Rökavvänjningsmodeller - Vilken interventionsmodell är mest effektiv? En systematisk litteraturstudie

Rökningsrelaterade sjukdomar utgör, trots minskning av antalet rökare, en mycket kostsam post på både individuell och samhällelig nivå. Genom sitt dagliga arbete möter sjuksköterskan många av de individer som vill och är i behov av att sluta röka. För att uppnå goda resultat i form av bestående rökfrihet krävs evidens för att avgöra vilken rökavvänjningsmodell som är den mest effektiva. Syftet med denna studie var att undersöka olika rökavvänjningsmodellers struktur och effektivitet med avseende på individer som står i kontakt med sjukhus. Studien avsåg även att undersöka huruvida den mest effektiva modellen bör anpassas utifrån kön och/eller sjukdomsbakgrund för att uppnå ett mer fördelaktigt resultat. Metoden bestod av en systematisk litteraturstudie baserad på en kvasiexperimentiell samt tolv randomiserade studier. Resultatet visade att en intensiv intervention, med rådgivning och motiverande samtal, som fortgår under ett minimum av sex månader efter utskrivning medför högst andel rökfria individer. Resultaten gav även en indikation på att interventionen bör anpassas efter sjukdomsbakgrund. För individer med låg motivation kan användandet av bupropion inledningsvis stärka dem och sedermera leda till presumtivt rökstopp.Smoking-related diseases are, despite the reduction in numbers of smokers, very expensive both from the individual and from a social point of view. Nurses, through their daily work, interact with many individuals whom express a willingness to stop smoking. For many individuals it is also a necessity to quit. In order to achieve persistent abstinence, evidence is required to determine which smoking cessation intervention is the most efficient. The purpose of this study was to examine the structure and performance of various smoking cessation models including individuals who are in contact with the hospital. This study also examined whether the most efficient model should be tailored according to gender and/or health status of the individual. The method consisted of a systematic literature review based on one quasi experiential and twelve randomized controlled studies. The results showed that an intensive intervention, with motivational counseling, over a minimum of six months after discharge leads to the highest cessation rates. The results also gave an indication that intervention should be tailored to fit the clinical picture. Low motivation in individuals may initially benefit from the use of bupropion and subsequently lead to presumptive abstinence

Self-Rated Physical Health and Unmet Healthcare Needs among Swedish Patients in Opioid Substitution Treatment

Background. Individuals with opioid dependence are at increased risk of deteriorating health due to the lifestyle connected to heroin use. Barriers surrounding the healthcare system seem to hinder patients to seek help through conventional healthcare, even after entering opioid substitution treatment (OST), resulting in a high level of unmet healthcare needs. However, this field is still unexplored, with only a few studies focusing on general health within this population. The first step, in order to provide suitable and accessible primary healthcare, is to assess the extent of physical symptoms and unmet healthcare needs within the OST population, which, to this point, has been sparsely studied. Aim. To assess OST patients’ self-rated physical health and healthcare seeking behaviour. Methods. Two-hundred and eighteen patients from four different OST sites answered a questionnaire regarding physical health and healthcare seeking. Results. Patients in OST have a high degree of physical symptoms and a high degree of unmet healthcare needs. Sixty-six percent reported suffering from musculoskeletal pain. Fifty-six percent reported gastrointestinal symptoms. Genital problems and airway symptoms were reported by 47%, respectively, and dental problems were reported by 69% of the respondents. General unmet healthcare needs were reported by 82%. Musculoskeletal pain was positively correlated with having an unstable housing situation (AOR 4.26 [95% CI 1.73-10.48]), negatively correlated with male sex (AOR 0.45 [95% CI 0.22-0.91]), and positively correlated with age (AOR 1.04 [95% CI 1.01-1.07]). No statistically significant correlates of respiratory, gastrointestinal, genital, or dental symptoms were found. Conclusion. Patients in OST carry a heavy burden of physical symptoms and unmet healthcare needs, potentially due to societal barriers. Patients’ frequent visits to the OST clinics offer a unique opportunity to build a base for easily accessible on-site primary healthcare

Healthcare utilization for somatic conditions among Swedish patients in opioid substitution treatment, with and without on-site primary healthcare

