Hvilken nytte, for hvem og til hvilken kostnad? En prospektiv studie av stoffmisbrukere i behandling

Hvert år bruker det offentlige betydelige ressurser på ulike tilbud til rusmiddelmisbrukere, men det har vært gjort få sammenlignende studier av nytten i forhold til kostnadene i ulike behandlingstiltak. Det er med andre ord et gap mellom de store pengesummene som brukes og den begrensede kunnskapen man har. Formålet med "nytte-kostnad" undersøkelsen og denne rapporten er derfor å bidra til et bedre kunnskapsgrunnlag for de som skal ta beslutninger om behandling av narkotikamisbrukere i Norge. For å kunne sammenligne ulike be handlingstiltak, samlet vi inn informasjon fra 482 klienter i 20 ulike behandlingstiltak. Klientene ble intervjuet tre ganger med ett års me llomrom. Utvelgelsen av klientene foregikk ved at alle klienter som kom til behandling i en viss tidsperiode ble spurt om å være med i undersøkelsen. De fleste klientene ble intervjuet for første gang i 1998/1999 da de bl e tatt inn til behandling, bortsett fra klientene i medikamentassistert rehabilitering (MAR) som ble rekruttert i 1999/2000. De forskjellige tiltakene bl e valgt slik at de representerte ulike behandlingsformer (døgnbehandling, poliklinisk behandling (PUT), MAR), samtidig som de var innenfor en pr aktisk geografisk rekkevidde for oppfølging. Oppfølgingsprosenten er meget god - 92% ved første oppfølging etter rekrutteringsintervjuet og 88% etter andre. I tillegg til de som ikke ble intervjuet ved noen av oppfølgingsund ersøkelsene, enten fordi de var døde eller fordi de ikke ble gjenfunn et, var det også noen som fortsatt var i behandling, noen som var i fengsel, på sykehus eller i andre "kontrollerte miljøer". Fordi vi ønsket å se hvor dan det gikk med klientene etter behandling, ble de som var i ulike "kontrollerte miljøer" ekskludert. Vi satt da igjen med en gruppe på 356 klienter, som vi hadde informasjon om før behandling, og som ikke var i et "kontrollert miljø" ved ett av oppfølgingsintervjuene Dersom vi ser på utvalget som helhet, viser tallene at klientene rapporterte om en betydelig reduksjon i rusmi ddelmisbruken etter behandling. I gjennomsnitt gikk bruken av heroin ned med 58% (fra 14 dager per måned før behandling til 6 dager per måned ved oppfølgingen). Tilsvarende gikk bruken av amfetami n ned med 67% og antall dager med bruk av cannabis gikk ned med 35%. Avhengig av hvordan man måler, var mellom 30 og 40% av klientene helt rusfrie ved oppfølgingsintervjuene. Ungdomstiltakene hadde den største andelen helt rusfrie ved oppfølgingene (over 39%), så fulgte døgntiltakene (minst 26%), og deretter PUT og MAR med henholdsvis 23% og 20% som hadde vært helt uten bruk av rusmidler den siste måneden før oppfølgingsintervjuet (i hovedsak to år etter påbegynt behandling). Klientene rapporterte også om en sterk reduksjon i antall dager med kriminalitet; fra gjennomsnittlig 9 dager per måned før behandling til 3 etter behandling (en reduksjon på 66%). Den selvrapporterte endringen bekreftes også av data innehentet fra strafferegisteret som viser at klientene hadde et gjennomsnitt på 20 dager per år i fengsel i årene før 1998, mens gjennomsnittet sank til 7 da ger i 2000. På andre indikatorer - som antall dager med psykiske problemer og antall dager i arbeid - var det også en forbedring, selv om denne ikke var så stor som for de andre indikatorene. Dersom vi ser på gruppen klienter hvor vi har opplysninger ved begge oppfølgingstidspunktene (182 klie nter som hadde vært i et "ikke- kontrollert miljø" i minst ett år), vise r det seg at noen av de viktigste endringene også var overraskende st abile. For eksempel var reduksjonen i bruken av heroin på 58% når man sammenligner bruken ved rekrutteringsintervjuet og første oppfølgi ngsintervju ett år etter. To år etter rekrutteringsintervjuet var reduksjone n fortsatt nesten like stor (56%) i forhold til rekrutteringsintervjuet

