Swedish Drug Research Articles

Morality boundary work in the making of the needle and syringe exchange program in Stockholm

Background Drug policy is prone to build on rationales based on different moralities rather than evidence. Less is known about how moralities influence drug policy implementation in practice. The aim was to analyze expressions of moralities among local policy-makers, professionals, and drug users in the context of the Stockholm needle and syringe exchange program (NSP). Methods Using political documentation from Stockholm (2003–2016), focus group (12 NSP staff), and 32 drug user interviews, moralities concerning drug policy and harm reduction were analyzed based on moral foundations theory and boundary work. Results Three main moral dilemmas were identified concerning the subjects, aims, and orientation of drug policy: whether drug users are worthy of inclusion to society; if the general public should be prioritized or the health of drug users, and the orientation of practices as based on control or autonomy. Policy debate was driven by virtues such as purity and authority, whereas staff and drug users valued care, fairness and liberty. Conclusions The prohibitionist and abstinence-oriented Swedish drug policy has created social boundaries on the practice-level. Hence, users’ perspectives, and those who care about them, should be extensively involved in political discussions to foster a more moral and humane drug policy.

Impact of the COVID-19 pandemic on initiation of antihypertensive drugs in Sweden: an interrupted time series study

ObjectivesAntihypertensives reduce the risk of myocardial infarction and stroke. Restrictions during the COVID-19 pandemic limited access to healthcare, which may have had a negative impact on drug prescribing. This study...

Svenska narkotikapolisföreningens tidskrift - polisens bild av ett problem?

Aim: To analyze how the Police in Sweden perceives the drug problem and how it relates to changes in drug politics in the direction of liberalization. Method: The material analyzed consists of a content-analysis of the magazine of the Swedish Narcotic Police Association, covering 145 issues since the start in 1988, concentrating on lead articles, editorials and other articles on principles and politics. Results: The magazine demonstrate an alarmistic view of the drug problem, criticize government agencies and the media for liberal views, question the motives of proponents of decriminalization and legalization, leaves the costs of control of drug interventions aside, and sees the Police as guardian of status quo and as the defender of the goal of Swedish drug policy: "a drug-free society".

Breastfeeding decreases the risk of developing psoriasis through to early adulthood.

Psoriasis is a genetically determined systemic skin disease, although environmental trigger factors are required for disease manifestation. Some of these triggers, such as stress, infections and drug exposure, have been identified. To explore the role of early nutrition as a risk factor for the development of psoriasis. Parents in the All Babies in Southeast Sweden (ABIS) prospective birth cohort (n = 16 415) answered questionnaires at birth and when their children were aged 1 and 3 years. A diagnosis of psoriasis was determined from the Swedish National Patient Register and National Drug Prescription Register. Statistical analyses were conducted using custom-written R scripts. Individuals breastfed for < 4 months and who received infant formula before 4 months of age had a higher risk of psoriasis [odds ratio (OR) 1.84 (P = 0.02) and OR 1.88 (P = 0.02), respectively]. At the 3-year follow-up, the increased consumption of fish, especially from the Baltic Sea, increased the risk of psoriasis (OR 9.61; P = 0.003). In addition, the risk of psoriasis increased following the consumption of a large volume of milk (OR 2.53; P = 0.04). Our study underscores, for the first time, the impact of very early nutrition on the manifestation of psoriasis through early adulthood. Exclusive breastfeeding for 4 months appears to be protective.

Validation of overall survival extrapolations made by TLV in the assessment of cost-effectiveness of oncology drugs in Sweden – A pilot study comparing extrapolated and observed life-years gained

Aim The aim of the study is to assess the accuracy of overall survival (OS) extrapolations in cost-effectiveness analysis made by the Dental and Pharmaceutical Benefits Agency (TLV) to decide on the reimbursement and use of oncology drugs in Sweden. Material and methods TLV appraisals for oncology drugs were identified during a 5-year period (2013-2017). To be included each appraisal and health economic model must include a TLV base case extrapolation of OS. Further, Kaplan-Meier (KM) estimates on OS from the original and follow-up clinical trials must be available. Potential follow-up trials on OS were identified in ClinicalTrials.gov and the Lund University Libraries databases, and in the Swedish Medical Products Agency (MPA) and the European Medicines Agency (EMA) databases. In cases where the KM estimates were not available, data points from figures published in TLV’s appraisals were extracted using the semi-automated tools Digitizelt and WebPlotDigitizer. The accuracy of survival extrapolations was assessed by comparing extrapolated and observed life-years (LYs), using three different measures: 1) difference in LYs between the treatment and control group; 2) LYs in the treatment group, 3) LYs in the control group. Results We study TLV’s preferred OS extrapolations and show that on average they overestimate the observed mean gain in LYs by 24%, and underestimate observed LYs by 3% and 11% in the treatment and control group, respectively. Conclusions We conclude that it is feasible to validate OS extrapolations by comparing extrapolated and observed life-years. Even if survival extrapolations are reasonably accurate for the treatment group, this may still imply that extrapolations of LYs gained deviates to a larger extent. Follow-up studies on OS should be carried out to an increased extent to be able to validate, update and improve OS extrapolations in cost-effectiveness analysis of oncology drugs.

