Chronic hepatitis C in Swedish subjects receiving opiate substitution therapy-Factors associated with advanced fibrosis.

Background: Opiate substitution therapy (OST) reduces the risk of death from directly drug-related causes in heroin users, allowing other chronic health problems to emerge. People who inject drugs (PWID) are exposed to hepatitis C virus (HCV), with an associated risk of chronic liver disease. We investigated HCV prevalence and liver-related morbidity in a cohort of OST recipients, and analyzed factors associated with significant hepatic fibrosis. Methods: All patients registered on 1 April 2008 in 4 clinics providing OST in the 3 largest cities in Sweden were eligible for inclusion. HCV viremic subjects were evaluated for fibrosis stage by liver biopsy, transient elastometry (TE), and/or a biochemical fibrosis index (Göteborg University Cirrhosis Index; GUCI). Factors associated with severity of fibrosis were determined by logistic regression analysis. Results: Out of 524 eligible patients, 277 consented to enrolment. Two hundred and thirty-six subjects (88%) were anti-HCV-positive, and 162 of these were viremic (69%). Significant liver fibrosis (defined as Ishak stages F3-F6, TE value ≥ 8.85 kPa, or GUCI > 0.33) was found in 69 out of 103 (67%) tested viremic patients, and was associated with alcohol intake (p = 0.03), higher body mass index (BMI; p = 0.04), and the presence of anti-HBc antibodies (indicating exposure to hepatitis B virus (HBV); p = 0.02). Conclusions: Significant liver fibrosis was detected in two-thirds of HCV viremic OST recipients in this cohort, and was associated with alcohol use, high BMI, and exposure to HBV. These findings indicate that the management of HCV and associated risk factors should be emphasized in Swedish OST programs

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.Peer reviewe

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.Peer reviewe

Craving in opioid use disorder : from neurobiology to clinical practice

Funding: Indivior UK Ltd.Opioid use disorder (OUD) is a major public health issue that has reached epidemic levels in some parts of the world. It is a chronic and complex neurobiological disease associated with frequent relapse to drug taking. Craving, defined as an overwhelmingly strong desire or need to use a drug, is a central component of OUD and other substance use disorders. In this review, we describe the neurobiological and neuroendocrine pathways that underpin craving in OUD and also focus on the importance of assessing and treating craving in clinical practice. Craving is strongly associated with patients returning to opioid misuse and is therefore an important treatment target to reduce the risk of relapse and improve patients’ quality of life. Opioid agonist therapies (OAT), such as buprenorphine and methadone, can significantly reduce craving and relapse risk, and it is essential that patients are treated optimally with these therapies. There is also evidence to support the benefits of non-pharmacological approaches, such as cognitive behavioral therapy and mindfulness-based interventions, as supplementary treatments to opioid agonist therapies. However, despite the positive impact of these treatments on craving, many OUD patients continue to suffer with negative affect and dysphoria. There is a clear need for further studies to progress our understanding of the neurobiological basis of craving and addiction and to identify novel therapeutic strategies as well as to optimize the use of existing treatments to improve outcomes for the growing numbers of patients affected by OUD.Publisher PDFPeer reviewe

