Thomas Clausen

• Bukten, Anne; Mehlum, Lars; Fazel, Seena; Lokdam, Nicoline Toresen; Tverborgvik, Torill & Skurtveit, Svetlana Ondrasova [Show all 12 contributors for this article] (2026). Sociodemographic, Criminological and Clinical Determinants in Suicide After Release From Prison: A 23‐Year National Cohort Study. Acta Psychiatrica Scandinavica. ISSN 0001-690X. doi: 10.1111/acps.70148. Full text in Research Archive Show summary

  ABSTRACT Background Suicide risk is elevated after prison release, but population‐level evidence on temporal risk patterns and associated factors remains limited. We aimed to describe characteristics of individuals who die by suicide after release from Norwegian prisons, compare their suicide mortality with the general population, and examine risk factors over time. Material and Methods Data from the Norwegian Prison Release Study (nPRIS), including all people in prison in Norway (2000–2022), were linked to the Norwegian Cause of Death Registry, the Norwegian Prison Registry, the Norwegian Patient Registry, and Statistics Norway. We calculated crude mortality rates (CMR) per 100,000 person‐years, standardized mortality ratios (SMR), annual age‐standardized years of life lost rate (ASYR), and Cox proportional hazards models. Results From 2000 to 2022, 1183 suicides (9.1% of all deaths; CMR 81; 95% CI 76–85) occurred after release (90% male). The SMR was higher in women (SMR 8.64; 95% CI 7.17–10.34) than men (SMR 3.98; 95% CI 3.76–4.22). In multivariable models (2009–2022; n  = 57,034; 516 suicides), strong independent associations with suicide 6 months post‐release included self‐harm (adjusted HR [aHR] 4.76; 95% CI 2.60–8.72), severe mental illness (aHR 1.95; 95% CI 1.16–3.27), release from high‐security prisons (aHR 1.93; 95% CI 1.12–3.33), and pretrial detention (aHR 1.82; 95% CI 1.06–3.13). Conclusions Suicide risk is substantially and persistently elevated relative to the general population, peaks immediately after release, and is concentrated among people with prior self‐harm, severe mental illness, and those released from high‐security settings.

• Bodal, Elen; Olsen, Nora Marie Temte; Olsen, Thomas; Edvardsen, Hilde Marie Erøy; Clausen, Thomas & Skurtveit, Svetlana Ondrasova [Show all 8 contributors for this article] (2026). Medical and non-medical gabapentinoid use in fatal drug poisonings in Norway: Linked postmortem toxicology and prescription data. Forensic Science International. ISSN 0379-0738. 389, p. 1–8. doi: 10.1016/j.forsciint.2026.113143. Full text in Research Archive
• Jobling, Nina; Mjåland, Kristian; Clausen, Thomas; Heldal, Anne Taraldsen; Thylstrup, Birgitte & Vederhus, John-Kåre (2026). Medication transitions and predictors of illicit substance use during opioid agonist treatment: a three-year follow-up study. Addiction science & clinical practice. ISSN 1940-0632. 21. doi: 10.1186/s13722-026-00711-0. Full text in Research Archive Show summary

  Background For opioid use disorder (OUD), pharmacological therapy using methadone or buprenorphine, plus psychosocial support, is the most effective opioid agonist treatment (OAT). Long-acting injectable buprenorphine (LAIB) is the newest buprenorphine formulation. This study evaluated LAIB within a naturalistic clinical setting, compared with standard OAT (sublingual buprenorphine and methadone). Methods This observational study included patients from an OAT outpatient clinic in Agder County, Norway. Data were extracted from hospital medical records in May 2022. The cohort was followed up in February 2025. Medication-group transitions and outcomes were assessed by examining switching, discontinuation, mortality, and illicit substance use over three years. Results The study included 424 patients. The LAIB group was significantly younger than the standard OAT groups. During the study period, 13.2% of patients switched medications, increasing the LAIB group from 17% to 22%. Comparable proportions of patients experienced negative outcomes: 10% discontinued treatment, and 4% died. At follow‑up, illicit substance-use problems were less frequent in the sublingual buprenorphine group than the other groups, a finding that appears to have been influenced by differential attrition. Baseline substance use was the strongest predictor of illicit substance use at follow‑up. Conclusions The LAIB group slightly increased during the study period. Transitions between medication groups appeared to yield better substance-use outcomes at follow-up in the sublingual buprenorphine group, compared to in other groups. Baseline substance use was the strongest predictor of illicit use at follow‑up, suggesting that individual clinical characteristics may contribute more to outcomes than the specific medication pathway.

• Grimsland, Frida; Gabrielsen, Karin Berle; Clausen, Thomas; Haugland, Siri Håvås & Vederhus, John-Kåre (2026). Child maltreatment and substance use: associations with alcohol use, nicotine use, and quality of life in a Norwegian population sample. Frontiers in Public Health. 14. doi: 10.3389/fpubh.2026.1821179. Full text in Research Archive Show summary

  Background Child maltreatment (CM) is a significant public health concern with long-term consequences for the child, including an increased likelihood of engaging in risky health behaviors, such as substance use, as well as impaired quality of life (QoL). The relationship between CM and specific substance use patterns, particularly the use of nicotine products such as Swedish snus, remains understudied. We investigated the relationship between CM and the use of nicotine and alcohol, as well as whether use of these substances mediates the association between CM and adulthood QoL. Methods This study utilized data from the Norwegian Counties Public Health Survey for Agder in 2023. Latent regression analysis was employed to examine the association between CM and QoL, as well as potential mediated associations involving substance use, while controlling for sociodemographic factors. Results Nicotine use in the past year was significantly more prevalent among individuals with a history of CM compared to the group with no history of CM (35.8% vs. 25.6%, p < 0.001). Both smoking (24.3% vs. 15.6%, p < 0.001) and snus use (17.6% vs. 13.3%, p < 0.001) were more common in the CM group, with differences remaining significant after adjustment for sociodemographic factors. No significant differences were found in alcohol use across various measures, including frequency of use, AUDIT-C scores, and binge drinking. Latent regression analysis showed that CM had an overall negative association with QoL [β = −0.61; 95% confidence interval (CI) −0.71, −0.51; p < 0.001]. A significant mediated association involving nicotine use was also observed (β = −0.12; 95% CI −0.16, −0.07; p < 0.001). Conclusion CM is associated with a higher prevalence of smoking and snus use, which are negatively associated with QoL. The findings suggest that targeted efforts to support QoL among individuals with a history of CM, including attention to nicotine use, may be relevant within broader strategies addressing living conditions and psychological wellbeing.

• Hagene, Helene Storbråten; Clausen, Thomas & Gjersing, Linn (2026). High-risk injecting practices among people who inject drugs in Norway: Prevalence, characteristics and associated factors. Journal of Substance Use and Addiction Treatment. ISSN 2949-8767. 189, p. 1–7. doi: 10.1016/j.josat.2026.209999. Full text in Research Archive
• Skeie, Ivar; Bech, Anne Berit; Clausen, Thomas; Hjemsæter, Arne Jan; Landheim, Anne Signe & Monsbakken, Bent Berntsen [Show all 8 contributors for this article] (2026). Comparison of mortality and causes of death between treatment-engaged individuals with severe alcohol or opioid use disorder: a prospective 19-year clinical cohort study. BMC Psychiatry. 26(1), p. 1–11. doi: 10.1186/s12888-026-07832-5. Full text in Research Archive Show summary

  BACKGROUND: Comparisons of long-term mortality between alcohol-use-disorder (AUD) and opioid-use-disorder (OUD) groups within clinical cohorts are scarce. This study aimed to do this within one clinical cohort comprising groups suffering various severe substance use disorders. METHODS: Design: Observational cohort design. Prospective study of mortality 1998–2016, Cox regression. Sample/setting: 464 persons in specialist SUD treatment at start of observation period. Three subgroups defined by SUD characteristics at the beginning of the observation period, were studied: participants with 1) OUD, on opioid agonist treatment (OAT), (OUD/OAT-group), 2) AUD, no other SUDs (AUD-alone group), 3) AUD as part of a poly-substance-use disorder (AUD/PSUD group). Measures/covariates: Comparison of mortality risks and causes of death (somatic diseases/traumatic causes/substance-induced deaths/unknown cause) between OUD/OAT versus AUD-alone, and AUD-alone versus AUD/PSUD groups. Hazard ratio (HR) adjusted for baseline age (1 January 1998), sex, and socioeconomic/SUD characteristics. RESULTS: AUD-alone versus OUD/OAT: Unadjusted mortality risk was higher in the AUD-alone group [HR 1.99 (95% CI 1.33–2.99)]. However, in adjusted analysis type of SUD showed no statistically significant association with increased mortality [aHR 0.91 (0.54–1.54)], only male sex and increasing baseline age were independently associated with increased mortality risk. Cause-of-death distributions were very similar and somatic diseases caused over 50% of deaths in both groups. AUD-alone versus AUD/PSUD: Unadjusted mortality risk was higher in the AUD-alone group [(HR 2.57 (1.65–4.00)]. However, in adjusted analysis type of SUD showed no statistically significant association with increased mortality [aHR 1.40 (0.81–2.44)], only male sex, increasing baseline age, and “not being in work or education at study inclusion” were independently associated with increased mortality risk. Substance-induced deaths were most common in the AUD/PSUD group (43%). CONCLUSION: In adjusted analyses there were no statistically significant differences in mortality risk between the three subgroups. Somatic diseases were the main cause of death. Besides efforts to improve social rehabilitation and to treat the substance use disorders as such, early and targeted lifestyle interventions, and measures for early detection, treatment and follow-up of somatic disorders are essential to reduce mortality in both AUD and OUD populations. CLINICAL TRIAL NUMBER: Not applicable

• Gjersing, Linn; Edvardsen, Hilde Marie Erøy & Clausen, Thomas (2025). Overdoseforebyggende politikk. In Gjersing, Linn; Clausen, Thomas & Edvardsen, Hilde Marie Erøy (Ed.), Overdoseboka. En helhetlig gjennomgang. Cappelen Damm Akademisk. ISSN 9788202852610. p. 92–100. Full text in Research Archive Show summary

  Boken omhandler et bredt spekter av temaer knyttet til overdoseproblematikk. Den går i dybden på rusmidlers virkning, risikofaktorer og relaterte helseutfordringer. Politikkens og myndighetenes rolle i forebygging og behandling presenteres. Boken utforsker også skadereduksjon og oppfølging i tjenesteapparatet, og gir et innblikk i brukeres, pårørendes og helsepersonells opplevelser og erfaringer. Videre belyses politiets arbeid, obduksjoner og registrering av dødsfall. Målet er at boken kan bidra til en mer helhetlig forståelse, og dermed bedre tjenester og en reduksjon av overdoser.

