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Heroin Addiction and Related Clinical Problems: 2024, 26, 52

The rise of the 'Opiate Rule' - A dismal parenthesis for Opioid Agonist Treatment in Sweden from 2010 to 2016

Bodil Monwell

Digital Object Identifier:
https://doi.org/10.62401/2531-4122-2024-52

Summary: Background: During the period 2010-2016, when the government regulation SOSFS 2009:27 on opioid agonist treatment [OAT] was in force, people with severe opioid dependence were excluded from OAT due to the 'opiate rule' for unclear reasons. This was despite strong research support and OAT recommended as an intervention by the World Health Organization and the Swedish Agency for Health Technology Assessment and Social Services Evaluation. The phenomenon of the 'opiate rule', i.e. that only those with documented addiction to heroin, morphine or opium were included in OAT, was unique to Sweden. Aims: To investigate the process of the OAT regulation, where the Opiate Rule was developed, where the definition of the diagnostic concept of 'opiate dependence' was changed. Methods: The design is a case study, with an inductive and descriptive approach. Material was collected from 1) authorities and publications in the field, 2) media archives, and 3) semi-structured interviews. Results: This study points to several enabling factors that have made the Opiate Rule possible. OAT and its regulation have been the subject of heated debate in Sweden over time, influenced by drug policy and ideological ideas. During the development and construction of the regulation, OAT remained a 'hot topic', in both the authority and public sphere. The working process of the regulation and the decision to bring it into force took place in a rather 'closed room' with a small number of officials involved. Officials whose personal ideas, opinions, knowledge, competence and power influenced both the process and design. Conclusions: The Opiate Rule as a phenomenon reveals risks of top-down management of health care. On this occasion, individual officials and decision-makers gained too much leeway and power – jeopardising the needs and rights of opioid-dependent patients to get vital opioid agonist medical treatment in Sweden during 2010-2016.

Keywords: Opioids; heroin; buprenorphine; methadone; opioid dependency; opioid addiction; opioid agonist treatment; opioid maintenance treatment; command-control; top down; health care regulations