PT27 How Much Does TLV Value Rarity? A Review of Reimbursement Decisions on Orphan Drugs in Sweden from 2017 through 2022

PT27 How Much Does TLV Value Rarity? A Review of Reimbursement Decisions on Orphan Drugs in Sweden from 2017 through 2022

‘A free position in midfield' – a qualitative study of faith-based social work with people who use drugs in Sweden

ABSTRACT Many faith-based organisations (FBOs) provide social work services to marginalised groups in need of care such as people who use drugs (PWUD), but little is known about how diaconal or faith-based social work with PWUD is carried out and how staff view their work. The aim of this study was to explore how social work with PWUD within FBOs in Sweden is conducted. This study is based on semi-structured qualitative interviews with 14 employees at a range of churches in Sweden. The empirical material was analysed with qualitative textual analysis. FBO staff channeled a personal calling to offer services through their organisations and found PWUD be in need mainly of emergency support. Staff engaged in boundary work such as differentiating between activities conducted at the church premises or on the streets. Staff accompanied clients to meetings with publicly funded welfare services to the benefit of the clients, and they appreciated their free role compared to social services staff. FBOs mainly act as stabilisers in relation to official public welfare services. The role of prophetic diaconal work aiming at social justice was limited and clients’ emergency needs were in focus, which indicates that FBOs in Sweden mainly complement welfare state services.

Knowledge support for environmental information on pharmaceuticals: experiences among Swedish Drug and Therapeutics Committees

BackgroundTwo publicly available Swedish knowledge support systems, “Pharmaceuticals and Environment” on Janusinfo.se and Fass.se, provide environmental information on pharmaceuticals. Janusinfo is provided by the public healthcare system in Stockholm and Fass is provided by the pharmaceutical industry. The objectives of this study were to investigate the experiences among Swedish Drug and Therapeutics Committees (DTCs) with using the databases, retrieve development proposals for these, and investigate the DTCs’ challenges with working with pharmaceuticals in the environment.MethodsA cross-sectional survey with 21 questions, both closed and open-ended, was distributed electronically in March 2022 to Sweden’s 21 DTCs. Descriptive statistics and inductive categorization were used for the analysis.ResultsA total of 132 respondents from 18 regions filled out the survey. The average regional response rate was 42%. The DTCs used the knowledge supports to consider environmental aspects of pharmaceuticals in their formularies and in education. Respondents were more familiar with Janusinfo compared to Fass but appreciated the availability of both. The DTCs especially valued the concrete proposals for certain active pharmaceutical ingredients on Janusinfo. Respondents requested that all medicinal products have environmental information on Fass. Challenges included lack of data, lack of transparency from the pharmaceutical industry and difficulties considering the environmental aspect of pharmaceuticals in their healthcare practice. Respondents wanted more knowledge, clear messages, and legislation to support their work to reduce the negative environmental impact of pharmaceuticals.ConclusionsThis study demonstrates that knowledge supports for environmental information on pharmaceuticals are valuable for the DTCs in Sweden, but the respondents experienced challenges in their work in this field. The study can provide insights to those in other countries interested in considering environmental aspects in their formulary decision-making.