Pregnant substance-abusing women in involuntary treatment: attachment experiences with the unborn child

Use of coercion against pregnant women who misuse substances was legalised in Norway in 1996. The background for the law was that substance abuse during pregnancy represents a significant health problem for the child. AIM – The main aim of this study was to explore if an attachment between the mother and her unborn child was possible in a context of coercion as experienced from the woman’s perspective. The women had many challenges, such as lack of social support and poor living conditions. MATERIAL – Data were collected in eight qualitative indepth interviews. FINDINGS – The main findings show how involuntary detention enabled safety for and connection with the unborn child. Within this context, the pregnant substance-abusing women’s own relational experiences and developmental histories represent the most significant barrier for their ability to bond with the expected child. CONCLUSIONS – The study underlines the importance of helping women with their own attachment experiences in order to break the generational transference of risk and pathology, and in this way, start the attachment process to the unborn child during the coerced treatment stay. Implications of the findings are discusse

Tapering from Methadone or Buprenorphine during Pregnancy: Maternal and Neonatal Outcomes in Norway 1996-20

Background: The tapering of methadone or buprenorphine during pregnancy is an understudied and controversial issue. The aim of this study was to determine to what extent women tapered their opioid medication dose during pregnancy and what the neonatal outcomes were for those who tapered compared to the women who did not. Methods: The study was a mixed prospective/retrospective national cohort study of 123 Norwegian women in opioid maintenance treatment (OMT) during pregnancy and their neonates. A standardized questionnaire was administered to the women and medical information that could be used for verification was collected from hospitals and municipalities. Results: Two of the women came off the OMT-medication during pregnancy and another 15% tapered their OMT-medication dose more than 50%. The birth weights of methadone-exposed neonates of the women who tapered more than 50% were significantly higher than for the methadone-exposed neonates of the women tapering between 11 and 50%. No other significant differences were found. Conclusion: Pregnant women in OMT who taper their OMT-medication dose should be monitored closely. We need studies that document the maternal well-being and fetal safety of maternal tapering of the OMT-medication during pregnancy. This is the peer-reviewed but unedited manuscript version of the following article: Tapering from Methadone or Buprenorphine during Pregnancy: Maternal and Neonatal Outcomes in Norway 1996-2009. Welle-Strand GK, Skurtveit S, Tanum L, Waal H, Bakstad B, Bjarkø L, Ravndal E. Eur Addict Res. 2015;21(5):253-61. The final, published version is available at http://www.karger.com/?doi=10.1159/00038167

Results from a Large, Multinational Sample Using the Childhood Trauma Questionnaire

Childhood maltreatment has diverse, lifelong impact on morbidity and mortality. The Childhood Trauma Questionnaire (CTQ) is one of the most commonly used scales to assess and quantify these experiences and their impact. Curiously, despite very widespread use of the CTQ, scores on its Minimization-Denial (MD) subscale—originally designed to assess a positive response bias—are rarely reported. Hence, little is known about this measure. If response biases are either common or consequential, current practices of ignoring the MD scale deserve revision. Therewith, we designed a study to investigate 3 aspects of minimization, as defined by the CTQ’s MD scale: 1) its prevalence; 2) its latent structure; and finally 3) whether minimization moderates the CTQ’s discriminative validity in terms of distinguishing between psychiatric patients and community volunteers. Archival, item-level CTQ data from 24 multinational samples were combined for a total of 19,652 participants. Analyses indicated: 1) minimization is common; 2) minimization functions as a continuous construct; and 3) high MD scores attenuate the ability of the CTQ to distinguish between psychiatric patients and community volunteers. Overall, results suggest that a minimizing response bias—as detected by the MD subscale—has a small but significant moderating effect on the CTQ’s discriminative validity. Results also may suggest that some prior analyses of maltreatment rates or the effects of early maltreatment that have used the CTQ may have underestimated its incidence and impact. We caution researchers and clinicians about the widespread practice of using the CTQ without the MD or collecting MD data but failing to assess and control for its effects on outcomes or dependent variables

Women Maintained on Opioid Drugs in Pregnancy. Investigation of Outcomes for Mother and Child. Evaluation of Care and Follow Up (EuropASI), 2011.

