Patient pathways in the treatment of opioid drug dependency – A register-based real world analysis using regional healthcare registers

Löfvendahl S & Steen Carlsson K

In a new report, the Swedish Institute for Health Economics (IHE) analyses treatment pathways for people with opioid dependence enrolled in programs at LARO clinics in the Skåne region in southern Sweden. LARO is the Swedish ackronym for Medication-Assisted Treatment of Opioid Dependence (Läkemedelsassisterad behandling vid opioidberoende). The WHO considers LARO to be an important tool for reducing the health and social consequences and to improve the well-being and social functioning of people affected by opioid dependence. LARO was first developed in the late 1960s in the US and but did not become an established alternative in Sweden until the early 1980s. However, it remained controversial and the broad national introduction has been gradual with the first Swedish national regulation in 2005. Region Skåne was among the first four healthcare regions to introduce LARO.

In the report, IHE investigated the use of healthcare resources, pharmaceutical use and contacts with social services for 2 429 persons identified the Skåne Healthcare Register (SHR) with indications of new or ongoing LARO treatment 2011-2017. Treatment patterns were observed and analysed for the period when LARO treatment was included in the Choice of healthcare reform in Region Skåne in 2014 (Vårdval LARO) and with the last observation year 2017. Secondly, IHE studied patterns during the first year of LARO treatment for persons admitted in LARO treatment programmes at designated LARO clinics.

Five key findings from the study were:

  1. Increased supply and improved access
    Both the number of LARO clinics and the number of people in LARO treatment have increased over time. In 2013 there were eight LARO clinics in Skåne and in 2017 there were 18 clinics. During the same period the number of patients in LARO treatment increased from 1 289 to 1 654 (28 percent).
  1. Additional healthcare use for people in LARO
    Among people with LARO visits every month during their first year in treatment, more than 40 percent used also non-LARO psychiatric care indicating a presence of psychiatric comorbidity.
  1. A high proportion of people in LARO remains in treatment if stable in the first year
    Among those who were possible to follow up until two years (288 persons out of 339 persons in stable LARO treatment) after LARO entrance, 92 percent remained in treatment after 18 months and 72 percent remained in treatment after 24 months. An important outcome measure for LARO success is retention measured as the percentage of people who remain in treatment compared to the number who started LARO.
  1. Increasing level of central purchases of LARO treatment medications
    There has been a general trend over the years towards greater proportion of study medications distributed in clinics compared to pharmacies. The results show a shift in the way the study medications buprenorphine mono, methadone and buprenorphine and naloxone in combination for opioid dependence were managed. During the period 2008 to 2011 these medications were predominately handled through prescriptions while after 2011, the persons using these medications to a higher extent received them the directly from a healthcare unit. Keeping the distribution of LARO medications at the LARO clinic may interfere with the objectives of the third phase of LARO treatment where one element of increasing independence and responsibility for treatment is the transition to pharmacy-based purchases of prescribed opioid dependency medication.
  1. Quality improvement in LARO treatment
    The overall shift in healthcare treatment pattern in terms of a larger proportion of team visits (visits where the LARO person meets with more than one types of healthcare personnel) over time may indicate a quality improvement in the LARO treatment as more types of healthcare personnel seems to be involved in treatment. During the period 2015 to 2017 the annual mean number of team visits (excl. physician) increased by 95 percent (21 to 41).


Download the report

IHE Report 2020:2, Lund: IHE, Sweden, 2020.