• Gjersing, Linn; Edvardsen, Hilde Marie Erøy & Clausen, Thomas (2025). Overdose og psykisk helse. In Gjersing, Linn; Clausen, Thomas & Edvardsen, Hilde Marie Erøy (Ed.), Overdoseboka. En helhetlig gjennomgang. Cappelen Damm Akademisk. ISSN 9788202852610. p. 65–69. Full text in Research Archive Show summary

  Boken omhandler et bredt spekter av temaer knyttet til overdoseproblematikk. Den går i dybden på rusmidlers virkning, risikofaktorer og relaterte helseutfordringer. Politikkens og myndighetenes rolle i forebygging og behandling presenteres. Boken utforsker også skadereduksjon og oppfølging i tjenesteapparatet, og gir et innblikk i brukeres, pårørendes og helsepersonells opplevelser og erfaringer. Videre belyses politiets arbeid, obduksjoner og registrering av dødsfall. Målet er at boken kan bidra til en mer helhetlig forståelse, og dermed bedre tjenester og en reduksjon av overdoser.

• Gjersing, Linn; Edvardsen, Hilde Marie Erøy & Clausen, Thomas (2025). Forekomst. In Gjersing, Linn; Clausen, Thomas & Edvardsen, Hilde Marie Erøy (Ed.), Overdoseboka. En helhetlig gjennomgang. Cappelen Damm Akademisk. ISSN 9788202852610. p. 47–53. Full text in Research Archive Show summary

  Boken omhandler et bredt spekter av temaer knyttet til overdoseproblematikk. Den går i dybden på rusmidlers virkning, risikofaktorer og relaterte helseutfordringer. Politikkens og myndighetenes rolle i forebygging og behandling presenteres. Boken utforsker også skadereduksjon og oppfølging i tjenesteapparatet, og gir et innblikk i brukeres, pårørendes og helsepersonells opplevelser og erfaringer. Videre belyses politiets arbeid, obduksjoner og registrering av dødsfall. Målet er at boken kan bidra til en mer helhetlig forståelse, og dermed bedre tjenester og en reduksjon av overdoser.

• Gjersing, Linn; Clausen, Thomas & Edvardsen, Hilde Marie Erøy (2025). Risikofaktorer og kjennetegn. In Gjersing, Linn; Clausen, Thomas & Edvardsen, Hilde Marie Erøy (Ed.), Overdoseboka. En helhetlig gjennomgang. Cappelen Damm Akademisk. ISSN 9788202852610. p. 56–62. Full text in Research Archive Show summary

  Boken omhandler et bredt spekter av temaer knyttet til overdoseproblematikk. Den går i dybden på rusmidlers virkning, risikofaktorer og relaterte helseutfordringer. Politikkens og myndighetenes rolle i forebygging og behandling presenteres. Boken utforsker også skadereduksjon og oppfølging i tjenesteapparatet, og gir et innblikk i brukeres, pårørendes og helsepersonells opplevelser og erfaringer. Videre belyses politiets arbeid, obduksjoner og registrering av dødsfall. Målet er at boken kan bidra til en mer helhetlig forståelse, og dermed bedre tjenester og en reduksjon av overdoser.

• Gjersing, Linn; Edvardsen, Hilde Marie Erøy & Clausen, Thomas (2025). Hva er en overdose? In Gjersing, Linn; Clausen, Thomas & Edvardsen, Hilde Marie Erøy (Ed.), Overdoseboka. En helhetlig gjennomgang. Cappelen Damm Akademisk. ISSN 9788202852610. p. 18–22. Full text in Research Archive Show summary

  Boken omhandler et bredt spekter av temaer knyttet til overdoseproblematikk. Den går i dybden på rusmidlers virkning, risikofaktorer og relaterte helseutfordringer. Politikkens og myndighetenes rolle i forebygging og behandling presenteres. Boken utforsker også skadereduksjon og oppfølging i tjenesteapparatet, og gir et innblikk i brukeres, pårørendes og helsepersonells opplevelser og erfaringer. Videre belyses politiets arbeid, obduksjoner og registrering av dødsfall. Målet er at boken kan bidra til en mer helhetlig forståelse, og dermed bedre tjenester og en reduksjon av overdoser.

• Skurtveit, Svetlana Ondrasova; McDonald, Rebecca Silvia; Handal, Marte; Hamina, Aleksi; Clausen, Thomas & Odsbu, Ingvild (2025). A comparison between individuals who died of intentional versus accidental overdoses. Suicidologi. ISSN 1501-6994. 30(2), p. 4–19. doi: 10.5617/suicidologi.12703. Full text in Research Archive Show summary

  The aim of the study was to describe differences between deaths from intentional versus accidental overdoses in Norway. This data linkage study comprised six nationwide health- and population registers. During the study period from 2011 to 2019, a total of 1,818 deaths from accidental and 363 deaths from intentional overdoses were registered. Pharmaceutically available opioids were more often found in post-mortem blood samples among intentional overdose deaths compared to accidental overdoses (73.0% vs 36.0%). Decedents in the intentional overdose group were on average eight years older, more frequently women with higher education and previous suicide attempts compared to accidental overdoses. Intentional overdose deaths more frequently had a lifetime history of chronic pain, cancer, as well as depression in the year prior to death. In the 30-day period prior to their death, a larger proportion of individuals in the intentional overdose group were dispensed opioids (43.0 % vs 21.4 %) and/or enzodiazepines (51.5 % vs. 38.7 %) compared to accidental overdoses. Intentional overdose deaths typically involve prescribed medicines and are more common among older, more often female individuals with a history of somatic disorders. This knowledge needs to be integrated into new and targeted prevention interventions.

• Melis, Francesca; Castel, Charlotte Jocelyne Yvonne; Eide, Desiree & Clausen, Thomas (2025). Health-related quality of life trajectories of patients in heroin-assisted treatment. Drug and Alcohol Dependence. ISSN 0376-8716. 275. doi: 10.1016/j.drugalcdep.2025.112839. Full text in Research Archive Show summary

  Background This study investigates health-related quality of life (HRQoL) in individuals with opioid use disorder enrolled in heroin-assisted treatment (HAT). While HRQoL in opioid maintenance treatment has been studied, less is known while in HAT. This study aim is to describe HRQoL in HAT, identify different HRQoL trajectories, and examine factors associated with class memberships. Methods This longitudinal cohort study is based on the multi-center Norwegian HAT project. The sample includes all consenting individuals enrolled in treatment from January 2022 to October 2024 (n = 108). HRQoL was assessed using the EuroQol EQ-5D-5L, and demographics were collected at baseline and multiple time points. Latent class linear mixed models were employed to identify HRQoL trajectory classes and explore differences in class memberships. Results At admission, participants demonstrated significant HRQoL difficulties across all dimensions, with severity levels higher than those of the general Norwegian population, particularly in Pain/Discomfort and Anxiety/Depression. Latent class analysis identified three distinct groups: the largest group (82 %) had a stable HRQoL trajectory, while smaller groups (8 % and 10 %) showed decline and improvement, respectively. Social support, clinic location, parental origin and at least one chronic symptoms were significant predictors of class membership. Conclusion The diverse, lower HRQoL profiles emphasize the need for personalized healthcare and support, making the HAT setting potentially valuable for such tailored care. Treatment participation helps most maintain fairly high HRQoL. The findings confirm the critical role of supportive relationships and effective chronic condition management in HRQoL outcomes.

• Finstad, Jeanette; Clausen, Thomas; Røise, Olav; Rosseland, Leiv Arne & Havnes, Ingrid Amalia (2025). Challenges in pain management and opioid prescribing practices following traumatic injury: a focus group study with orthopedic surgeons and general practitioners. Scandinavian Journal of Primary Health Care. ISSN 0281-3432. 43(4), p. 864–879. doi: 10.1080/02813432.2025.2517769. Full text in Research Archive
• Myklebust, Lars Henrik; Eide, Desiree; Wüsthoff, Linda Elise Couessurel; Melis, Francesca; Oldervoll, Ann & Pirro, Silvana De [Show all 7 contributors for this article] (2025). Changes in self-reported mental health, anxiety and depression among patients in heroin-assisted treatment: Findings from a Norwegian trial project. European Addiction Research. ISSN 1022-6877. 31, p. 286–296. doi: 10.1159/000547375. Full text in Research Archive Show summary

  Introduction: Norway’s heroin-assisted treatment (HAT) project started in 2022, aimed at targeting individuals with severe opioid use disorder (OUD) who did not benefit from first-line, conventional opioid agonist treatment. The use of pharmaceutical diacetylmorphine in HAT may particularly benefit patients with comorbid psychiatric disorders due to its structured nature, which includes daily contact with outpatient clinics. However, previous findings on mental health outcomes in HAT have been inconclusive. The main aim of this study was to explore changes in patients’ self-rated mental health and anxiety and depression over the first 12 months of HAT in Norway. Methods: We used data from 2 questions about patients’ self-rated mental health and anxiety and depression collected from 79 patients at the start of treatment (baseline) and at 3, 6, and 12 months into treatment. Ordinal logistic regression models were used to examine the changes in the responses over the observational period and to explore the potential effects of predictors such as gender and age, self-reported substance use, and clinic site. Results: We found a gradual improvement in self-rated mental health from baseline over the observational period, with a statistically significant shift in response distribution at the 12-month mark (p = 0.017). The distribution of responses indicating “good” mental health increased with a 35% improvement at 12 months, with a corresponding decline of 48% in “bad” mental health. For self-rated anxiety and depression, we found no change in severity of self-rated symptoms. A decline of 48% in the proportion of responses reporting severe symptoms at 12 months was aligned with a simultaneous increase of 17% reporting moderate symptoms. Age and previous suicide attempts were significant predictors of both outcomes; gender influenced anxiety and depression only, whereas clinic site influenced only mental health ratings. Conclusion: HAT appears to gradually improve patients’ self-rated mental health over time, possibly by enhancing overall psychological well-being. Self-rated symptoms of anxiety and depression may not be affected by this treatment, indicating that psychiatric conditions can persist in HAT for those struggling with them. This highlights the importance of specific psychiatric assessments and targeted interventions for at least a subset of patients, underscoring the need for integrated treatment approaches within HAT programs that address both substance use and co-occurring psychiatric disorders.