Improving maintenance treatment of heroin addiction : The role of buprenorphine

Background: Heroin addiction is a condition with high morbidity and mortality. The discovery of Methadone Maintenance Treatment (MMT) by Dole and co-workers 1964 represented the first major advance in the treatment of this condition. Through the work of Gunne et al in Uppsala, MMT was implemented in Sweden already in 1966. The use of this treatment has, however, been limited in Sweden. Some of the concerns have been related to safety issues. Methadone, a full opiate agonist, can lead to overdose and death due to respiratory depression. Buprenorphine, a partial opiate agonist, has a greater safety margin to overdosing, and therefore offers a safer alternative. Here, we studied efficacy of buprenorphine maintenance treatment (BMT) in the context of a comprehensive treatment package, and its place in a rational treatment strategy vs. methadone. We also examined the effects of buprenorphine on neuroendocrine hyperactivity in heroin addiction. Finally, we compared pregnancy outcomes in MMT and BMT pregnancies. Aims: The following research questions were addressed: the efficacy of buprenorphine combined with psychosocial interventions; a comparison between gold standard MMT and a novel stepped treatment strategy using buprenorphine as first-line treatment; whether BMT leads to a normalization of the hyperactive HPA axis, and the possible link to negative affect; a comparison of fetal growth and neonatal outcomes in two consecutive case series consisting of BMT and MMT exposed pregnancies. Methods: In two RCTs, with 40 subjects in study I and 96 subjects in study II, we measured retention in treatment, performed ASI interviews, and monitored illicit drug use by urine screens. In an experimental study, we used the metyrapone challenge (a chemically induced indirect stress provocation that measures HPA axis responsiveness), the Profile of Mood States self-report instrument and genotyping. The observational pregnancy study measured intrauterine growth, birth outcome, malformations, neonatal adaptation, neonatal abstinence syndrome (NAS) and infant mortality. Results: Study I: 1-year retention was 75% and 0% in the buprenorphine and placebo groups, respectively (p= 0.0001). Urine screens were about 75% negative for illicit drugs in the patients remaining in treatment (subjects in buprenorphine group). Study II: Overall, 6-month retention was 78%. Stepped treatment and enhanced MMT outcomes were virtually identical. Among completers of stepped treatment, 46% remained on buprenorphine-naloxone. Proportion of urine samples free of illicit opiates increased over time and reached approximately 80% in both arms. Problem severity decreased significantly and uniformly in both arms. Study III: Although BMT appeared to normalize HPA axis response to metyrapone in heroin addicts, negative affect remained elevated in this group compared to healthy controls. Study IV: In the buprenorphine-exposed pregnancies NAS occurred in 19 cases (40.4%), only 7 (14.9%) needing withdrawal treatment, compared to 77.8% and 52.8% after intrauterine methadone exposure, respectively. Conclusions: The combination of buprenorphine and intensive psychosocial treatment is safe and highly efficacious. A stepped treatment of heroin addiction appears equally efficacious compared to optimally delivered MMT. Together with prior data on the advantageous safety of buprenorphine, this suggests that broad implementation of strategies using buprenorphine as first-line treatment should be considered. Response to metyrapone was dampened in heroin addicts maintained on buprenorphine. Despite the normalized HPA axis function, increased measures of negative affect were seen in the buprenorphine maintained group, implying a dissociation of HPA axis responsiveness and affect in heroin addiction. Finally, our preliminary data suggest that buprenorphine may offer advantages during pregnancies complicated by heroin addiction

Verkligt värde i praktiken : En studie av tillförlitligheten vid fastighetsvärdering till verkligt värde

The ongoing harmonization process aims to incorporate IFRS regulations into the Swedish accounting. As a consequence investment property’s starting from 2005 may be valued using the fair value method, in accordance to IAS 40. This involves major changes for listed property enterprises that from now on can value a large extent of their assets to fair value. All parties don’t appreciate this progress, opponents to fair value have expressed great concern that fair value don’t work in practice. They claim that fair value measurement is too subjective and unreliable, and that it will malfunction during periods of financial turmoil. Further they claim that it is not suitable with the European accounting tradition, consisting of a high degree of conservatism and prudence. This thesis aims to examine the accuracy of fair value measurement in the case of Swedish investment property firms. This is done by identifying realized value changes in the corporate annual reports, which will indicate how well the estimated value is consistent with the realized exit price of the property. The findings of this thesis indicate that there exist an average deviation of 11,6 percent between the book value and the realized exit price. Further this study finds no evidence that the financial turmoil in 2008 complicates the use of fair value in any significant way. However, the study provides a clear indication that conservatism and prudence still influence Swedish accounting. This given that 94 percent of the book values were lower then the realized exit price.

Treatment for chronic hepatitis C in a cohort of opiate substitution therapy recipients in three Swedish cities - completion rates and efficacy.

Opiate substitution treatment (OST) programs could provide opportunities for management of comorbidities, such as hepatitis C virus (HCV) infection, in people who inject drugs. We aimed to prospectively evaluate the real-life feasibility of interferon/ribavirin-based HCV treatment in OST recipients, with a special focus on psychiatric status and health-related quality of life

Nordic-European Public Investor Initiative: Experience sharing and joint advice on EU policy

This report has a dual content. Firstly, it describes joint policy advice presented by the Nordic-European Public Investor Initiative members to the EU Commission regarding structural fund regulations for the 2014-2020 programming period. Secondly, the report includes brief descriptions of existing programmes and models used in the different European countries in which the member organisations are based