Debating the Drug Policy in Sweden: Stakeholders’ Moral Justifications in Media 2015–2021

Drug-related harms continue to increase globally and governments struggle in search of effective and legitimate countermeasures. The choice between policy options is intertwined with the arguments that dominate drug policy discussions, which in turn are closely related to who has access to the policy debate. In this study, we examine stakeholders’ visibility and moral justifications of argumentation in the Swedish drug policy debate in the media (2015–2021). Justification analysis (JA) is used as a methodological and theoretical tool to illustrate the moral principles behind the claims by the stakeholders. The results show that the most visible stakeholders were politicians, government agencies and molders of public opinion. Furthermore, the stakeholders with successful active attempts to participate in the debate were molders of public opinion, NGOs, and politicians. The silent stakeholders in the media were people who use drugs and significant others. Stakeholders generally revolve around a dividing line regarding the restrictive features of Swedish drug policy, and were divided into proponents, opponents and neutral ones. All stakeholder groups included all three sides, hence reflecting the ingroup dissonance that may explain the continuing deadlock in Swedish drug policy. Justifications that value evidence-based policymaking ( industrial worth) was used in the argumentation by the majority of the stakeholder groups, often combined with other moral justifications. This notion challenges the dichotomy of evidence and values in drug policy debates. Proponents relied more on the justifications that value paternalism ( domestic worth), while opponents leaned toward the justifications valuing civil rights and social justice ( civic worth). The development of Swedish drug policy may depend on the relative strength of these two value positions ( domestic versus civic worth) in society and among stakeholders in power. This study continues the discussion of making contesting values explicit in the drug policy, serving a riveting case for international comparison.

HTA66 Price Increases of Prescription Drugs in Sweden – In Which Cases Are They Approved?

HTA66 Price Increases of Prescription Drugs in Sweden – In Which Cases Are They Approved?

Use of ALK-tyrosine kinase inhibitors (ALK TKI) in clinical practice, overall survival, and treatment duration – a Swedish nationwide retrospective study

Background The real-world treatment and outcomes of patients with anaplastic lymphoma kinase positive (ALK+) advanced non-small cell lung cancer treated with ALK Tyrosine Kinase Inhibitor (TKI) drugs in Sweden is not well described. Material and methods A retrospective population-based cohort study was conducted using Swedish national registers. All patients with a filled prescription for an ALK TKI between January 2012 and October 2020 were included. The sequencing of ALK TKI and duration of treatment (DOT) were described, and overall survival (OS) was estimated using the Kaplan–Meier method. Patients were stratified based on treatment with frontline chemotherapy, presence of CNS metastases prior to the first ALK TKI, and generation of ALK TKI agent. Results Among the total of 579 patients, 549 (95%) underwent a therapy sequence in line with current clinical practice with 204 (37%) patients receiving frontline chemotherapy. Single-line ALK TKI was given to 366 patients (crizotinib: 211; alectinib: 146; ceritinib: 9), whereas 128 patients received two different ALK TKI (frontline crizotinib: 100, alectinib: 24, ceritinib: 4); 40 patients received three lines and 15 patients four ALK TKI lines or more. With frontline chemotherapy, the mean (standard deviation) DOT was 1.07 (1.25) years for the entire TKI therapy sequence compared to 1.23 (1.28) years with frontline ALK TKI. The median (95% confidence interval) OS was 1.83 (1.48–2.13) years for the entire cohort, 1.44 (0.89–1.98) years for patients given frontline chemotherapy, and 2.02 (1.60–2.58) years for patients given frontline ALK TKI. Conclusion This study provides a unique overview of the patient population treated with ALK TKI in Sweden and reveals the treatment patterns applied in real clinical practice. More research is needed when longer follow-up data are available for later-generation ALK TKI, to fully understand ALK TKI sequencing and its effect on patient survival in a real-world setting.

Improved adherence to statins following pictorial intervention. Sub study of visualization of subclinical atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA)

Abstract Introduction VIPVIZA is a prospective, randomised controlled trial with open label and masked evaluators, integrated in Västerbotten intervention programme (VIP), a population-based CVD screening and prevention programme examining 40,50,60-year-olds. In VIPVIZA subclinical atherosclerosis was identified by ultrasound and pictorial information about carotid plaque presence, carotid thickness and risk assessment was provided to participants and their physicians. After examination, participants were randomized to pictorial information (intervention) or as usual care (control). Previous studies from VIPVIZA have shown that the time to initiation of statins is lower and the proportion of statin users is higher in the intervention group. Purpose To study whether the pictorial risk information intervention made participants with pre intervention prescription of statins more adherent to statin treatment. Method During 2013–2016, 3532 participants in VIPVIZA were screened by carotid ultrasound examination, of which 46% had plaque, 546 had expedited prescriptions of statins (ATC codes: C10AAxx, C10B, C10BA, C10BX) prior to inclusion. Participants were followed from inclusion until 3-year follow-up examination. Adherence calculations were based on Swedish prescription drug registry (PDR). For adherence calculations we assumed that medication is used as prescribed. Dose change of same medication is considered, and number of days' supply is recalculated if a dispensing event contains a change of dose. The new dose comes into effect the day of dispensing a prescription with a dose change. For the follow-up period the number of days with potential use (based on supply) is divided by days from baseline examination until 3-year examination, yielding a value in the interval [0,1] where 0 is non adherent and 1 perfect adherence. Remaining supply of medication at the end of follow-up period is disregarded. Adherence was also dichotomised at 0.8. Results The average adherence to statins was higher in the intervention group for participants with carotid plaque, 0.844 vs 0.773, confidence interval 95% for mean difference (−0.125, −0.018), p=0.009. The intervention group with carotid plaque had the best adherence of all subgroups, but the difference in adherence within the intervention group (plaque vs no plaque) was non-significant. With respect to sex the difference in mean adherence between intervention and control for males was 0.826–0.795 while for females 0.815–0.742. With dichotomised adherence the increase in the intervention group is significant for females, p=0.027. See table 1. Conclusion Providing information about subclinical atherosclerosis increases adherence to statins, especially in participants with plaque and females. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swedish Research Council

Long-term time trends in reactivated herpes simplex infections and treatment in Sweden

BackgroundOur aim was to describe the annual prevalence of herpes simplex virus (HSV) reactivation in relation to solar ultraviolet (UV) radiation and antiviral drug use in the Swedish adult population.MethodsThe study comprised 2879 anti-HSV-1 immunoglobulin (Ig) G positive subjects from five different cohorts who had donated serum from 1988 to 2010. The sera were analyzed for anti-HSV IgM using enzyme-linked immunosorbent assay. Associations between the presence of anti-HSV IgM antibodies, the apolipoprotein E ε4 allele and the serum sampling year were assessed by logistic regression. Seasonality of anti-HSV IgM was evaluated in a UV radiation model.Data of antiviral drugs for the entire Swedish population were compiled from two different nationwide databases: the Swedish Prescribed Drug Register and the Swedish Association of the Pharmaceutical Industry.ResultsCross-sectional and longitudinal analyses indicated that the prevalence of anti-HSV IgM antibodies declined between 1988 and 2010 (odds ratio [OR] = 0.912, p < .001), while the total annual use of antiviral drugs in Sweden gradually increased from 1984 to 2017. Higher UV radiation was associated with higher prevalence of anti-HSV IgM antibodies (OR = 1.071, p = .043).ConclusionThe declining time trend of HSV reactivation in a Swedish cohort coincides with a steady increase of antiviral drug use in the Swedish general population.

Police officers' attitudes and practices toward harm reduction services in Sweden - a qualitative study.

Since the 1980s, Swedish drug policy has combined a restrictive zero tolerance approach with the vision of a "drug-free society". However, in recent years, access to harm reduction services has increased through local initiatives and new national guidelines. The possible success of these services may be affected in part by police drug law enforcement. The aim of this study was to explore how Swedish police officers act toward and view harm reduction services in a national drug policy setting of zero tolerance toward drug use. Applying a qualitative research design, we conducted 19 in-depth interviews with police officers who worked with drug law enforcement in Malmö. We conducted a qualitative textual analysis of the data. Officers largely supported harm reduction services and refrained from overtly enforcing drug laws in their vicinity. Officers engaged in boundary work that assigned the responsibility of care of marginalized people who use drugs (PWUD) to the health care system, while including policing of drug market problems, young PWUD and dealers in their own jurisdiction. Opioid substitution treatment was seen as positive, although diversion of medicines was pointed out as a problem. Needle exchange programs were seen as offering important public health services and a no-go zone for the police. Several officers wanted to carry naloxone on duty but requested more information about its use. The general support among police officers for harm reduction services is an indication of a changing drug policy landscape in Sweden. Drug policy should take police officers' views into consideration and there is a need for collaboration between police and harm reduction services. Further research should focus on how the police conduct boundary work since police actions may impact on the success of harm reduction services.