• Nesse, Linda & Clausen, Thomas (2025). Treatment satisfaction among patients in opioid agonist treatment in Norway: A multicenter cohort study. Nordic Studies on Alcohol and Drugs (NAD). ISSN 1455-0725. 42(4), p. 353–364. doi: 10.1177/14550725251351711. Full text in Research Archive Show summary

  Background: Treatment satisfaction is an important indicator of patients’ perceptions of opioid agonist treatment (OAT) for opioid dependence. In addition, treatment satisfaction may have implications for treatment outcomes. The present study aimed to explore treatment satisfaction among OAT patients one year after enrollment, as well as the role of different psychosocial and treatment characteristics in treatment satisfaction. Methods: The study was based on data from the NorComt project (2012–2016), which used a multicenter cohort design with structured questionnaire-based interviews. The sample consisted of 175 OAT patients in Norway who rated their treatment satisfaction (high, mixed, low) one year after enrollment in a new treatment episode in OAT. Treatment satisfaction (high versus mixed or low) was used as a dependent variable in logistic regression models, with demographic characteristics, well-being, substance use, and treatment characteristics as independent variables. Results: Overall, 54.9% of the participants reported high satisfaction with OAT one year after enrollment, while 25.7% reported mixed satisfaction and 19.4% low satisfaction. Of the 175 participants who reported on treatment satisfaction, 161 remained in treatment at follow-up. Reporting an active occupational status and an individual treatment plan in OAT was associated with increased odds for reporting treatment satisfaction, while reporting ongoing substance use was associated with decreased odds for reporting treatment satisfaction. Conclusions: Psychosocial, situational factors, as well as coordinated, integrated support, may play a role in OAT patients’ treatment satisfaction. To identify facilitators and barriers in OAT, it is vital to address relevant needs and goals for treatment from the perspectives of patients.

• Melis, Francesca; Kvamme, Timo L.; Tjagvad, Christian; Eide, Desiree; Thylstrup, Birgitte & Clausen, Thomas [Show all 7 contributors for this article] (2025). Health-related quality of life measures as predictors for recurrent hospitalization and mortality among patients in heroin-assisted treatment. Quality of Life Research. ISSN 0962-9343. 34, p. 3365–3376. doi: 10.1007/s11136-025-04019-5. Full text in Research Archive Show summary

  Purpose Individuals with opioid use disorder face complex health needs often necessitating hospital-based care, and many reported low health-related quality of life (HRQoL). This study assessed HRQoL factors as predictors of recurrent hospital-based care and mortality among heroin-assisted treatment (HAT) patients, identified patient groups with distinct HRQoL trajectories, and compared their hospital contact hours and mortality rates with the general population. Methods A longitudinal cohort study was conducted, involving 541 HAT patients in Denmark from 2010 to 2018, along with a matched sample from the general Danish population. Using recurrent event regression and latent class growth analysis, we analyzed predictors of recurrent hospitalization and established trajectory groups. HRQoL was assessed using the 36-Item Short Form Health Survey (SF-36) and linked to multiple national registry data which provided demographic variables, hospital utilization, and mortality data. Results “General health” emerged as the largest and only significant predictor of recurrent hospitalization. Mortality was predicted by age and ‘role limitations due to emotional problems’. We identified four trajectory groups based on “general health ”, showing either a decreasing or stable trajectory. Groups differed significantly in terms of average hospital contact hours and mortality and all groups had lower ‘general health’ scores and greater mortality than the representative Danish sample. The most severe group had four times higher usage of hospitalization hours. Conclusion SF-36 ‘general health’ is a key risk stratification tool for HAT patients predicting outcomes like hospitalization and mortality. Identifying high-risk individuals can help clinicians implement timely (somatic) care, particularly for long-term patients.

• Nyman, Anna Armika Tussilago; Bogstrand, Stig Tore; Clausen, Thomas & Edvardsen, Hilde Marie Erøy (2025). Toksikologiske funn ved overdoseselvmord 2016–21. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 145(2). doi: 10.4045/tidsskr.23.0836. Full text in Research Archive
• Edvardsen, Hilde Marie Erøy; Clausen, Thomas; Bogstrand, Stig Tore & Skurtveit, Svetlana Ondrasova (2025). The role of prescribed opioids in Norwegian overdose deaths in 2005-2021. European Journal of Clinical Pharmacology. ISSN 0031-6970. 81, p. 1633–1641. doi: 10.1007/s00228-025-03897-5. Full text in Research Archive
• Todd-Kvam, John James Rea; Sugahara, Gustavo Toshiaki Lopes; Muller, Ashley & Clausen, Thomas (2025). Quality of life whilst ageing in opioid agonist treatment: a narrative analysis. BMC Public Health. 25(1), p. 1–15. doi: 10.1186/s12889-025-22438-4. Full text in Research Archive Show summary

  Background Norway has an increasing number of ageing opioid agonist treatment (OAT) patients, with 44% of the 8200 Norwegian OAT patients over 50 in 2023. Methods This study examines the narratives of ageing OAT patients through semi-structured interviews with twelve patients who had been in OAT for 10–20+ years. We used narrative analysis to understand what they experience as important in enhancing or diminishing their quality of life as they age. Results Positive relationships, treatment, and stable housing were narrated as enhancing quality of life, while loneliness and isolation, memory problems, comorbidities, and victimization were narrated as diminishing it. Conclusion Patients experience OAT as both lifesaving as well as potentially limiting their life-quality, illustrating the inbuilt dilemmas of OAT. The study suggests an age-informed treatment model and identifies three thematic implications for practice and further research (on memory issues, victimisation and network-building).

• Melis, Francesca; Clausen, Thomas; Castel, Charlotte Jocelyne Yvonne; Dadras, Omid; Pirro, Silvana De & Myklebust, Lars Henrik Ryther [Show all 9 contributors for this article] (2024). Patient Characteristics From Norway’s First Heroin-Assisted Treatment Clinics. Substance use & addiction journal. 46(1), p. 13–24. doi: 10.1177/29767342241271991. Full text in Research Archive Show summary

  Background: Heroin-assisted treatment (HAT) is an evidence-based treatment option for opioid use disorder (OUD), available in a limited number of countries. Norway implemented a 5-year HAT project in 2022, aiming to assess its effectiveness and its potential integration into the country’s OUD treatment system. This study describes and compares patients’ baseline characteristics from the Oslo and Bergen HAT clinics, providing a comprehensive picture of the unique population and the real-world application of HAT. Methods: This cross-sectional study examines the baseline characteristics of consenting HAT patients within the first 2 years of operation (n = 86). Self-reported questionnaires gathered sociodemographics, previous treatment experiences, self-reported crime, and substance use, as well as motivations and expectations for treatment. Comparisons between the clinics were carried out using t-tests, Mann–Whitney U tests, Chi-square, and Fisher’s exact test. Results: The majority of the patients were enrolled at the Oslo clinic (76%) and were male (80%). At admission, the average age was 45.9, with a significantly younger group in Bergen (42.5 vs 47.3, P < .05). While no patients reported being unhoused, 17% noted unstable housing within the preceding month. Unemployment was prevalent (91%) alongside previous treatment experiences (95%), with a median of 2 prior medication types. In the 3 months preceding HAT initiation, 78% of patients reported being victims of crime, and 44% committed at least one crime. Over their lifetime, 2 in 5 participants (41%) had experienced an unwanted overdose and 43% had shared syringes and equipment. Conclusion: This study reveals a cohort experiencing societal marginalization, including unstable housing, unsatisfactory prior OUD treatment, high-risk behaviors, and frequent interactions with criminal activities, predominantly as victims. While the Oslo and Bergen clinics serve a similar patient profile, notable differences emerged in the reasons for discontinuing past OUD treatment and crime-related factors.

• Hatlo, Cornelia Haarr; Clausen, Thomas; Muller, Ashley & Sugahara, Gustavo (2024). Pet ownership, physical activity and mental health among people in opioid maintenance treatment: A prospective, observational study. Heroin Addiction and Related Clinical Problems. ISSN 1592-1638. 26(1). doi: 10.62401/2531-4122-2024-11. Full text in Research Archive
• Borschmann, Rohan; Keen, Claire; Spittal, Mathew J.; Preen, David; Pirkis, Jane & Larney, Sarah [Show all 52 contributors for this article] (2024). Rates and causes of death after release from incarceration among 1 471 526 people in eight high-income and middle-income countries: an individual participant data meta-analysis. The Lancet. ISSN 0140-6736. 403(10438), p. 1779–1788. doi: 10.1016/S0140-6736(24)00344-1. Full text in Research Archive
• Ericson, Øystein Bruun; Eide, Desiree; Brendryen, Håvar; Lobmaier, Philipp Paul & Clausen, Thomas (2024). Scaling up! Staff e-learning for a national take-home naloxone program. Frontiers in Digital Health. 6. doi: 10.3389/fdgth.2024.1404646. Full text in Research Archive
• Bjørnestad, Endre Dahlen; Vederhus, John-Kåre & Clausen, Thomas (2024). Change in substance use among patients in opioid maintenance treatment: baseline to 1-year follow-up. Harm Reduction Journal. 21(1), p. 101–101. doi: 10.1186/s12954-024-01005-x. Full text in Research Archive Show summary

  Background Individuals with opioid use disorder (OUD) often have concurrent use of non-opioid substances. When patients enter opioid maintenance treatment (OMT), less is known about outcomes regarding the use of other types of drugs. Here we aimed to investigate changes in substance use among patients entering outpatient OMT, from treatment initiation to 1-year follow-up. Methods We used data from the prospective Norwegian Cohort of Patient in OMT and Other Drug Treatment Study (NorComt). Among 283 patients who entered OMT at participating facilities across Norway, 179 were assessed at follow-up. Of these patients, 131 were in a non-controlled environment, and were included in the present analysis. The main outcome was change in substance use. Logistic regression analysis was applied to identify factors associated with abstinence from all substances (other than agonist medication) at follow-up. Results Along with opioid use, most patients reported polysubstance use prior to entering treatment. No significant differences were found in baseline characteristics between the included and non-included groups when examining attrition. At the 1-year follow-up, reduced substance use was reported. While in treatment, around two-thirds of patients continued using other drugs to varying degrees. At follow-up, about one-third of patients reported abstinence from all drugs, apart from the agonist medication. Factors related to abstinence included a goal of abstinence at baseline (OR = 5.26; 95% CI 1.14–19.55; p = 0.013) and increasing age (OR = 1.05; 95% CI 1.00–1.09; p = 0.034). Conclusions The majority of patients entering OMT used other substances in addition to opioids. About one-third of patients reported abstinence at the 1-year follow up. Although the majority of patients continued co-use of other drugs while in treatment, for most substances, less than 10% reported daily use at follow-up, with the exception of cannabis which was used daily/almost daily by about 2 in 10. Higher age and treatment goal at the start of OMT were important factors related to reducing concomitant substance use during treatment. These findings suggest that many patients entering OMT are in need of treatment and support related to the use of other substances, to further improve prognosis. Clinical trial registration Clinicaltrials.gov no. NCT05182918. Registered 10/01/2022 (the study was retrospectively registered).