The project "Women Maintained on Opioid Drugs in Pregnancy. Investigation of Outcomes for Mother and Child. Evaluation of Care and Follow Up, 2011" aims to investigate women in opioid maintenance treatment (OMT) and their partners over time. Women in OMT inhave a past characterized by drug abuse, which can be challenging in the beginning of parenthood. The study examines changes in mothers' substance use, psychological problems, and other challenges, from one to four years after their children were born. The project also describes kindergarten attendance and prevalence and type of child protective services involvement when the children were four years old. The project is divided in to three projects; the EuropASI, SCL-25 and MCMI-III. This file consists of data from EuropASI

A 10-year prospective study of mortality among Norwegian drug abusers after seeking treatment

Injecting drug users have a mortality risk between 10 and 20 times higher than the general population, and the persistent high mortality rate in most Western countries, and especially in Norway, is a major public health concern. Naturalistic, prospective studies following drug abusers over many years are needed in order to investigate the most important predictors of mortality and for planning strategic preventive measures. Four hundred and eighty-one drug abusers were followed prospectively for 10 years after admission to treatment during the period 1998-2009. Following instruments were used: the European Addiction Severity Index, Symptom Checklist-25 and Millon Clinical Multiaxial Inventory-II. Information on deaths and causes of death were obtained from the National Death Register. Cox regression analysis was used to analyze factors hypothesized to be associated with the risk of death. A total of 74 deaths were registered during the observation period, which represents a mortality rate of 1.5 per 100 person-years. The main cause of death was overdose, and the relative risk of mortality among males was twice that of females. Fifteen percent of the drug users in the study died during the 10 years after admission to index treatment. This represents an annual mortality rate of 1.5; which is in line with most similar studies from Europe, showing a mortality rates in the range of 1-2% per year. The main cause of death was overdose (68%). Preventive strategies aiming to reduce mortality among drug users have to be manifold and gender specific, taking into account drug abusers’ life conditions, their modes of thought and how they go about living their lives. © 2015 Ravndal E, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Searching for Sobriety: How Persons with Severe Mental Illness Experience Abstaining from Substance Use

Individuals diagnosed with severe mental illness (SMI) are more vulnerable to substances than are other people. Many people with SMI tend to attain full remission of their substance use, but others relapse frequently. There is more research on the reasons for substance use than on the reasons for abstaining among these individuals. Information from the latter may contribute to a better understanding of how individuals with SMI experience abstaining from substance use. Objective: The aim of this explorative study was to examine experiences of abstaining from substances of persons diagnosed with SMI. We examined both the reasons given and the requirements and strategies used when abstaining. Methods: A qualitative study with semi-structured interviews was conducted, and a descriptive and explorative design was applied. This study included a purposeful sample of 11 patients with SMI and substance use being treated by assertive community treatment teams. Results: The main reasons for quitting substance use were social relationships and meaningful activities. The stated requirements and strategies used in the search for sobriety were detachment towards people and places, positive thinking, controlling feelings and emotions, and fear of dependency. Conclusion: Our results are consistent with those from other qualitative studies on the importance of social relationships and meaningful activities as expressed reasons for abstaining. The strategy of actively avoiding a former adverse milieu to reach sobriety is consistent with findings from one similar study. The strategies of fear of adverse consequences, positive thinking, and controlling feelings and emotions found in the present study have not been reported by other qualitative studies. © 2014 Pettersen H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited