Malmö Treatment Referral and Intervention Study (MATRIS). Studies of opioid maintenance treatment in patients referred from a needle exchange program.

Background: Opioid maintenance treatment (OMT) with methadone and more recently buprenorphine is an evidence-based treatment for heroin dependence. Needle exchange programs (NEP) started in many countries in the 1980s to reduce the risk of HIV among people who inject drugs (PWID). NEPs have more recently been proposed as a potential conduit to treatment for drug dependence. The general aim of this thesis was to evaluate a model for referral of opioid-dependent individuals from a NEP to OMT and to evaluate the clinical course for these individuals starting OMT, regarding selected outcome measures. Methods: Participants were included at the NEP in Malmö between October, 2011, and April, 2013. All participants were referred to a research facility for OMT run by the Addiction Centre Malmö. At the baseline assessment, participants were asked about substance use, psychiatric and medical history. The participants’ health-related quality of life (HRQoL) was also assessed with the instrument EQ-5D. Patients were randomized to a strengths-based case management intervention (CMI) or a referral-only group (control). EQ-5D was repeated after 3 months of OMT. The clinical course with regard to retention in treatment, psychiatric diagnoses and inpatient care was assessed through patient records. Results: Out of 100 potential study participants at the NEP who were invited to participate, 79 accepted to be included in the study. Of those, 75 turned up for study inclusion, baseline interview and randomization. Thirty-six participants were assigned to CMI and 39 to the control group. Seventy-one participants successfully started OMT. Among patients randomized, 95% of the intervention group and 94% of the control group started treatment. Thus, entry was not related to being in the control or intervention group. Of the patients who started OMT, a majority (82%) were still in treatment after 12 months. The EQ-5D visual analogue scale (VAS) measure for the whole study sample was considerably lower than a sample from a Swedish reference population. The EQ-5D VAS measure was found to significantly increase from baseline to 3 months into treatment. During the 3year follow-up, 65% of participants were hospitalized for any psychiatric reason at least once. Using sedatives at baseline predicted hospitalization, and detoxification from sedatives, including benzodiazepines, was the most common cause. Seventy-two percent of the participants received a psychiatric diagnosis during the 3-year follow-up. When excluding substance use diagnoses, however, only 41% received a diagnosis with the most prevalent being anxiety disorders (27% of all participants). Conclusions: Our results suggest that a NEP is a clinical setting that allows for efficient referral of heroindependent individuals to opioid maintenance treatment. Even in a NEP population, with a high degree of substance use problems and social instability, there was a significant improvement in HRQoL in the short term and, importantly, a majority of the participants were still in treatment after 12 months. Hospitalization was predicted by patients’ baseline use of sedatives, and the most common reason for hospitalization during a 3-year follow-up was dependence on sedatives including benzodiazepines. This was also the most common psychiatric diagnosis apart from opioid dependence.