• Odsbu, Ingvild; Hjellvik, Vidar; Handal, Marte; Hamina, Aleksi; Clausen, Thomas & Lid, Torgeir Gilje [Show all 8 contributors for this article] (2024). Psykiske lidelser og plager ved vedvarende opioidbruk for langvarige ikke-kreftrelaterte smerter – en registerstudie. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 144(2), p. 1–15. doi: 10.4045/tidsskr.23.0414. Full text in Research Archive Show summary

  Bakgrunn Kunnskap om psykiske lidelser blant pasienter med vedvarende opioidbruk for behandling av langvarige ikke-kreftrelaterte smerter er viktig, da psykiske lidelser og plager kan bidra til å forsterke eller vedlikeholde smerte og påvirke evnen til å håndtere egen sykdom. Vi har undersøkt forekomst av psykiske lidelser og plager, inkludert rusmiddellidelser, hos pasienter med vedvarende opioidbruk i 2019. Materiale og metode Personer ≥ 18 år med vedvarende opioidbruk og personer ≥ 18 år med minst én registrert psykisk lidelse i spesialisthelsetjenesten i 2019 ble inkludert. Data ble hentet fra nasjonale helseregistre. Pasienter som fikk opioider for langvarige smerter på blå resept ble sammenlignet med dem som fikk opioider utelukkende på hvit resept. Resultater Forekomsten av psykiske lidelser og plager var 34 % blant 14 403 personer som fikk opioidene forskrevet på blå resept, og 42 % blant 38 001 personer som fikk opioidene på hvit resept. Dette tilsvarer 2–3 ganger økt forekomst sammenlignet med den generelle befolkningen. Det var spesielt høyere forekomst av angstlidelser og rusmiddellidelser. Det var høyest forekomst av psykiske lidelser og plager i aldersgruppen 18–44 år (49–55 %). Fortolkning Blant pasienter med vedvarende opioidbruk var det en stor andel med psykiske lidelser og plager, som er kjente risikofaktorer for å utvikle problematisk opioidbruk og avhengighetssyndrom. HOVEDFUNN Forekomst av diagnostiserte psykiske lidelser og plager blant pasienter med vedvarende opioidbehandling av langvarige ikke-kreftrelaterte smerter i 2019 var høyest i den yngste aldersgruppen (18–44 år) og blant dem som fikk opioider utelukkende på hvit resept. Pasienter med vedvarende opioidbruk hadde 2–3 ganger høyere forekomst av psykiske lidelser, inkludert rusmiddellidelser, diagnostisert i spesialisthelsetjenesten sammenlignet med den generelle befolkningen. Rusmiddellidelser var hyppigst blant unge menn.

• Mcdonald, Rebecca Silvia; Eide, Desiree; Skurtveit, Svetlana Ondrasova & Clausen, Thomas (2024). Pills and the damage done: the opioid epidemic as man-made crisis. Frontiers in Public Health. 11. doi: 10.3389/fpubh.2023.1241404. Full text in Research Archive Show summary

  The prescription opioid epidemic has slowly evolved over the past quarter century with increasingly detrimental consequences for public health. Man-made crises are often unforeseen and characterized by a situation without natural causes where – because of human intent, error, negligence, or the failure of manmade systems – the level of needs in the population exceeds available resources to counter the problem. This paper presents the prescription opioid epidemic as a man-made crisis and explores the public health impact of opioid manufacturers and other industries producing commodities with addictive potential as a shared vulnerability among countries. We examine this concept within the framework of the commercial determinants of health. We address three key aspects of the commercial determinants of health: (1) Cross-industry mechanisms, (2) policy inertia, and (3) the role of industry in science. Within cross-industry mechanisms, we explore parallels between prescription opioid epidemic and unhealthy commodity industries in terms of marketing, corporate use of misinformation, and diversionary tactics. Next, we examine how policy inertia has dominated the slow response to this man-made crisis. Lastly, we discuss how results from clinical trials are used as a key marketing strategy for drugs. The origins of the prescription opioid epidemic may be traced to innovations in drug development with the promise of improved pain management. However, through multiple factors, including fraudulent marketing from pharmaceutical industry and policy inertia, the resulting crisis represents a multi-system failure of regulation exploited by corporate greed.

• Kostovski, Emil; Hamina, Aleksi; Hjellvik, Vidar; Clausen, Thomas & Skurtveit, Svetlana Ondrasova (2024). Increased cancer incidence and mortality among people with opioid use-related disorders: A nation-wide cohort study. Addiction. ISSN 0965-2140. 119(9), p. 1575–1584. doi: 10.1111/add.16524. Full text in Research Archive Show summary

  Background and aims Studies on cancer incidence and mortality among people with opioid use-related disorders are lacking. We aimed to measure cancer-specific incidence, mortality and survival among people diagnosed with opioid use-related disorders in Norway during 2010–18. Design and setting This was a cohort study conducted in Norway during 2010–18. Participants Individuals (n = 20 710) diagnosed with opioid use-related disorders. Measurements We conducted a cohort study utilizing a data-linkage of national health and population registers. Information on opioid use-related disorders was extracted from specialized healthcare, malignancies from the Cancer Registry of Norway and deaths from Cause of Death Registry. Cancer incidence and mortality were compared with the general population by calculating sex-specific age-standardized incidence (SIR) and mortality (SMR) ratios. One-year survival rates were computed. Findings Compared with the general population, people with opioid use-related disorders were at an increased risk of developing cancer overall [SIR = 1.2, 95% confidence interval (CI) = 1.1–1.3] with a higher than twofold cancer mortality rate (SMR = 2.3, 95% CI = 2.0–2.7). Excess risk was observed for liver (12.6, 95% CI = 9.1–17.0), larynx (4.7, 95% CI = 1.7–10.2), lung (3.5, 95% CI = 2.8–4.3) and pancreas cancer (2.6, 95% CI = 1.6–4.0), whereas reduced risk was found for melanoma (0.5, 95% CI = 0.3–0.9), breast (0.6, 95% CI = 0.4–0.9) and prostate cancers (0.3, 95% CI = 0.1–0.4). Site-specific SMRs were significantly elevated for liver (12.3, 95% CI = 8.5–17.2), lung (3.9, 95% CI = 3.0–5.0), pancreas (3.0, 95% CI = 1.7–4.8) and colon cancers (1.9, 95% CI = 1.1–3.1). The average 1-year survival rate after a cancer diagnosis was low in liver, pancreas and colon cancer, ranging from 10 to 15% less than that of the general population. Conclusions In Norway, cancer incidence and cancer-related mortality appear to be elevated among individuals with opioid use-related disorders.

• Gabrielsen, Karin Berle; Clausen, Thomas; Haugland, Siri Håvås & Vederhus, John-Kåre (2024). Gradual improvement in functioning and mental distress during long-term outpatient SUD treatment – A prospective pre-post study. Addictive Behaviors Reports. ISSN 2352-8532. 19, p. 1–8. doi: 10.1016/j.abrep.2024.100525. Full text in Research Archive Show summary

  Background Globally, outpatient programs for substance use disorder (SUD) treatment have gained prominence. To assess the broader clinical implications of this trend we investigated shifts in functioning experienced by outpatients undergoing treatment. Methods We describe the clinical characteristics of a cohort of 93 SUD patients in a Norwegian outpatient treatment clinic. Using paired-samples t-tests, we examined changes in perceived functioning, mental distress, and other clinically relevant outcome variables in a 5-month time interval during the treatment course. Results We obtained follow-up data for 67 (72%) of the included patients, with no significant difference in patient-related factors between those who completed the treatment course and those who were not assessed at follow-up. Perceived functioning increased significantly from study inclusion (Time 0) (mean 19.8, standard deviation ± 8.8) to its conclusion (Time 1) (24.3, ±9.3; t (66) = 4.5, (95% CI: 2.5–6.5, p < 0.001). We also identified significant improvement in most other measured variables, including mental distress, self-reported sleep quality, restlessness, and obsessive thinking. Substance use–related variables showed a modest, non-significant improvement at T1. Conclusion During a 5-month course of outpatient treatment, patients’ subjective experience of functioning improved significantly. Those with the lowest functioning levels at T0 improved the most. Structured monitoring may be a valuable clinical tool for personalizing intervention, enhancing treatment outcomes, and supporting the clinical decision-making process.

• Ericson, Øystein Bruun; Eide, Desiree; Lobmaier, Philipp Paul & Clausen, Thomas (2024). Mortality risk and causes of death among people who use opioids in a take-home naloxone cohort. Drug and Alcohol Dependence. ISSN 0376-8716. 255. doi: 10.1016/j.drugalcdep.2024.111087. Full text in Research Archive Show summary

  Background People who use opioids (PWUO) have an excess mortality from a range of causes. The cumulative effect of behavioral, social, and health risk factors complicates the interpretation of the effects of suitable interventions. This study explores mortality causes among a cohort of PWUO in the take-home naloxone (THN) program. Methods This was a prospective cohort study of PWUO who received THN between 2015 and 2023. Participant data was linked with death registry data. Crude mortality rates and standardized mortality ratios (SMRs) were calculated for all causes, internal causes, and accidental opioid overdoses (AOOs). In addition to age and gender, risk factors like main route of administration, polydrug use, self-experienced overdoses, and using while alone were fitted in a Cox Regression model to explore factors associated with mortality. Results The 2194 participants had a considerably higher mortality ratio for all causes investigated when compared to the general population (SMR=10.9, 95 % CI = 9.3,12.6). AOOs were the most prevalent cause of death (49 %). Those who reported frequent opioid use while alone had an elevated risk of dying of 2.6 (95 % CI = 1.1,6.4) compared to those who never used while alone. Conclusions Frequent opioid use while alone was associated with elevated mortality risk, supporting the importance of overdose prevention education with naloxone distribution, and additional efforts to improve environmental and social areas for safer drug-use practices among PWUO. The variety of mortality causes found in this study illustrates the need for multifaceted and targeted interventions for people at risk of overdosing.

