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Heroin Addiction and Related Clinical Problems: 2024, 26, 53

The Opiate Rule - An inferior regulating of opioid agonist treatment in Sweden 2010-2016 and how was it handled in practice

Bodil Monwell

Digital Object Identifier:
https://doi.org/10.62401/2531-4122-2024-53

Summary: Introduction: During the period when SOSFS 2009:27 was in force from 2010 to 2016, people with severe opioid dependence who lacked documentation for heroin, morphine and opium, referred to here as the Opiate Rule, were excluded from OAT. This is despite strong research support for OAT treating this condition. Aims: To investigate how the Opiate Rule was handled among clinicians and users during 2010-2016. Methods: The design is a case study. Material was collected from 1) authorities archives and publications, 2) media archives, and 3) semi-structured interviews. Results: Several strategies were developed among clinicians, but also those with opioid dependence, to deal with the Opiate Rule. One was 'Washing', i.e. health care providers increased their efforts to find 'heroin, morphine or opium' in the documentation. Another was the ‘Negative qualification’ of those in need of OAT, a dangerous strategy when starting to use the 'correct' substance in order to document samples for inclusion. A third was the literal interpretation that 'We behaved' and followed the Opiate Rule. A fourth strategy was the pragmatic solution: 'We solved it' - more or less outside the regulatory framework. The final strategy was 'Unofficial OAT', where OAT providers created different ‘files’ and gave people in need of OAT methadone or buprenorphine without including them in OAT programs. Conclusion: There are risks in top-down management of health care, as demonstrated in this study by The Opiate Rule in Sweden 2010-2016. Strategies among clinicians and users may have contributed to the fact that people with severe opioid dependence still received necessary medical care during these years.

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