Background: Opioid substitution treatment (OST) populations are aging and have increased mortality and somatic morbidity compared to general populations internationally. While OST patients have poor self-rated physical health and unmet healthcare needs, documented healthcare utilization has been sparsely investigated. The aim of this study was to assess registered healthcare utilization for somatic conditions in a sample of Swedish OST patients, and compare healthcare utilization among OST patients with and without use of on-site primary healthcare (PHC). Methods: Patients in OST in Malmö, Sweden, were recruited for a survey study conducted in 2017–2018. Survey data were compared with comprehensive patient records from specialized and primary care during one year prior to study inclusion (total n = 190). All patient records were examined for healthcare utilization, source of healthcare (PHC, emergency care and secondary care), and documented diagnoses and symptoms. Factors associated with healthcare utilization were analyzed by using logistic regression analysis. Patients with and without on-site PHC were compared by using descriptive statistics and Chi-2 test. Results: A total of 88% of the sample had been in direct or indirect contact with somatic healthcare during one year (PHC 66%; emergency care 28%; secondary care 67%). The most prevalent somatic diagnoses were infectious diseases (39%) and symptom diagnoses (37%). Respiratory, dermatological and musculoskeletal diagnoses, and trauma/intoxication were documented in 21–26% of the sample, respectively. PHC utilization was associated with older age and being born in Sweden. Among patients with on-site PHC (n = 25), the number utilizing secondary care was 84%, and certain diagnostic codes were more frequent in this group. Conclusion: OST patients are seemingly underserved as regards their physical health. Since increased OST access decreases opioid overdose fatalities, the life expectancy among OST patients is likely to increase and thereby also increases the risk of age-related conditions. Thus, easily accessible physical healthcare is of great importance in this group. On-site PHC might be a way to establish healthcare contact with OST patients, especially for non-acute conditions, although further research is needed

Healthcare contacts regarding circulatory conditions among swedish patients in opioid substitution treatment, with and without on-site primary healthcare

Patients in Opioid Substitution Treatment (OST) have increased mortality and morbidity, with circulatory conditions suggested to be a contributing factor. Since OST patients tend to have unmet physical healthcare needs, a small-scale intervention providing on-site primary healthcare (PHC) in OST clinics was implemented in Malmö, Sweden in 2016. In this study, we assessed registered circulatory conditions and healthcare utilization in OST patients with and without use of on-site PHC. Patients from four OST clinics in Malmö, Sweden, were recruited to a survey study in 2017–2018. Medical records for the participants were retrieved for one year prior to study participation (n = 192), and examined for circulatory diagnoses, examinations and follow-ups. Patients with and without on-site PHC were compared through descriptive statistics and univariate analyses. Eighteen percent (n = 34) of the sample had 1≤ registered circulatory condition, and 6% (n = 12) attended any clinical physiology examination or follow-up, respectively. Among patients utilizing on-site PHC (n = 26), the numbers were 27% (n = 7) for circulatory diagnosis, 15% (n = 4) for examinations, and 12% (n = 3) for follow-up. OST patients seem underdiagnosed in regard to their circulatory health. On-site PHC might be a way to diagnose and treat circulatory conditions among OST patients, although further research is needed

Healthcare seeking among Swedish patients in opioid substitution treatment – a mixed methods study on barriers and facilitators

Background: Patients in opioid substitution treatment (OST) have poorer health than the general population. Thus, they do not seek somatic health care to the extent that is medically motivated. Barriers hindering patients from seeking medical help through the conventional healthcare system result in a high degree of unmet healthcare needs. Barriers to, and facilitators of, OST patients’ healthcare seeking have been sparsely examined. Methods: Mixed methods were employed. The quantitative part consisted of a cross-sectional questionnaire covering questions on physical health, healthcare seeking, and barriers thereof, which was collected from 209 patients in OST. A sub-sample of eleven OST patients participated in semi-structured interviews, for the qualitative part of the study, covering experience of healthcare, lifestyle, and self-images, expectations, and ideals of Swedish healthcare. Results: Confirmed by qualitative data, quantitative data revealed deprioritization, fear of stigma and of being treated badly, and problems in navigation throughout the healthcare system, leading to unsuccessful establishment of contact, being most common reasons for not seeking somatic healthcare. Thus, interviewees provided a deeper knowledge of the barriers stigma, lack of means to prioritize health and difficulties navigating throughout the healthcare system, leading to resignation and deprioritization. On-site primary healthcare (PHC) seemed to contribute to increased access and utilization of healthcare. Conclusion: Individual and structural barriers decreasing access to healthcare lead to increased inequalities in healthcare utilization, adding to an already deteriorating health of this ageing population. Integration of on-site primary healthcare and OST could provide acceptable and accessible healthcare

Characteristics of and Experience Among People Who Use Take-Home Naloxone in Skåne County, Sweden