• Finstad, Jeanette; Røise, Olav; Clausen, Thomas; Rosseland, Leiv Arne & Havnes, Ingrid Amalia (2024). A qualitative longitudinal study of traumatic orthopaedic injury survivors' experiences with pain and the long-term recovery trajectory. BMJ Open. 14(1). doi: 10.1136/bmjopen-2023-079161. Full text in Research Archive Show summary

  Objectives To explore trauma patients’ experiences of the long-term recovery pathway during 18 months following hospital discharge. Design Longitudinal qualitative study. Setting and participants Thirteen trauma patients with injuries associated with pain that had been interviewed 6 weeks after discharge from Oslo University Hospital in Norway, were followed up with an interview 18 months postdischarge. Method The illness trajectory framework informed the data collection, with semistructured, in-depth interviews that were analysed thematically. Results Compared with the subacute phase 6 weeks postdischarge, several participants reported exacerbated mental and physical health, including increased pain during 18 months following discharge. This, andalternating periods of deteriorated health status during recovery, made the pathway unpredictable. At 18 months post-discharge, participants were coping with experiences of reduced mental and physical health and socioeconomic losses. Three main themes were identified: (1) coping with persistent pain and reduced physical function, (2) experiencing mental distress without access to mental healthcare and (3) unmet needs for follow-up care. Moreover, at 18 months postdischarge, prescribed opioids were found to be easily accessible from GPs. In addition to relieving chronic pain, motivations to use opioids were to induce sleep, reduce withdrawal symptoms and relieve mental distress. Conclusions and implications The patients’ experiences from this study establish knowledge of several challenges in the trauma population’s recovery trajectories, which may imply that subacute health status is a poor predictor of long-term outcomes. Throughout recovery, the participants struggled with physical and mental health needs without being met by the healthcare system. Therefore, it is necessary to provide long-term follow-up of trauma patients’ health status in the specialist health service based on individual needs. Additionally, to prevent long-term opioid use beyond the subacute phase, there is a need to systematically follow-up and reassess motivations and indications for continued use throughout the recovery pathway.

• Bjørnestad, Endre Dahlen; Vederhus, John-Kåre & Clausen, Thomas (2024). Change in self-reported somatic symptoms among patients in opioid maintenance treatment from baseline to 1-year follow-up. BMC Psychiatry. 24(1). doi: 10.1186/s12888-024-05590-w. Full text in Research Archive Show summary

  Background High somatic comorbidity is common among patients in treatment for opioid use disorder (OUD). The present study aims to investigate changes in self-reported somatic health conditions and somatic symptoms among patients entering opioid maintenance treatment (OMT) programs. Methods We used data from the Norwegian Cohort of Patients in OMT and Other Drug Treatment (NorComt) study. Of 283 patients who entered OMT, 176 were included for analysis at a 1-year follow-up. Participants provided self-reported data during structured interviews on somatic conditions, somatic symptoms, substance use severity measures, and mental distress. A multivariable linear regression analysis identified factors associated with changes in the burden of somatic symptoms. Results Patients entering OMT reported a high prevalence of somatic conditions at the beginning of treatment, with 3 of 5 patients reporting at least one. The most prevalent condition was hepatitis C, followed by asthma and high blood pressure. Patients reported experiencing a high number of somatic symptoms. The intensity of these symptoms varied across a wide spectrum, with oral health complaints and reduced memory perceived as the most problematic. Overall, for the entire sample, there was no significant change in somatic symptoms from baseline to 1 year. Further analysis indicated that those who reported a higher burden of somatic symptoms at baseline had the greatest improvement at the 1-year follow-up. A higher number of somatic conditions and higher mental distress at baseline was associated with improvements in somatic symptoms burden at follow-up. Conclusions Patients in OMT report a range of somatic conditions and somatic symptoms. Given the wide range of symptoms reported by patients in OMT, including some at high intensity levels, healthcare providers should take into consideration the somatic healthcare needs of individuals in OMT populations. Clinical trial registration Clinicaltrials.gov no. NCT05182918. Registered 10/01/2022 (the study was retrospectively registered).

• Todd-Kvam, John James Rea & Clausen, Thomas (2024). Practitioner perspectives on working with older patients in opioid agonist treatment (OAT) in Norway: opportunities and challenges. Addiction science & clinical practice. ISSN 1940-0632. 19(1). doi: 10.1186/s13722-024-00473-7. Full text in Research Archive Show summary

  Background Norway has a growing proportion of ageing opioid agonist treatment (OAT) patients, with 42% of the 8300 Norwegian OAT patients aged over 50 in 2022. This study aims to explore practitioners’ views and experiences from treatment of ageing OAT patients. Methods Data were collected as a series of semi-structured interviews with treatment staff (roles interviewed: doctor, psychologist, social worker, nurse, and learning disability nurse). Participants were recruited from three OAT outpatient clinics, one with an urban catchment area and two with a mix of urban and rural. The interviews incorporated questions on patients’ somatic and mental health, strengths and weaknesses of the service for this group, and patients’ quality of life. Results Older patients were perceived to be more often stable in terms of substance use and housing situation, but also experiencing some key challenges in terms of cognitive impairment, loneliness and isolation, and comorbidities. Both the practitioner-patient relationship and healthcare interactions outside OAT had the potential to impact treatment quality positively or negatively depending on how they were managed. Conclusions Treating older patients in a way that respects and enhances their dignity is important. We argue that this requires better services for those whose functioning is impacted by cognitive impairment/dementia, an age-informed treatment model for this patient group, along with urgent work to improve municipal-level services given practitioners describe them as unacceptable in certain areas.

• Nielsen, Suzanne; Horn, Freya; McDonald, Rebecca Silvia; Eide, Desiree; Walley, Alexander Y & Binswanger, Ingrid [Show all 11 contributors for this article] (2024). Development of pharmacy-based best practices to support safer use and management of prescription opioids based on an e-Delphi methodology. Research in Social and Administrative Pharmacy. ISSN 1551-7411. doi: 10.1016/j.sapharm.2024.09.001. Full text in Research Archive Show summary

  Background Opioid utilization and related harm have increased in recent decades, notably in Australia, the United States, Canada, and some European countries. For people who are prescribed opioids, pharmacies offer an accessible, regular point-of-contact, providing a unique opportunity to address opioid prescription drugs risks. Objective This project aimed to develop consensus-based, best practice statements for improving the safer use of prescription opioids through community pharmacy settings. Methods The e-Delphi technique is used to obtain consensus from experts about issues where conclusive evidence is lacking, using multiple rounds of online participation. The investigator group identified an international group of potential participants with relevant expertise who were invited to the study, and asked to identify other experts for invitation. The e-Delphi process comprised three online rounds, involving (1) statement idea generation, (2) developing statement consensus, and (3) confirming and ranking statements. Results A diverse group of 42 experts (76 % female, 6 countries) participated, comprising pharmacists (n = 24, 57 %), medical doctors of differing specialties (n = 12, 29 %), and/or researchers (n = 28, 67 %), with a mean of 15 years’ professional experience (SD = 8.08). Eighty-five statements were initially developed in Round 1, and 78 were supported with amendments, with suggestions to merge and remove items in Round 2, resulting in 72 final statements which were all endorsed in Round 3. Items spanned seven themes: education, monitoring outcomes and risk, deprescribing and pain management, overdose education and naloxone, opioid agonist treatment, staff education, and overarching practices. Preferred terminology was determined in Round 2 and confirmed in Round 3. Conclusions Community pharmacies offer a unique opportunity to support the safer use of prescription opioids. These 72 best practice statements provide practical guidance on specific practices that pharmacists can undertake to support patients' safer use of prescription opioids and prevent or reduce harms from prescribed opioid use.

• Hamina, Aleksi; Odsbu, Ingvild; Hjellvik, Vidar; Lid, Torgeir Gilje; Clausen, Thomas & Skurtveit, Svetlana Ondrasova (2023). Fatal drug overdoses in individuals treated pharmacologically for chronic pain: a nationwide register-based study. British Journal of Anaesthesia. ISSN 0007-0912. 132(1), p. 86–95. doi: 10.1016/j.bja.2023.10.016. Full text in Research Archive Show summary

  Introduction Chronic pain patients may be at an increased risk for drug overdoses as a result of comorbid psychiatric disorders and treatment with risk-increasing prescription medications, such as opioids. We aimed to characterise fatal drug overdoses and investigate factors associated with the deaths among individuals who had been treated pharmacologically for chronic pain. Methods We included all individuals who received analgesics reimbursed for chronic pain in Norway during 2010–9 (n=569 047). Among this population, we identified all individuals with drug overdoses as cause of death (cases). Extracting data from national registries on diagnoses, filled prescriptions, and socioeconomic variables, we used a nested case-control design to compare the cases with age- and sex-matched controls from the study population. Results Overall, 623 (0.11%) individuals in the study population died of an overdose. Most, 66.8%, had overdosed accidentally, and 61.9% as a result of pharmaceutically available opioids. Compared with the controls (n=62 245), overdoses overall were associated strongly with substance use disorders (adjusted odds ratio 7.78 [95% confidence interval 6.20–9.77]), use of combinations of opioids, benzodiazepines and related drugs and gabapentinoids (4.60 [3.62–5.85]), previous poisoning with pharmaceuticals (2.78 [2.20–3.51]), and with living alone the last year of life (2.11 [1.75–2.54]). Intentional overdoses had a stronger association with previous poisonings with pharmaceuticals whereas accidental overdoses were strongly associated with substance use disorders. Conclusions This study shows the need for better identification of overdose and suicide risk in individuals treated for chronic pain. Extra caution is needed when treating complex comorbid disorders, especially with overdose risk-increasing medications.

• Eide, Desiree; Mcdonald, Rebecca Silvia; Hamina, Aleksi; Clausen, Thomas; Odsbu, Ingvild & Skurtveit, Svetlana Ondrasova (2023). Prescription high-risk polysubstance use among opioid maintenance treatment patients. International journal of drug policy. ISSN 0955-3959. doi: 10.1016/j.drugpo.2023.104196. Full text in Research Archive Show summary

  Background Among individuals receiving buprenorphine or methadone as opioid maintenance treatment (OMT), concomitant use of other central nervous system depressants, including prescription drugs, can increase risk of overdose. We aimed to 1) determine the prevalence of use of high-risk prescription drugs (opioid analgesics, benzodiazepines, benzodiazepine-related drugs, and gabapentinoids) among OMT patients, 2) calculate its associations with different mental health and pain-related diagnoses, and 3) compare prevalence of concomitant use with the general population. Methods A national sample comprising all individuals filling at least one prescription of OMT drugs in Norway in 2019 was formed. Healthcare registry data were linked to investigate high-risk prescription drug use and different diagnoses. We calculated one-year prevalence of use, amount dispensed in defined daily doses (DDDs), and the number of prescribers for the different high-risk prescription drugs. Logistic regression was used to determine associations (adjusted odds ratios; aOR, 95% confidence intervals (CIs)) between diagnoses and use. Prevalence of use was calculated both in the OMT patient sample and the general population. Results Among the OMT patient sample (n=7,299), 47.6% (n=3,476) filled prescriptions for benzodiazepines. For each high-risk prescription drug group, there was a median of 1-2 prescribers. Musculoskeletal diagnoses were the strongest factor for concomitant high-risk prescription drug use for both males (aOR 3.23, CI: 2.72-3.85) and females (aOR 3.07, CI: 2.42- 3.90). The 1-year prevalence of benzodiazepine use was 11.4 times higher for males and 7.1 times higher for females in OMT than the general population. The amount in DDDs was higher for every drug for OMT patients than the general population, particularly for benzodiazepines. Conclusions OMT patients frequently filled prescriptions for high-risk drugs, and in higher dosages than the general population. However, we found little evidence of ‘doctor shopping.’ Given that these prescription drugs carry overdose risk, particularly when combined with OMT drugs, our findings emphasize the continued need for education and caution to both prescribers and patients on their concomitant use with OMT.

