, while using the drugs for euphoric purposes was a less common motive. Most respondents had bought or received the substances from patients in OST, but dealers were also a significant source of non-prescribed methadone and buprenorphine. Geographical differences of use, motives, and sources suggest that prescription practices in OST have a great impact on which substances are used outside of the treatment. CONCLUSIONS: Experiences of non-prescribed use of methadone and buprenorphine are extremely common among those in OST in southern Sweden. As the use is typically driven by pseudo-therapeutic motives, increased access to OST might decrease the illicit demand for these substances. Buprenorphine/naloxone has a lower abuse potential than buprenorphine and should therefore be prioritized as the prescribed drug. Supervised dosage and other control measures are important provisions in the prevention of drug diversion and non-prescribed use among people not undergoing OST.

Long-term self-treatment with methadone or buprenorphine as a response to barriers to opioid substitution treatment: the case of Sweden.

BACKGROUND: It is well known that illicit use of methadone and buprenorphine is common among people with an opioid dependence. Less notice has been taken of the fact that these substances are also used for extended periods of self-treatment, as a way of handling barriers to OST. In this study, motives for self-treatment are investigated, as well as attitudes and perceived barriers to OST among drug users with an opioid dependence in Sweden. METHOD: The study is based on qualitative research interviews with 27 opioid users who have treated themselves with methadone or buprenorphine for a period of at least three months. RESULTS: The duration of self-treatment among the interviewees varied from 5 months to 7 years. Self-treatment often began as a result of a wish to change their life situation or to cut back on heroin, in conjunction with perceived barriers to OST. These barriers consisted of (1) difficulties in gaining access to OST due to strict inclusion criteria, limited access to treatment or a bureaucratic and arduous assessment process, (2) difficulties remaining in treatment, and (3) ambivalence toward or reluctance to seek OST, primarily due to a fear of stigmatization or disciplinary action. Self-treatment was described as an attractive alternative to OST, as a stepping stone to OST, and as a way of handling waiting lists, or as a saving resource in case of involuntary discharge. CONCLUSION: Illicit use of methadone and buprenorphine involve risks but may also have important roles to play for users who are unwilling or not given the opportunity to enter OST. A restrictive and strict rehabilitation-oriented treatment model may force many to manage their own treatment. More generous inclusion criteria, a less complex admission process, fewer involuntary discharges, and less paternalistic treatment may lead to increasing numbers seeking OST. Control measures are necessary to prevent diversion and harmful drug use but must be designed in such a way that they impose as few restrictions as possible on the daily life of patients.

Diversion of methadone and buprenorphine from opioid substitution treatment: the importance of patients' attitudes and norms.

AIMS: Methadone and buprenorphine diversion by patients in opioid substitution treatment (OST) is a poorly understood phenomenon. We study the norms and attitudes on diversion among OST patients, including the role these norms and attitudes play as diversion risk factors. We also study whether perceived quality of care, social bonds to treatment staff, and deterrence can be associated with diversion. METHODS: Structured interviews were conducted with 411 patients from eleven OST programs. In total, 280 interviews were done on site by the researchers, while 131 interviews were conducted through peer interviewing by specially trained patients. The data was analyzed through frequency- and averages-calculations, cross-tabulations, and logistic regression analysis. RESULTS: Most patients consider diversion as mostly positive (83.7%), morally right (76.8%), and without any significant risk of detection (66.9%). Individual differences in norms and risk perceptions may play a role in explaining variations in diversion; patients who consider it right to share medication with friends report higher treatment-episode diversion than other patients (OR 1.455, p = 0.016). Patients who perceive control measures as effective report lower diversion than other patients (OR = 0.655, p = 0.013). Furthermore, data indicate that patients who are satisfied with the care and service are less prone to engage in diversion. Social bonds with treatment staff seem to be less importance. CONCLUSIONS: The norm system described by patients resemble Bourgois' 'moral economy of sharing' concept-not sharing drugs with friends in withdrawal is considered unethical. Efforts to decrease diversion may focus on lifestyle-changing interventions, and reducing black market demand for illicit medications by expanding access to treatment.

Diversion of methadone and buprenorphine from opioid substitution treatment: patients who regularly sell or share their medication.

Diversion-the practice of patients selling or sharing their medication-is a much debated problem of opioid substitution treatment. Regular diversion by patients was studied at 11 opioid substitution treatment programs in the south of Sweden. Using quantitative and qualitative data, it was investigated whether those patients differ from other patients, their motives for and means of diversion, and who the recipients are. Regular diverters are a small, yet heterogeneous group. Continued illicit drug use, however, stands out as a common risk factor. Pecuniary need and a desire to help friends are other important motives. The client base mainly consists of people from the regular diverters' own drug milieus.

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.

Diversion of methadone and buprenorphine from opioid substitution treatment: a staff perspective.

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.

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

BACKGROUND: Illicit 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. METHODS: The 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. RESULTS: Illicit 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. CONCLUSIONS: Illicit 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.