Standards for opioid use disorder care: An assessment of Nordic approaches.

AIMS: Outcomes in opioid use disorder (OUD) in Nordic countries have improved with integrated treatment and harm-reduction programmes. Approaches and the standard of care are different across the region. Evidence of treatment needs and current approaches are defined from evidence to inform development of a common standard. METHOD: Evidence of population sizes and treatment approach collected. Common standards for care (harm reduction, pharmacotherapy, psychology/social therapy) defined for each country. RESULTS: Evidence defines number in treatment; potential population needing treatment not defined for all countries. Populations sizes, treatment access (ratio in treatment programme compared to total country population) defined: Sweden 4,000 in OUD care (access ratio 40); Finland 3,000 (55); Norway 8,000 (154); Denmark 7,500 (132). Approach to treatment similar: integrated treatment programmes standard. Care provided by specialists in outpatient clinics/primary care; secondary care/inpatient services are available. Harm reduction is limited in Sweden but available and more accessible elsewhere. Treatment entry criteria: access relatively unlimited in Norway and Denmark, more limited in Finland and Sweden. Standards of care defined: easy access to high-quality services, individual planning, care not limited by time, management of relapse, education for patients, continuous engagement, holistic approach including management of comorbidities, needle equipment programmes without limit, treatment in prisons as community. CONCLUSION: There are opportunities to improve OUD care in the Nordics. Policy makers and clinicians can advance OUD care and share common success factors. Collaborative work across the Nordic countries is valuable. Further research in clinical practice development can yield important results for the benefit of patients with OUD.

Principles for managing OUD related to chronic pain in the Nordic countries based on a structured assessment of current practice.

BACKGROUND: Long-term use of opioid analgesics (OA) for chronic pain may result in opioid use disorder (OUD). This is associated with adverse outcomes for individuals, families and society. Treatment needs of people with OUD related to chronic pain are different compared to dependence related to use, and also injection, of illicit opioids. In Nordic countries, day-to-day practical advice to assist clinical decision-making is insufficient. AIM: To develop principles based on expert clinical insights for treatment of OUD related to the long-term use of OA in the context of chronic pain. METHODS: Current status including an assessment of barriers to effective treatment in Finland, Denmark, Iceland, Norway, Sweden was defined using a patient pathway model. Evidence to describe best practice was identified from published literature, clinical guidelines and expert recommendations from practice experience. RESULTS: Availability of national treatment guidelines for OUD related to chronic pain is limited across the Nordics. Important barriers to effective care identified: patients unlikely to present for help, healthcare system set up limits success, diagnosis tools not used, referral pathways unclear and treatment choices not elucidated. Principles include the development of a specific treatment pathway, awareness/ education programs for teams in primary care, guidance on use of diagnostic tools and a flexible treatment plan to encourage best practice in referral, treatment assessment, choice and ongoing management via an integrated care pathway. Healthcare systems and registries in Nordic countries offer an opportunity to further research and identify population risks and solutions. CONCLUSIONS: There is an opportunity to improve outcomes for patients with OUD related to chronic pain by developing and introducing care pathways tailored to specific needs of the population.

Interim buprenorphine treatment in opiate dependence: A pilot effectiveness study.

BACKGROUND: Interim methadone treatment (i.e., temporary medication-only treatment) has been tested in a few U.S. studies as a method for facilitated referral to and initiation of opioid maintenance treatment in heroin dependence. However, despite the favorable safety profile of buprenorphine compared with methadone, interim treatment with buprenorphine rarely has been tested and reported in the scientific literature. The present pilot effectiveness study aims to assess the feasibility of an interim buprenorphine treatment for initiation of individuals with opiate dependence into full-scale opioid maintenance treatment, and to study baseline predictors of successful transfer to full-scale treatment. METHODS: Interim treatment was introduced in a high-threshold setting with waiting lists to opioid maintenance treatment. Consecutive patients on the waiting list were offered the option to enter interim treatment. The interim program was a medication-only condition with supervised daily doses of buprenorphine-naloxone. The main outcome was successful transfer to full-scale opioid maintenance treatment, which required a drug-free urine sample. RESULTS: Forty-four patients entered interim buprenorphine treatment. Among them, 57% (n = 25) were successfully transferred to full-scale treatment after an average of 44 days. Remaining patients could not be transferred, generally because they did not manage to become drug-free. Successful transfer to full-scale treatment was associated with a lower baseline Alcohol Use Disorders Identification Test (AUDIT) score (4.4 vs. 12.6; P < .001) and tended to be associated with lower cannabis use (5.2 vs. 10.4 days during the past 30 days; P = .06) and lower heroin use (7.2 vs. 9.9 days; P = .09) prior to baseline. In a logistic regression analysis, only lower AUDIT score predicted successful treatment entry. CONCLUSIONS: According to these pilot data, supervised buprenorphine-naloxone in a medication-only interim treatment condition appears to be a feasible way to improve treatment initiation in a high-threshold setting. Polydrug use, including higher levels of alcohol consumption, may predict a more complicated course in interim treatment.