• Rolova, Gabriela; Eide, Desiree; Gabrhelík, Roman; Odsbu, Ingvild; Clausen, Thomas & Skurtveit, Svetlana Ondrasova (2023). Gender differences in physical morbidity in opioid agonist treatment patients: population-based cohort studies from the Czech Republic and Norway. Substance Abuse Treatment, Prevention, and Policy. 18(1). doi: 10.1186/s13011-023-00557-8. Full text in Research Archive Show summary

  Background Physical diseases represent a significant burden for opioid agonist treatment (OAT) patients. This study described physical morbidity in two national cohorts of OAT patients focusing on gender differences. Methods This population-based cohort study linking multiple health registers investigated physical diseases (ICD-10) in patients receiving OAT in the Czech Republic (N = 4,280) and Norway (N = 11,389) during 2010–2019. Gender-stratified analysis was performed. Results Overall, we found a large burden of physical morbidity across gender groups in OAT patients. In the Czech Republic and Norway, women in OAT had a significantly higher prevalence of physical diseases across most diagnostic chapters, notably genitourinary diseases and neoplasms. Injuries/external causes and infectious/parasitic diseases were among the most common diseases in both women and men. Viral hepatitis accounted for over half of infectious morbidity in women and men in both cohorts. Conclusions Our findings support the need for early screening, detection, and treatment of diseases and conditions across organ systems and the integration of health promotion activities to reduce physical morbidity in OAT patients. The gender differences underline the need for a tailored approach to address specific medical conditions.

• Ellingsen, Maren Mikkelsen; Clausen, Thomas; Johannesen, Sunniva Launes; Martinsen, Egil Wilhelm & Hallgren, Mats (2023). Effects of Acute Exercise on Affect, Anxiety, and Self-Esteem in Poly-Substance Dependent Inpatients. European Addiction Research. ISSN 1022-6877. 29(4), p. 285–293. doi: 10.1159/000531042. Full text in Research Archive Show summary

  Introduction: Negative affect and anxiety frequently precede the onset of drug use in those with substance use disorder (SUD). Low self-esteem may increase the risk of relapse. We examined the short-term effects of exercise on affect, anxiety, and self-esteem in inpatients with poly-SUD. Methods: This is a multicenter randomized control trial (RCT) with a crossover design. Thirty-eight inpatients (37.3 ± 6.4 years; 84% male) from three clinics participated in 45 min of soccer, circuit training, and control condition (psychoeducation) in a random order. Positive and negative affect (PANAS), state anxiety (single item), and self-esteem (Rosenberg SE-scale) were measured immediately before, immediately after, 1-h, 2-h, and 4-h post-exercise. Heart rate and ratings of perceived exertion were taken. Effects were assessed using linear mixed effects models. Results: Compared to the control condition, there were significant post-exercise improvements in positive affect (β = 2.99, CI = 0.39: 5.58), self-esteem (β = 1.84, CI = 0.49: 3.20), and anxiety (β = −0.69, CI = −1.34: −0.04) after circuit training (shown) and soccer. Effects persisted 4-h post-exercise. Reductions in negative affect were observed 2-h (circuit training: β = −3.39, CI = −6.35: −1.51) and 4-h (soccer: β = −3.71, CI = −6.03: −1.39) post-exercise, respectively. Conclusion: Moderately strenuous exercise undertaken in naturalistic settings may improve mental health symptoms in poly-SUD inpatients for up to 4-h post-exercise.

• Mcdonald, Rebecca Silvia; Bech, Anne Berit & Clausen, Thomas (2023). Flexible delivery of opioid agonist treatment during COVID-19 in Norway: qualitative and quantitative findings from an online survey of provider experiences. BMC Health Services Research. 23(1). doi: 10.1186/s12913-023-09959-7. Full text in Research Archive Show summary

  Background For patients receiving daily opioid agonist treatment (OAT) for opioid dependence, several countries relaxed treatment guidelines at the beginning of the COVID-19 pandemic. This involved longer take-home intervals for methadone and buprenorphine doses as well as a reduction in supervised dosing and drug screening. To date, little is known about the medium or long-term experience of OAT deregulation. Therefore, we conducted a survey to explore how OAT providers perceived greater flexibility in OAT service delivery at the end of the second year of the pandemic. Methods Nationwide cross-sectional study of twenty-three OAT units in 19 publicly funded hospital trusts in Norway. OAT units were sent a 29-item online questionnaire comprising closed-format and open-ended questions on treatment provider experiences and changes in OAT service delivery during the past 12 months (January to December 2021). Results Twenty-three (of whom female: 14; 60.8%) managers or lead physicians of OAT units completed the questionnaire reporting that, in 2021, most OAT units (91.3%, n = 21) still practiced some adjusted approaches as established in the beginning of the pandemic. The most common adaptions were special protocols for COVID-19 cases (95.7%, n = 22), increased use of telephone- (91.3%, n = 21) and video consultations (87.0%, n = 20), and longer take-home intervals for OAT medications (52.2%, n = 12). The use of depot buprenorphine also increased substantially during the pandemic. According to the OAT providers, most patients handled flexible treatment provision well. In individual cases, patients’ substance use was identified as key factor necessitating a reintroduction of supervised dosing and drug screening. Collaboration with general practitioners and municipal health and social services was generally perceived as crucial for successful treatment delivery. Conclusions Overall, the Norwegian OAT system proved resilient in the second year of the COVID-19 pandemic, as its healthcare workforce embraced innovation in technology (telemedicine) and drug development (depot buprenorphine). According to our nationally representative sample of OAT providers, most patients were compliant with longer take-home doses of methadone and buprenorphine. Our findings suggest that telemedicine can be useful as adjunct to face-to-face treatment and provide greater flexibility for patients.

• Melis, Francesca; Hesse, Morten; Eide, Desiree; Thylstrup, Birgitte; Tjagvad, Christian & Brummer, Julie Elizabeth [Show all 7 contributors for this article] (2023). Who receives heroin-assisted treatment? A comparison of patients receiving opioid maintenance treatment in Denmark. Drug and Alcohol Dependence. ISSN 0376-8716. 254. doi: 10.1016/j.drugalcdep.2023.111051. Full text in Research Archive Show summary

  Background Since 2010, heroin-assisted treatment (HAT) has been one of the treatment options available to people with opioid use disorder (OUD) in Denmark. This study aimed to characterize HAT patients at treatment start and compare their individual characteristics to those of patients entering traditional opioid maintenance treatment (OMT) with methadone or buprenorphine during the same period. Methods Patients who initiated HAT or OMT with methadone or buprenorphine in Denmark from 2010 to 2018 were included (n=6798). Multiple national registers were linked to compare treatment groups in terms of socio-demographic variables, previous OUD treatment episodes, hospital-based care, and criminal conviction history. Results Nearly all HAT patients had a history of methadone treatment (91%) and half had residential treatment experience (48%). In the year previous to admission, HAT patients recorded the highest percentages of non-fatal overdoses (12%) and chronic hepatitis C diagnoses (16%), and the lowest percentages of psychiatric disorders (11%) compared to traditional OMT patients. Criminal convictions were also common: 39% of the HAT group had committed a property crime and 18% a drug-related crime the year before HAT entry. During the study period, an overall reduction in OMT enrollments for each year was recorded. The HAT proportion to the total remained fairly stable (4%−10%), while the buprenorphine proportion increased. Conclusions In Denmark, OMT patients exhibited numerous vulnerabilities at treatment start, and among the patient groups, HAT patients were the most burdened. HAT seems to reach the target group and adhere to formulated eligibility criteria.

• Haugom, Espen Woldsengen; Benth, Jurate Saltyte; Stensrud, Bjørn; Ruud, Torleif; Clausen, Thomas & Landheim, Anne Signe (2023). Shared decision making and associated factors among patients with psychotic disorders: a cross-sectional study. BMC Psychiatry. 23(1). doi: 10.1186/s12888-023-05257-y. Full text in Research Archive Show summary

  Background: Shared decision making is a process where patients and clinicians collaborate to make treatment choices based on the patients' preferences and best available evidence. The implementation of shared decision making remains limited for patients with psychotic disorders despite being recommended at policy level, being advocated as ethical right and wanted by the patient's. A barrier to implementation that is often mentioned is reduced decision-making capacity among patients. The challenges of implementing shared decision making highlights a need for more knowledge on shared decision making for these patients. Moreover, the association between patient-related characteristics and shared decision making is unclear, and further research have been suggested. More knowledge of factors associated with involvement in shared decision making can enhance understanding and help to empower patients in the decision-making process. The current study examined the extent of reported shared decision making among patients with a psychotic disorder in mental health care and factors associated with shared decision making. Methods: This study included 305 participants with a psychotic disorder from 39 clinical inpatient and outpatient sites across Norway. Shared decision making was assessed using the CollaboRATE survey. A linear mixed model was estimated to assess characteristics associated with shared decision making scores. Results: The CollaboRATE mean score was 6.3 (ranging from 0 to 9), the top score was 14.1% and increased global satisfaction with services was significantly associated with a higher level of shared decision making (regression coefficient 0.27, 95% confidence interval (0.23; 0.32), p < 0.001). Conclusions: The low top score shows that few patients felt that they received the highest possible quality of shared decision making, indicating that many patients found room for improvement. This suggests that services for patients with psychotic disorders should be designed to give them a greater role in decision making. Shared decision making might play a key role in mental health care, ensuring that patients with psychotic disorders are satisfied with the services provided. Trial registration: NCT03271242, date of registration: 5 Sept. 2017.

