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- Monwell, Bodil
(författare)
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En dyster parentes – opiatregeln i svensk LARO-behandling 2010–2016
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Opioids are well documented to arouse euphoria, relieve pain, and to have a high dependency potential. Opioid dependence is a serious chronic condition with a high risk of extensive worsened health, relapse and premature death.Opioid maintenance treatment (OMT) is well researched and has strong scientific support. In Sweden, OMT over time was subjected to polarised and infected political debate and has been strictly regulated by the National Board of Health and Welfare (NBHW). During 2010–2016 NBHW redefined the diagnostic concept of “opiate dependence” in the regulation SOSFS 2009:27. Dependence to only three opioids: heroin, opium or morphine, could give eligibility to OMT (here called the “opiate rule”). The purpose stated was to prevent those dependent to other opioides, e.g. buprenorphine,from receiving OMT. Applicants with severe opioid dependence were thereby divided into two subgroups: those with “opiate” dependence related to heroin, morphine or opium, and those with opioid dependence who lacked documentation in relation to the three opiates. The question is whether there were differences between these groups concerning problem severity or substance-related diagnostics that could justify differences in access to OMT?A population (n = 127) actualised for OMT during 2005-2011 in Jönköping County is studied regarding severity of problems, diagnostics and trajectories in and out of treatment. In order to provide precise drug use data, a cognitive tool for taking anamnestic information, called the Drug List, was developed.In Study I, using the Addiction Severity Index, the two groups were found to be quite similar in severity of health problems, social situation and drug problems, including overdoses and injections.In Study II, the Drug List was found to be superior to a traditional way of taking anamnestic data, more sensitive and giving more precise data, without taking more time. Validity was shown in relation to faked drugs.In Study III, using a structured diagnostic interview, ADDIS, with the Drug List, showed that both two groups qualified for severe opioid dependence, that opiates and other opioids had contributed equally to the development of opioid dependency, and that the two groups also had similar additional substance dependence problems.Study IV investigated how “the opiate rule” affected practice by interviewing representatives of OMT clinics as well as a representative of a users’ association. The regulation created dilemmas for clinics as well as for users. Users developed a strategy of getting "negative merits" for being eligible to OMT. Clinicians developed strategies to find ways “around” the regulation in order to admit patients in OMT.Study V followed those who had applied for OMT and found four trajectory subgroups – those denied OMT, those discharged, those readmitted, and those who remained in treatment. The study provides evidence for a more positive development being related to more involvment in OMT concerning health, social situation as well as substance use problems. Being denied or discharged is related to increased risks of a negative development.The thesis conclude that there was no support for dividing applicants according to “the opiate rule”. The purpose of top-down control using regulations, is to guarantee uniform and knowledge-based care. In this case the regulation had negative effects in these respects, increasing risks for the applicants, and lost credibility from the profession. The opiate rule in SOSFS 2009:27 is therefore a dismal parenthesis in the history of OMT in Sweden, and could be studied to prevent similar mistakes in the future.
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| 2. |
- Svensson, Leif, 1981-
(författare)
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A Theology for the Bildungsbürgertum : Ritschl in Context
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The subject of this historical-theological investigation is the German Lutheran theologian Albrecht Ritschl (1822-1889). Ritschl’s theology is understood in the context of the de-Christianization of the German Bildungsbürgertum (educated middle class). It is demonstrated that an ambition to counteract this tendency runs all through Ritschl’s theological thinking. More specifically, the study argues that Ritschl’s theology can be seen as a response to three intellectual challenges to Christianity in general and Lutheranism in particular – historical criticism, materialism, and anti-Lutheran polemics.Part I concentrates on historical criticism and Ritschl’s interpretation of history. Chapter 1, which presents Leopold von Ranke’s historicist-oriented historical school at the University of Berlin and Ferdinand Christian Baur’s theological Tübingen school, provides the wider setting of Ritschl’s historical analysis. It is argued, in chapter 2, that those schools had a significant impact – albeit in different ways – on Ritschl’s understanding of history. The contribution of Ritschl to the so-called first quest for the historical Jesus is analyzed in chapter 3, which also points out that Johannes Weiss’ and Albert Schweitzer’s apocalyptic critique of the first quest undermined the historical foundation of Ritschl’s theology.In part II, the focus is on materialism and the metaphysical framework of Ritschl’s theology. Chapter 4 discusses anthropological materialism, scientific materialism, and late idealism – three intellectual movements of relevance to Ritschl’s metaphysics. In chapter 5, Ritschl’s metaphysical framework is described as an attempt to safeguard the spiritual dimension of existence against the threat of materialism. This chapter also argues that Ritschl’s metaphysics is indebted to Hermann Lotze’s late idealist philosophy. Chapter 6 highlights the relationship between Ritschl’s metaphysics and his protest against “classical metaphysical theology,” and examines how Ritschl’s metaphysical framework leads him to reject natural theology and the classical Christological and trinitarian dogmas.Part III discusses Ritschl’s theological ethics or understanding of Christian life in the context of the values of the Bildungsbürgertum and against the background of anti-Lutheran polemics. In chapter 7, an overview of the ethos of the educated middle class is provided. The subject of chapter 8 is Ritschl’s defense of Luther’s cultural importance against Paul de Lagarde’s criticism of the Lutheran Reformation. Chapter 9 carries out an analysis of Ritschl’s thinking on Christian life and its modern sources, especially noting the influences of Immanuel Kant and Friedrich Schleiermacher, and exploring the similarities between Ritschl’s ethics and the values of the educated middle class.In the Conclusion, the findings of the investigation are summarized in the claim that Ritschl’s responses to historical criticism, materialism, and anti-Lutheran polemics demonstrate that his theology in many respects was a theology for the Bildungsbürgertum. The concluding chapter also reflects on the implications of the present study for the common characterization of Ritschl as a Kulturprotestant (mediator between the Protestant Reformation and modern culture), problematizes Ritschl’s interpretation of the historical Jesus, and argues that Ritschl’s theological project was essentially abandoned by his most famous students.