Background: Opioid overdose related injury or death can be prevented by bystander naloxone administration. For naloxone to be present when and where overdoses occur, opioid prevention education and naloxone distribution (OPEND) must be established on a broad level. This is the 30-month follow-up of the first multi-site naloxone project in Sweden, implemented at 31 sites in the County of Skåne 2018. Aim: To address participant characteristics and factors associated with returning for naloxone refill and with having used naloxone for overdose reversal. An additional aim was to describe self-reported reasons for naloxone refill and overdose experiences. Methods: Data were collected during June 2018—December 2020 through questionnaires at baseline and upon naloxone refill of the initial and subsequent naloxone kit. Descriptive statistics was used to address participant characteristics, those returning for naloxone refill and reporting overdose reversal. Chi-2 test was used for variable comparison between groups. Factors associated with overdose reversals were examined by logistic regression analysis. Reasons for naloxone refill, overdose situation and management were presented descriptively. Results: Among 1,079 study participants, 22% (n = 235) returned for naloxone refill, of which 60% (n = 140) reported a total of 229 overdose reversals. Reversals were more likely to be reported by participants trained at needle exchange programs (NEPs) [adjusted odds ratio (AOR) = 5.18, 95% Confidence interval (CI) = 3.38–7.95)], with previous experience of own (AOR = 1.63, 95% CI = 1.03–2.58) or witnessed (AOR = 2.12, 95% CI = 1.05–4.29) overdose, or who had used sedatives during the last 30 days before initial training (AOR = 1.56, 95% CI = 1.04–2.33). A majority of overdoses reportedly occurred in private settings (62%), where the victim was a friend (35%) or acquaintance (31%) of the rescuer. Conclusion: Participants with own risk factors associated with overdose (e.g., injection use, concomitant use of benzodiazepines and previous experience of own overdose) were more likely to report administering naloxone for overdose reversal. Overdose management knowledge was high. The findings indicate that implementation of multi-site OPEND reaches individuals at particularly high risk of own overdose in settings with limited previous harm reduction strategies and favors a further scaling up of naloxone programs in similar settings

Malmö Treatment Referral and Intervention Study—High 12-Month Retention Rates in Patients Referred from Syringe Exchange to Methadone or Buprenorphine/Naloxone Treatment

BackgroundHeroin dependence is associated with high mortality. Opioid agonist treatment (OAT) with methadone or buprenorphine has strong evidence for treatment of this relapsing condition. In our setting, OAT has been associated with strict and demanding intake procedures, often with requirements of social stability, but also high, approximately 80 percent 12-month retention rates. In a recent randomized controlled trial, we demonstrated high rates of successful rapid referral from a syringe exchange programme (SEP) to treatment with methadone or buprenorphine, including actual treatment initiation. The objectives of this study were to assess 12-month retention rates, in order to assess whether a novel referral program of current drug users at a SEP would achieve retention rates comparable to more traditional intake procedures.MethodsThe present report is a 12-month follow-up of 71 patients who successfully started treatment with methadone or buprenorphine/naloxone. Patient data from baseline and at 12 months were collected.ResultsOut of the 71 patients who started treatment, 58 (82%) were still in treatment after 12 months.ConclusionThis was a population, referred from a SEP, with a high drug use severity on admission and no pretreatment requirement for social stability, but there were still high retention rates at 12 months comparable to regular opioid agonist clinics in our setting

Protocol for a multi-site study of the effects of overdose prevention education with naloxone distribution program in Skåne County, Sweden

Background: Continuously high rates of overdose deaths in Sweden led to the decision by the Skåne County to initiate the first regional take-home naloxone program in Sweden. The project aims to study the effect of overdose prevention education and naloxone distribution on overdose mortality in Skåne County. Secondary outcome measures include non-fatal overdoses and overdose-related harm in the general population, as well as cohort-specific effects in study participants regarding overdoses, mortality and retention in naloxone program. Methods: Implementation of a multi-site train-the-trainer cascade model was launched in June 2018. Twenty four facilities, including opioid substitution treatment units, needle exchange programs and in-patient addiction units were included for the first line of start-up, aspiring to reach a majority of individuals at-risk within the first 6 months. Serving as self-sufficient naloxone hubs, these units provide training, naloxone distribution and study recruitment. During 3 years, questionnaires are obtained from initial training, follow up, every sixth month, and upon refill. Estimated sample size is 2000 subjects. Naloxone distribution rates are reported, by each unit, every 6 months. Medical diagnoses, toxicological raw data and data on mortality and cause of death will be collected from national and regional registers, both for included naloxone recipients and for the general population. Data on vital status and treatment needs will be collected from registers of emergency and prehospital care. Discussion: Despite a growing body of literature on naloxone distribution, studies on population effect on mortality are scarce. Most previous studies and reports have been uncontrolled, thus not being able to link naloxone distribution to survival, in relation to a comparison period. As Swedish registers present the opportunity to monitor individuals and entire populations over time, conditions for conducting systematic follow-ups in the Swedish population are good, serving the opportunity to study the impact of large scale overdose prevention education and naloxone distribution and thus fill the knowledge gap. Trial registration: Naloxone Treatment in Skåne County - Effect on Drug-related Mortality and Overdose-related Complications, NCT 03570099, registered on 26 June 2018