Patient choice of treatment provider was introduced within opioid substitution treatment in the southern Swedish county of Skåne in 2014. Substitution treatment has often been criticised for being strict, rule-based, and driven by an ethos of discipline. This study explores the patients' views and experiences of patient choice, particularly as a potential means of empowerment. The study is based on semistructured interviews with 33 patients at six substitution treatment clinics in two cities. Patient choice within substitution treatment has empowered the patients in that many are able to choose their treatment provider and transfer to another provider. The interviewees appreciated the possibility to choose and transfer, and felt that they had gained more influence on their treatment. Experiences of poor staff conduct and the new clinic's policies and practice on prescribing benzodiazepines were important reasons for choosing and transferring between clinics. In particular, the patients stressed the importance of the possibility to leave a clinic they felt offered substandard treatment, and the psychologically important feeling of knowing that they could transfer to another facility. However, patient choice in addiction treatment is very rare in Sweden, and the demographic structure limits the development of patient choice within substitution treatment.

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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.

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.

Problematic opioid use constitutes an extensive global problem. Correspondingly, opioid-related mortality is high and has increased in several Western countries, including Sweden, during the 2000s. In Sweden, the most effective treatment method, opioid substitution treatment (OST), was for a long time limited with respect to the number of patients. The treatment was also characterized by strict rules and conducted in a high-threshold manner, which has meant that it has not been fully appealing to people with problematic opioid use. Therefore, in Skåne County in southern Sweden, patient choice of treatment provider was introduced for OST in 2014 with the intention to increase the number of treatment places and strengthen patient empowerment. The overall aims of this thesis are (1) to investigate opioid-related deaths in Skåne with a focus on contact with care-providing authorities and in relation to increased access to OST, and (2) to examine patients’ and clinic managers’ attitudes towards the introduction of the patient choice reform for OST and their views of the reform's objectives of increased accessibility to OST and strengthening patients' empowerment and influence over their treatment. The four papers in this thesis are based on two research projects with various empiric material. Paper I and II are based on data on opioid overdose deaths from a period of two years before and two years following the introduction of the patient choice reform. Forensic data regarding the presence of various substances and which opioid caused the death, as well as demographic data and information on contact with care-providing authorities (health care, social services, and the Prison and Probation Service), were collected. Paper I examines clinical background and contact with care-providing authorities of opioid-related fatalities, as well as differences with regard to which opioid caused the death. Paper II examines the possible impact of the intervention on the development of opioid-related deaths in the region. National mortality data were also used in this study to investigate the development in Skåne compared to the rest of Sweden. The second research project focused on stakeholders’ views on the implementation of the patient choice reform. Paper III includes interviews with 33 OST patients, and paper IV consists of interviews with the managers of all OST clinics in Skåne. The results from paper I show that of the 180 deceased in opioid overdose included in the study, almost 90 per cent had been in contact with one of the examined care-providing authorities during the year prior to death. Few differences appeared with regard to which opioid contributed to the death. Paper II indicates that there has been no significant change in opioid-related deaths in Skåne after the patient choice reform and increased access to OST. An analysis on national mortality data however showed a significant yearly decrease in drug-related deaths in Skåne compared to other Swedish counties in the years following the reform (2015–2017). No change was noted in deaths related to methadone or buprenorphine in Skåne. The proportion of deaths among patients in OST increased after the introduction of the reform. The third paper indicates that patients in OST in Skåne have gained increased empowerment and influence over their treatment since the patient choice reform was introduced. Patients especially appreciated the knowledge that they could make an exit and change clinics if they so wished, even if they so far had chosen not to. In paper IV, the clinic managers were largely positive to the trend towards increased influence for patients over their treatment situation. They were more critical of the fact that there was no major differentiation between treatment providers, and that the competition that arose after the patient choice reform mainly was related to prescribing benzodiazepines. Conclusions drawn from the papers in this thesis include that patient choice of treatment provider can be viewed as a means of empowerment for patients in OST, which was regarded as positive by both patients and treatment providers. The limitations of such a system for providing OST that emerged were lack of diversity between clinics and that the competition between treatment providers largely comprised of differing views on the prescription of benzodiazepines. Further, improved access to low-threshold OST in Skåne was not associated with an increased overdose death-rate. The result that people who died from opioid overdose to a very large extent are known to society’s care-providing authorities suggests that there are considerable opportunities to reach people with problematic opioid use for therapeutic and harm reducing measures such as low-threshold OST and take-home naloxone.