Quantifying the Zero-Price Effect in the Field: Evidence from Swedish Prescription Drug Choices

We use Swedish data on consumer choices of therapeutically equivalent drugs to measure the zero-price effect. The Swedish benefit scheme for prescription drugs is a tier system, where each patient’s copay share is a step function of his/her qualified accumulated expenditure and can ultimately drop to zero. The copay tier a patient falls into is exogenously determined by his/her health and drug needs. In any given month, a patient pays the copay share of the lowest priced drug, plus the price difference between the chosen drug and the lowest priced drug in the same therapeutically equivalent exchange group. Therefore, when consumers cross the threshold of the zero-copay tier, the net price for the lowest priced drug will switch from a small positive amount to zero. This unique quasi-random environment allows us to apply the regression discontinuity design to quantify the zero-price effect. We do so for the full sample, as well as for two subsamples that should be less affected by state dependence. Based on a linear (quadratic) specification, the estimated zero-price effect reduces choice shares of the noncheapest alternatives by 12% (13%), 39% (48%), and 23% (25%) in the full sample, new diagnoses sample, and switchers sample, respectively.

Emerging Marketing Research on Healthcare and Medical Decision Making: Toward a Consumer-Centric and Pluralistic Methodological Perspective

Emerging Marketing Research on Healthcare and Medical Decision Making: Toward a Consumer-Centric and Pluralistic Methodological Perspective

Criminality among Young People With Substance Use Problems in Sweden: A One-Year Follow-Up Study

Swedish drug policy has a strong focus on minor drug violations. This longitudinal study analyses the association between criminality and substance use problems among young people who have received outpatient treatment and risk factors that predict continued problems with criminality. Research on this target group is under development in Sweden, but there are few follow-up studies. The study indicates that about one-quarters of the young people who begin outpatient treatment have been convicted of crimes at 1-year follow-up. Most of them who had been convicted with offences also have ongoing problems with substance use and three-quarters of the young people had been charged with a drug-related offence. More than five risk factors give an elevated risk of continued criminality. Interventions meeting the needs of young people, moving away from the current emphasis on penal law principles, may also contribute to reduced criminality in this target group.

Effects of ‘doctor shopping’ behaviour on prescription of addictive drugs in Sweden

Free choice of health care providers is aimed to improve the quality of health care by increasing both access to it and the competition between providers. However, it may also give patients possibilities for doctor shopping (DS) behaviour, i.e., visiting different providers to receive illicit drug prescriptions. Abuse of prescribed addictive drugs is a growing problem worldwide and is associated with increased mortality, lower quality of life and other problems on both the individual and societal level. We study DS behaviour for three categories of addictive drugs – opioid painkillers, benzodiazepine anxiolytics, and z-hypnotic sleeping drugs, in the outpatient care sector in Västerbotten County, Sweden. Our dataset contains all drug prescriptions purchased by the residents of Västerbotten in the period from January 2014 to April 2016 (approximately 160,000 observations). To identify signs of addictive prescription drugs abuse by DS, we analyse overlapping prescriptions. We use ‘Defined Daily Doses' (DDDs), which is the average treatment dose of a specific drug per day for adults, as a proxy for the treatment duration. To control for medically legitimate overlaps, we compare overlapping prescriptions within a clinic with overlapping prescriptions between different clinics. Our empirical results suggest that there is a significant and positive relationship between the number of overlapping doses and the number of unique providers in the overlap. More specifically, we find that visiting different providers on average gives patients up to three additional DDDs per day. This is three times higher than the standard treatment dose. We discuss policy implications in the concluding discussion.

Many oxycodone-related deaths linked to pharmacodynamically-interacting drugs in Sweden

Many oxycodone-related deaths linked to pharmacodynamically-interacting drugs in Sweden

Antiepileptic medicines in men and women with stroke in Sweden, a registry-based study.

Background and aimTo describe the utilization of the first antiepileptic drug (AED) in men and women with previous stroke in a nationwide population.MethodsPrescription data, patient's age, and sex were collected from the Swedish Drug Register and cross‐linked to diagnosis data from the National Patient Register and data from Statistics Sweden. Patients with a first dispensation of an AED after stroke between 1 January 2007 and 31 December 2014 were included.ResultsA total of 10 958 patients with stroke were initiated on AED treatment (51% women, mean age 75 years). Gabapentin (n = 3073, 28%), pregabalin (n = 2476, 22%), carbamazepine (n = 2330, 21%), levetiracetam (n = 1158, 10%), and valproic acid (n = 833, 7%) were the most dispensed AEDs. After stratification by the presence of a neuropathic pain diagnosis, gabapentin, and pregabalin were the most used AEDs. In contrast, after stratification for epilepsy/convulsions diagnosis, carbamazepine and levetiracetam were the most initiated AEDs.ConclusionThis study suggests that AED is mainly used for neuropathic/poststroke pain and the study shows gabapentin and pregabalin to be the most used AEDs. For epilepsy, carbamazepine and levetiracetam were the most used AEDs in patients with previous stroke.