Patient choice as a means of empowerment in opioid substitution treatment: a case from Sweden

Abstract

Patient choice of treatment provider was introduced within opioid substitution treatment in the southern Swedish county of Skåne in 2014. Substitution treatment has often been criticised for being strict, rule-based, and driven by an ethos of discipline. This study explores the patients’ views and experiences of patient choice, particularly as a potential means of empowerment. The study is based on semi-structured interviews with 33 patients at six substitution treatment clinics in two cities. Patient choice within substitution treatment has empowered the patients in that many are able to choose their treatment provider and transfer to another provider. The interviewees appreciated the possibility to choose and transfer, and felt that they had gained more influence on their treatment. Experiences of poor staff conduct and the new clinic’s policies and practice on prescribing benzodiazepines were important reasons for choosing and transferring between clinics. In particular, the patients stressed the importance of the possibility to leave a clinic they felt offered substandard treatment, and the psychologically important feeling of knowing that they could transfer to another facility. However, patient choice in addiction treatment is very rare in Sweden, and the demographic structure limits the development of patient choice within substitution treatment.

Keywords:

• Opioid substitution treatment
• patient choice
• empowerment
• benzodiazepines
• service user involvement

Notes

Acknowledgements

We wish to thank all participants in the study. We also wish to thank Anders Håkansson, Lena Lindgren, Torkel Richert, Bengt Svensson and Lisa Wallander for their close readings and suggestions for this article. We are also thankful to the two anonymous reviewers for their helpful and important comments on previous versions of the article.

Disclosure statement

No potential conflict of interest was reported by the authors.

Author contributions

BJ planned the original project. LA and BJ designed the study and developed the interview questionnaire. LA did all of the interviews, conducted most of the analysis and wrote the first draft. Revisions were made jointly by LA and BJ. Both authors read and approved the final manuscript.

Notes

1 Patient choice means that substitution treatment in Skåne is pursued in accordance with national legislation, that is, according to the Act on System of Choice in the Public Sector (2008:962). Under the Act, the pursuit of treatment is predicated upon competition between treatment providers, public and private alike, so that service contracts are continually made with all treatment providers that meet the accreditation requirements (Konkurrensverket, 2014).Swedish substitution treatment is regulated by directives issued by The National Board of Health and Welfare. These directives determine, for example, who may be offered treatment. According to the current directives (HSLF-FS 2016:1), substitution treatment patients shall be at least 20 years old and have at least a one-year history of opioid dependence. The current directives came into force in February 2016, replacing the directives (SOSFS 2009:27) which were in force when patient choice was launched in April 2014.In addition to what is laid down in the national directives, the accreditation criteria decree on such matters as staffing and staff competences required at a substitution treatment clinic and what kind of services the clinics shall offer. A patient fulfilling the admission criteria must not be denied treatment.The Act on System of Choice relies on a remuneration system based on treatment appointments and performance. The appointments are registered (differently with different kinds of appointments), which generates a predetermined sum in compensation. The clinics are not guaranteed any patients; the compensation is always based on the patients’ decision to choose a given clinic. Also, the treatment takes place without competition on price, as the Act on Choice of System works on the premiss that competition is based on quality and availability, and that the patients ought to be able to choose the treatment provider that will best meet their needs and requirements. The remuneration system of the patient choice for substitution treatment was designed to put a premium on work with challenging patients, to promote high patient retention, and to prevent patients from being discharged from treatment (KEFU 2015).Patients are allowed to change clinics every six months at the most. Patient transfer shall be preceded by joint planning between the old and the new clinic. It is the responsibility of the new clinic to make contact with the old clinic and to obtain the patient records (Region Skåne 2016). The treatment is financed through county taxation and is in principle free of charge to the patients. The treatment providers are allowed to charge patient fees, but there is an upper limit of SEK 1100 annually payable by the patients themselves. When this amount is reached, the patients are entitled to receive outpatient care free of charge in the entire region.

2 Benzodiazepines are generally the most sought after prescription drug amongst patients in substitution treatment. By other pharmaceuticals, we primarily mean the so-called z-drugs (e.g. zopiclone and zolpidem). The majority of deadly overdoses in Sweden are polydryg intoxications where opioids have been taken together with other drugs, most of all benzodiazepines. Such deaths also occur among patients in substitution treatment, but are so far rare in Sweden (Fugelstad, Johansson & Thiblin, 2010; Leifman, 2016; Ledberg, 2017).

3 The average waiting time from application to the beginning of treatment has been almost halved from 46 days at the end of 2013 to 25 days at the end of 2017 (Andersson & Johnson 2018). According to evaluations, the increased number of patients (an increase of more than 50 percent in four years) has been a result of private treatment providers’ freedom of establishment, combined with a backlog of demand among people with opioid dependence (KEFU 2015; Andersson & Johnson 2018).

4 Previous treatment experiences were not an inclusion criterion, but our aim was that the majority of the interviewees would have a history of substitution treatment both before and after the introduction of patient choice. Eight of the interviewees had received treatment for under two years in total, five interviewees for two to five years, 14 persons had been in treatment for a total of five to ten years, and six persons for more than ten years in all. There were no big differences between the clinics regarding treatment experiences. The patients interviewed at the private clinics with a restrictive view on prescribing benzodiazepines, had a somewhat shorter total period of treatment experience. The mean age of the interviewees based on clinics, following how the clinics are presented in Table 1 from top to bottom, were 39, 42, 47, 36, 35 and 46 years.

5 This clinic changed ownership in 2017, and the current aim is to wean patients off prescribed benzodiazepines.

6 No, it should not, said Region Skåne. The two private clinics that prescribed the most benzodiazepines were monitored and inspected on several occasions during 2015–2017, both by the county and the Health and Social Care Inspectorate, the authority in charge of supervising the Swedish health care services. Both clinics were required to take measures and have since scaled down their prescriptions.

Additional information

Funding

This work was supported by Skåne Regional Council.