Violence and diversion of prescribed opioids among individuals in opioid maintenance treatment. A complementary methods study of violent crime convictions in a national cohort and qualitative interviews among prisoners

Abstract

Background: Opioid dependence is linked to crime, morbidity and mortality, directly through drug overdoses and indirectly via drug-related mortality, accidents, suicides and violence. Violence in general is a major health concern worldwide. Opioid maintenance treatment, OMT, is found to reduce mortality, morbidity and criminal behaviour, but less is known about the effect of OMT on violent crime. A possible negative consequence of OMT is diversion of methadone and buprenorphine and rising overdose deaths related to these medications among individuals not enrolled in OMT. The aim of this thesis is to study violent crimes prior to, during and after OMT in a national cohort and to generate new knowledge about OMT-enrolled individuals’ experiences and understandings of being both violent and non-violent offenders, the role of substances in such crimes as well as their understandings and motivations related to diversion of prescribed opioids. Materials and methods: Two complementary data collection methods have been used. Violent convictions were investigated by use of cross-registry methods for a complete longitudinal national OMTcohort of 3221 individuals with an observation period of 9 years and a qualitative study among 12 imprisoned, OMT-enrolled individuals. 28 semi-structured interviews were thematically analyzed with a reflexive and interactive approach. Findings: Violent crime rates were significantly reduced during OMT compared with before treatment. The rate of convictions for violent crime during OMT was halved among those who remained in treatment. The reduction was less pronounced for those who left treatment: for this group, the rate of violent convictions after OMT was higher than before treatment. The risk of convictions for violent and non-violent crime during OMT was highest for those with violent convictions prior to treatment. In the qualitative part of the study, it was found that substances and, in particular, high-dose benzodiazepines were deliberately used to induce temporary ‘antisocial selves’ capable of transgressing individual moral codes and performing non-violent and violent criminal acts, mainly to support costly heroin use prior to OMT. During OMT, impulsive and uncontrolled substance use just prior to the violent acts that the participants were imprisoned for was reported. Benzodiazepines were also used to reduce memories of and alleviate the guilt associated with having committed violent crimes. The study participants maintain moral standards, engage in complex moral negotiations, and struggle to reconcile their moral transgressions. They were found to exhibit a considerable amount of self-control, selfregulation and/or self-initiation of external control related to intake of methadone and buprenorphine in various settings. Their acquired norm of sharing with others in a drug using community was carried along when entering OMT. Several had developed strategies to avoid selling or giving of methadone or buprenorphine to others. Giving one’s opioid prescriptions to an individual in withdrawal, was seen as an act of helping. Individuals enrolled in OMT might thus be trapped between practicing norms of helping and sharing and adhering to treatment regulations. Conclusions: Opioid dependent individuals with violent convictions should have access to OMT. Treatment providers should identify individuals with histories of violent behavior. The situation that precede and motivate violent behavior and the potential role of substances prior to and after such crimes should be explored with the patient in question. What appears as a severe antisocial personality disorder may be partly explained by substance use. Treatment providers should explore the living conditions and social lives of individuals applying for and enrolled in OMT. To following OMT guidelines may entail breaking a personal and drug culture norm of sharing and helping by means of providing OMT medications to those in need. Opioid-dependent couples should be encouraged to apply for and enroll in OMT at the same time, if both are motivated for starting treatment. Some individuals might know what particular configurations of internal and external control they need in order to achieve their own treatment goals in OMT. An individual’s experience and ability to execute self-control and self-regulation with regard to drug taking may be seen as a resource throughout the course of treatment.