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| 3. |
- Irewall, Anna-Lotta, 1987-
(författare)
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Recurrent events and secondary prevention after acute cerebrovascular disease
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background Patients who experience a stroke or transient ischemic attack (TIA) are at high risk of recurrent stroke, but little is known about temporal trends in unselected populations. Reports of low adherence to recommended treatments indicate a need for enhanced secondary preventive follow-up to achieve the full potential of evidence-based treatments. In addition, socioeconomic factors have been associated with poor health outcomes in a variety of contexts. Therefore, it is important to assess the implementation and results of secondary prevention in different socioeconomic groups.Aims The aims of this thesis were to assess temporal trends in ischemic stroke recurrence and evaluate the implementation and results of a nurse-led, telephone-based follow-up program to improve blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) levels after stroke/TIA.Methods In study I, we collected baseline data for unique patients with an ischemic stroke event between 1998 and 2009 (n=196 765) from the Swedish Stroke Register (Riksstroke). Recurrent ischemic stroke events within 1 year were collected from the Swedish National Inpatient Register (IPR) and the cumulative incidence was compared between four time periods using the Kaplan-Meier survival analysis and the logrank test. Implementation (study II) and 1-year results (study III-IV) for the secondary preventive follow-up were studied in the NAILED (Nurse-based Age-independent Intervention to Limit Evolution of Disease) study. Between 1 Jan 2010 and 31 Dec 2013, the baseline characteristics of consecutive patients admitted to Östersund Hospital for acute stroke or TIA were collected prospectively (n=1776). Consenting patients in a condition permitting telephone-based follow-up were randomized to nurse-led, telephone-based follow-up or follow-up according to usual care. Follow-up was cunducted at 1 and 12 months after discharge and the intervention included BP and LDL-C measurements, titration of medication, and lifestyle counseling. In study II, we analyzed factors associated with non-participation in the randomized phase of the NAILED study, including association with education level. In addition, we compared the 1-year prognosis in terms of cumulative survival between participants and non-participants. In study III, we compared differences in BP and LDL-C levels between the intervention and control groups during the first year of follow-up and, in study IV, in relation to level of education (low, ≤10 years; high, >10 years).Results The cumulative 1-year incidence of recurrent ischemic stroke decreased from 15.0% to 12.0%. Among surviving stroke and TIA patients, 53.1% were included for randomization, 35.7% were excluded mainly due to physical or cognitive disability, and 11.2% declined participation in the randomized phase. A low level of education was independently associated with exclusion, as well as the patient’s decision to abstain from randomization. Excluded patients had a more than 12-times higher risk of death within 1 year than patients who were randomized. After 1 year of follow-up, the mean systolic BP, diastolic BP, and LDL-C levels were 3.3 mmHg (95% CI 0.3 to 6.3), 2.3 mmHg (95% CI 0.5 to 4.2), and 0.3 mmol/L (95% CI 0.1 to 0.4) lower in the intervention group than among controls. Among participants with values above the treatment goal at baseline, the differences in systolic BP and LDL-C levels were more pronounced (8.0 mmHg, 95% CI 4.0 to 12.1; 0.6 mmol/L, 95% CI 0.4 to 0.9). In the intervention group, participants with a low level of education achieved similar or larger improvements in BP and LDL-C than participants with a high level of education. In the control group, BP remained unaltered and the LDL-C levels increased among participants with a low level of education.Conclusion The 1-year risk of ischemic stroke recurrence decreased in Sweden between 1998 and 2010. Nurse-led, telephone-based secondary preventive follow-up is feasible in just over half of the survivors of acute stroke and TIA and achieve better than usual care in terms of BP and LDL-C levels, and equality in BP improvements across groups defined by education level. However, a large proportion of stroke survivors are in a general condition precluding this form of follow-up, and their prognosis in terms of 1-year survival is poor. Patients with a low education level are over-represented within this group and among patients declining randomization for secondary preventive follow-up.
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