• Gabrhelík, Roman; Hesse, Morten; Nechanská, Blanka; Handal, Marte; Mravčík, Viktor & Tjagvad, Christian [Show all 11 contributors for this article] (2023). Large variations in all-cause and overdose mortality among >13,000 patients in and out of opioid maintenance treatment in different settings: a comparative registry linkage study. Frontiers in Public Health. 11. doi: 10.3389/fpubh.2023.1179763. Full text in Research Archive Show summary

  Background Opioid maintenance treatment (OMT) has the potential to reduce mortality rates substantially. We aimed to compare all-cause and overdose mortality among OMT patients while in or out of OMT in two different countries with different approaches to OMT. Methods Two nation-wide, registry-based cohorts were linked by using similar analytical strategies. These included 3,637 male and 1,580 female patients enrolled in OMT in Czechia (years 2000–2019), and 6,387 male and 2,078 female patients enrolled in OMT in Denmark (years 2007–2018). The direct standardization method using the European (EU-27 plus EFTA 2011–2030) Standard was employed to calculate age-standardized rate to weight for age. All-cause and overdose crude mortality rates (CMR) as number of deaths per 1,000 person years (PY) in and out of OMT were calculated for all patients. CMRs were stratified by sex and OMT medication modality (methadone, buprenorphine, and buprenorphine with naloxone). Results Age-standardized rate for OMT patients in Czechia and Denmark was 9.7/1,000 PY and 29.8/1,000 PY, respectively. In Czechia, the all-cause CMR was 4.3/1,000 PY in treatment and 10.8/1,000 PY out of treatment. The overdose CMR was 0.5/1,000 PY in treatment and 1.2/1,000 PY out of treatment. In Denmark, the all-cause CMR was 26.6/1,000 PY in treatment and 28.2/1,000 PY out of treatment and the overdose CMR was 7.3/1,000 PY in treatment and 7.0/1,000 PY out of treatment. Conclusion Country-specific differences in mortality while in and out of OMT in Czechia and Denmark may be partly explained by different patient characteristics and treatment systems in the two countries. The findings contribute to the public health debate about OMT management and may be of interest to practitioners, policy and decision makers when balancing the safety and accessibility of OMT.

• Eide, Desiree; Skurtveit, Svetlana Ondrasova; Clausen, Thomas; Hesse, Morten; Mravčík, Viktor & Nechanská, Blanka [Show all 12 contributors for this article] (2023). Cause-Specific Mortality among Patients in Treatment for Opioid Use Disorder in Multiple Settings: A Prospective Comparative Cohort Study. European Addiction Research. ISSN 1022-6877. 29(4), p. 272–284. doi: 10.1159/000530822. Full text in Research Archive Show summary

  Introduction: Among people receiving current or previous opioid maintenance treatment (OMT), the leading cause of premature death is an opioid overdose. However, other causes of mortality remain high in this group. An understanding of causes of deaths across multiple settings can be useful in informing more comprehensive prevention responses. The aim of this study was to describe all non-overdose causes of death in three national cohorts (Czechia, Denmark, and Norway) among OMT patients and to explore associations of non-overdose mortality with age and gender. Methods: This prospective comparative cohort study used national mortality registry databases for OMT patients from Czechia (2000–2019), Denmark (2000–2018), and Norway (2010–2019). Crude mortality rates and age-standardized mortality rates (ASMRs) were calculated as deaths per 1,000 person years for cause-specific mortality. Results: In total, 29,486 patients were included, with 5,322 deaths recorded (18%). We found variations in causes of death among the cohorts and within gender and age groups. The leading non-overdose causes of death were accidents in Czechia and Denmark, and neoplasms in Norway. Cardiovascular deaths were highest in Czechia, particularly for women in OMT (ASMR 3.59 vs. 1.24 in Norway and 1.87 in Denmark). Conclusion: This study found high rates of preventable death among both genders and all age groups. Different demographic structures, variations in risk exposure, as well as variations in coding practices can explain the differences. The findings support increased efforts towards screening and preventative health initiatives among OMT patients specific to the demographic characteristics in different settings.

• Gjerde, L. C.; Skurtveit, S.; Handal, M.; Nesvåg, R.; Clausen, T. & Lid, T. G. [Show all 9 contributors for this article] (2023). Mental disorder prevalence in chronic pain patients using opioid versus non-opioid analgesics: A registry-linkage study. European Journal of Pain. ISSN 1090-3801. 27(7), p. 884–895. doi: 10.1002/ejp.2121. Full text in Research Archive Show summary

  Background Chronic pain and mental disorders are leading causes of disability worldwide. Individuals with chronic pain are more likely to experience mental disorders compared to individuals without chronic pain, but large-scale estimates are lacking. We aimed to calculate overall prevalence of mental health diagnoses from primary and secondary care among individuals treated for chronic pain in 2019 and to compare prevalence among chronic pain patients receiving opioid versus non-opioid analgesics, according to age and gender. Methods It is a population-based cohort study. Linked data from nationwide health registers on dispensed drugs and diagnoses from primary (ICPC-2) and secondary (ICD-10) health care. Chronic pain patients were identified as all patients over 18 years of age filling at least one prescription of an analgesic reimbursed for non-malignant chronic pain in both 2018 and 2019 (N = 139,434, 69.3% women). Results Prevalence of any mental health diagnosis was 35.6% (95% confidence interval: 35.4%–35.9%) when sleep diagnoses were included and 29.0% (28.8%–29.3%) when excluded. The most prevalent diagnostic categories were sleep disorders (14% [13.8%–14.2%]), depressive and related disorders (10.1% [9.9%–10.2%]) and phobia and other anxiety disorders (5.7% [5.5%–5.8%]). Prevalence of most diagnostic categories was higher in the group using opioids compared to non-opioids. The group with the highest overall prevalence was young women (18–44 years) using opioids (50.1% [47.2%–53.0%]). Conclusions Mental health diagnoses are common in chronic pain patients receiving analgesics, particularly among young individuals and opioid users. The combination of opioid use and high psychiatric comorbidity suggests that prescribers should attend to mental health in addition to somatic pain. Significance This large-scale study with nation-wide registry data supports previous findings of high psychiatric burden in chronic pain patients. Opioid users had significantly higher prevalence of mental health diagnoses, regardless of age and gender compared to users of non-opioid analgesics. Opioid users with chronic pain therefore stand out as a particularly vulnerable group and should be followed up closely by their physician to ensure they receive sufficient care for both their mental and somatic symptoms.

• Eshrati, Sahar; Saberizafarghandi, MohammadBagher; Vameghi, Meroe; Arezoomandan, Reza; Ranjbar, Hadi & Clausen, Thomas [Show all 7 contributors for this article] (2023). Main problems experienced by the neighbors of open drug scenes, Tehran, Iran: a mixed-method study. Harm Reduction Journal. 20(1). doi: 10.1186/s12954-023-00880-0. Full text in Research Archive Show summary

  Background Despite law enforcement and health interventions, open drug scenes have led to problems in many countries. The problems are, however, insufficiently explored. There are different types of drug scenes in Iran. This study aimed to explore the issues related to neighbors of one of the drug scenes in Tehran known as Farahzad. Methods Data were generated via semi-structured interviews in the first step of the current mixed-method study (2020–2021). Interviewees were people who use drugs (PWUDs), residents and business owners (N = 25). In the next step, a quantitative observation was conducted for eight days. The results were analyzed using conventional content analysis and descriptive statistics. Results The perceived problems were ambivalent attitudes about drug scene-related activities, violate of the territory of the self of the effected residents, and everyday concerns. The observation results indicated that men who use drugs are involved in drug scene-related activities more than women are. PWUDs try to hide their activities from the public view. Their efforts were considered “self-regulatory strategies” in the drug scene. Conclusions Despite efforts of PWUDs to keep their activities invisible, drug scene-related issues are intolerable for neighbors. Neighbors and PWUDs have ambivalent attitudes. While they are concerned about the human rights of each other, drug scene-related activities have disturbed the neighbor’s daily life and economic activities. Although law enforcement and harm reduction interventions reduce some of the problems, one of the approaches should be improving the coexistence between the neighbors and the residents of the drug scene to achieve broader and more sustainable compromises.

• Finstad, Jeanette; Clausen, Thomas; Rosseland, Leiv Arne; Røise, Olav & Havnes, Ingrid Amalia (2022). Patient experiences after physical trauma: The negative effect of the COVID-19 pandemic on recovery. International Journal of Environmental Research and Public Health (IJERPH). ISSN 1661-7827. 19:12258(19), p. 1–9. doi: 10.3390/ijerph191912258. Full text in Research Archive Show summary

  The coronavirus disease 2019 (COVID-19) pandemic generated a crisis within the healthcare system, during which acute, COVID-19-related health needs were prioritized over less urgent needs, including vulnerable subgroups. This study explored experiences of recovery among survivors of physical injuries associated with severe pain during the COVID-19 pandemic in Norway. In-depth interviews were conducted among 13 participants. Findings generated by a thematic analysis revealed that the pandemic, including the contagion control measures and interrupted healthcare, were of negative consequence for the participants’ recovery experiences and mental and physical health. Despite experiencing severe pain and perceived needs for support, the participants experienced being deprioritized by the healthcare system. They experienced a reduced capacity to cope with pandemic-related stress and to perform everyday tasks, which they perceived as generating an additional burden for their loved ones. Alcohol was reported to be used in an effort to relieve the associated mental distress. As suggested by this study, injury survivors constitute a vulnerable subgroup for whom the continuity of rehabilitation services during a national crisis, as well as the integration of mental health support, can be essential for mitigating the negative impact of the crisis on recovery and for promoting optimal long-term health outcomes. Keywords: COVID-19; pandemic; physical trauma; recovery; rehabilitation; mental health; substance use; qualitative research

• Karlsson, Ann Tarja; Vederhus, John-Kåre; Clausen, Thomas; Weimand, Bente Margrethe; Solli, Kristin Klemmetsby & Tanum, Lars Håkon Reiestad (2022). Impact of Impulsivity, Hyperactivity, and Inattention on Discontinuation Rate among Opioid-Dependent Patients Treated with Extended-Release Naltrexone. International Journal of Environmental Research and Public Health (IJERPH). ISSN 1661-7827. 19(18), p. 1–8. doi: 10.3390/ijerph191811435. Full text in Research Archive Show summary

  Previous studies have indicated elevated levels of impulsivity, hyperactivity, and inattention (IHI) among opioid-dependent patients seeking outpatient treatment with extended-release naltrexone (XR-NTX). This led us to hypothesize that IHI may be associated with a higher discontinuation rate for XR-NTX treatment. In a group of 162 patients with opioid dependence, discontinuation prior to the full 24 weeks of the study period (six injections and attending the study visit at 24 weeks) occurred in 49% of the patients, primarily in the early stage of treatment. IHI above the clinical cut-off on the adult ADHD self-report scale (ASRS) was not associated with a risk of premature discontinuation. This finding was not altered when controlling for socio-demographics, substance, use and mental health severity. Conclusively, high levels of IHI per se is not contradictive for XR-NTX treatment in regard to concern for premature discontinuation.

• Gabrielsen, Karin Berle; Clausen, Thomas; Haugland, Siri Håvås; Hollup, Stig Arvid & Vederhus, John-Kåre (2022). Infralow neurofeedback in the treatment of substance use disorders: a randomized controlled trial. Journal of Psychiatry & Neuroscience. ISSN 1180-4882. 47(3), p. 222–229. doi: 10.1503/jpn.210202. Full text in Research Archive Show summary

  Background Infralow neurofeedback (ILF-NF) was recently developed as a subtype of traditional, frequency-based neurofeedback that targets cerebral rhythmic activity below 0.5 Hz and improves brain self-regulation. The efficacy of ILF-NF in the treatment of substance use disorder has not yet been evaluated, but clinical evidence suggests that it may prevent relapse by improving functioning in various life domains. The current study aimed to fill this research gap and extend empirical evidence related to this issue. Methods Ninety-three patients with substance use disorders at an outpatient unit in Norway were randomized to receive 20 sessions (30 minutes each) of ILF-NF training combined with treatment as usual (TAU), or TAU alone. The primary outcome was quality of life post-treatment as an overall measure of functioning. We analyzed between-group differences using Student t tests. Results We found no significant differences in quality of life between groups. We found similar nonsignificant results for most of the secondary outcome measures, including drug use, sleep, anxiety and depression. Compared to TAU, the ILF-NF + TAU group reported significantly lower restlessness scores post-treatment (mean difference −1.8, 95 % confidence interval −3.1 to −0.5; p = 0.006). Limitations: This study was limited by broad inclusion criteria and a lack of placebo control (sham neurofeedback treatment). Conclusion ILF-NF offered limited additional benefit when combined with TAU, except in the area of restlessness. Future studies could further investigate the relationship between ILF-NF, restlessness and substance use in targeted subpopulations to illuminate relapse mechanisms.

• Vederhus, John-Kåre; Rørendal, Malin; Skårdal, Madelene; Næss, Marianne Otterstad; Clausen, Thomas & Kristensen, Øistein (2022). Successful outcomes with low–threshold intervention for cannabis use disorders in Norway - an observational study. PLOS ONE. 17(6), p. 1–12. doi: 10.1371/journal.pone.0269988. Full text in Research Archive Show summary

  Aims Cannabis is the most commonly used regulated drug by European youths. Yet, few cannabis-specific interventions have been examined in Europe. The Cannabis Cessation Program (CCP) was developed in Sweden in the 1990s and has been implemented in some Norwegian municipalities. The present study aimed to examine outcomes of this intervention in the Norwegian setting. Method The respondents (N = 102) were recruited in four community-based CCPs in Norway. We examined their changes in cannabis use, other substance use, mental distress, well-being, sense of coherence (SoC), and social networks, from baseline (T0) to post-treatment (T1) and up to a 3-month follow-up period (T2). Changes were evaluated with pair-wise t-tests. Result Seventy-six participants (75%) completed the 8-week program, according to plan. All participants reported a significant reduction in cannabis use at T1 (average reduction ~16 days per month) and at T2 (N = 59; ~13 days per month). Among those that completed the program, 67% was abstinent from cannabis at T1 and 37% was abstinent at T2. An intention-to-treat analysis showed that 50% (51/102) and 22% (22/102) were abstinent from cannabis use at T1 and T2, respectively. In parallel to abstinence, we observed a substantial reduction in mental distress and an increase in well-being and SoC. Respondents socialized with fewer friends with current substance use, but drug-free social networks were not expanded. Conclusion Our findings suggested that the CCP was a valuable, low-threshold manual-based intervention for cannabis use disorders. It showed considerable potential for reducing individuals’ cannabis use. Clinical trial registration Clinicaltrials.gov no. NCT04989205. Registered 12 July 2021, i.e., the study was retrospectively registered.

• Hamina, Aleksi; Muller, Ashley Elizabeth; Clausen, Thomas; Skurtveit, Svetlana Ondrasova; Hesse, Morten & Tjagvad, Christian [Show all 11 contributors for this article] (2022). Prescription opioids among older adults: ten years of data across five countries. BMC Geriatrics. 22(429). doi: 10.1186/s12877-022-03125-0. Full text in Research Archive Show summary

  Background Opioid use has increased globally in the recent decade. Although pain remains a significant problem among older adults, susceptibility to opioid-related harms highlights the importance of careful opioid therapy monitoring on individual and societal levels. We aimed to describe the trends of prescription opioid utilisation among residents aged ≥65 in all Nordic countries during 2009–2018. Methods We conducted cross-sectional measurements of opioid utilisation in 2009–2018 from nationwide registers of dispensed drugs in Denmark, Finland, Iceland, Norway, and Sweden. The measures included annual opioid prevalence, defined daily doses (DDDs) per 1000 inhabitants per day (DIDs), and morphine milligram equivalents (MMEs) per user per day. Results From 2009 to 2018, an average of 808,584 of adults aged ≥65 used opioids yearly in all five countries; an average annual prevalence of 17.0%. During this time period, the prevalence decreased in Denmark, Norway, and Sweden due to declining codeine and/or tramadol use. Iceland had the highest opioid prevalence in 2009 (30.2%), increasing to 31.7% in 2018. In the same period, DIDs decreased in all five countries, and ranged from 28.3 in Finland to 58.5 in Denmark in 2009, and from 23.0 in Finland to 54.6 in Iceland in 2018. MMEs/user/day ranged from 4.4 in Iceland to 19.6 in Denmark in 2009, and from 4.6 in Iceland to 18.8 in Denmark in 2018. In Finland, Norway, and Sweden, MMEs/user/day increased from 2009 to 2018, mainly due to increasing oxycodone utilisation. Conclusions The stable or decreasing opioid utilisation prevalence among a majority of older adults across the Nordic countries coincides with an increase in treatment intensity in 2009–2018. We found large cross-national differences despite similarities across the countries’ cultures and healthcare systems. For the aged population, national efforts should be placed on improving pain management and monitoring future trends of especially oxycodone utilisation.

• Hamina, Aleksi; Odsbu, Ingvild; Borchgrevink, Petter Chr.; Chen, Li-Chia; Clausen, Thomas & Espnes, Ketil Arne [Show all 18 contributors for this article] (2022). Cohort Description: Preventing an Opioid Epidemic in Norway – Focusing on Treatment of Chronic Pain (POINT) – A National Registry-Based Study. Clinical Epidemiology. 14, p. 1477–1486. doi: 10.2147/CLEP.S382136. Full text in Research Archive Show summary

  Aim: The POINT project aims to provide evidence to optimise chronic pain management, prevent adverse consequences of opioids, and improve chronic pain patients’ pain relief, functional capacity, and quality of life. We describe the outline of the project and its work packages. More specifically, we describe a cohort of persons with chronic pain and a cohort of long-term opioid users identified from a national registry linkage. Data Sources: The project utilises data from nationwide healthcare and population registers in Norway. Using the Norwegian Prescription Database, we identified a cohort of persons who have been dispensed drugs reimbursed for chronic pain and a cohort of persons who used opioids long term from 2010 to 2019. Data from the Norwegian Registry for Primary Health Care and the Norwegian Patient Registry (2008– 2019), Cancer Registry (1990– 2018) Cause of Death Registry (2010– 2019) and demographic and socioeconomic registers from Statistics Norway (2010– 2019) were linked to the cohorts. Study Population: There were 568,869 participants with chronic pain. Sixty-three percent of the cohort was women, and the mean age was 57.1 years. There were 336,712 long-term opioid users (58.6% women; 60.9 years). In chronic pain and long-term opioid user cohorts, the most frequent musculoskeletal diagnosis was back pain diagnosed in primary care (27.6% and 30.7%). Psychiatric diagnoses were also common. Main Variables: Upcoming studies will utilise psychiatric and somatic diagnoses from the patient registers, drug use from the prescription register, causes of death, demographics, and socioeconomic status (eg, education, income, workability, immigrant status) as exposures or outcomes. Conclusion and Future Plans: The two cohorts have numerous pain-related diagnoses, especially in the musculoskeletal system, and noticeably frequent somatic and psychiatric morbidity. The POINT project also includes later work packages that explore prescriber and patient perspectives around safe and effective treatment of chronic pain.

• McDonald, Rebecca; Breidahl, Sibella; Abel-Ollo, Katri; Akhtar, Shabana; Clausen, Thomas & Day, Ed [Show all 12 contributors for this article] (2022). Take-Home Naloxone Kits: Attitudes and Likelihood-Of-Use Outcomes from a European Survey of Potential Overdose Witnesses. European Addiction Research. ISSN 1022-6877. doi: 10.1159/000521197. Full text in Research Archive Show summary

  Background: Injectable naloxone is already provided as take-home naloxone (THN), and new concentrated intranasal naloxone is now being introduced in Europe. Despite evidence of the effectiveness and cost-effectiveness of THN, little is known about the attitudes of key target populations: people who use opioids (PWUO), family/friends, and staff. We examined the acceptability of different naloxone devices (ampoule, prefilled syringe, and concentrated nasal spray) across 5 European countries. Objectives: The aim of this study was to compare THN target groups (PWUO vs. family/friends vs. staff) in their past rates of witnessed overdose and THN administration (as indicators of future use), current THN device preference, and THN carriage on the day of survey. Method: Cross-sectional survey of respondents (age ≥18) in addiction treatment, harm reduction, and recovery services in Denmark, England, Estonia, Norway, and Scotland. A purpose-developed questionnaire (59 items) was administered in the local language electronically or in a pen-and-paper format. Results: Among n = 725 participants, 458 were PWUO (63.2%), 214 staff (29.5%), and 53 (7.3%) family members. The groups differed significantly in their likelihood-of-future THN use (p < 0.001): PWUO had the highest rate of previously witnessing overdoses (352; 77.7%), and staff members reported the highest past naloxone use (62; 30.1%). Across all groups, most respondents (503; 72.4%) perceived the nasal spray device to be the easiest to use. Most reported willingness to use the spray in an overdose emergency (508; 73.5%), followed by the prefilled syringe (457; 66.2%) and ampoules (64; 38.2%). Average THN carriage was 18.6%, ranging from 17.4% (PWUO) to 29.6% (family members). Conclusion: Respondents considered the concentrated naloxone nasal spray the easiest device to use. Still, most expressed willingness to use the nasal spray as well as the prefilled syringe in an overdose emergency. Carriage rates were generally low, with fewer than 1 in 5 respondents carrying their THN kit on the day of the survey.

• Ericson, Øystein Bruun; Eide, Desiree; Lobmaier, Philipp Paul & Clausen, Thomas (2022). Staff preferences towards electronic data collection from a national take-home naloxone program: a cross-sectional study. Substance Abuse Treatment, Prevention, and Policy. 17(1). doi: 10.1186/s13011-022-00440-y. Full text in Research Archive
• Skurtveit, Svetlana Ondrasova; Odsbu, Ingvild; Gjersing, Linn; Handal, Marte; Lid, Torgeir Gilje & Clausen, Thomas [Show all 7 contributors for this article] (2022). Individuals Dying of Overdoses Related to Pharmaceutical Opioids Differ from Individuals Dying of Overdoses Related to Other Substances: A Population-Based Register Study. European Addiction Research. ISSN 1022-6877. 28(6). doi: 10.1159/000526145. Full text in Research Archive Show summary

  Background: Pharmaceutical opioid (PO) overdose deaths have increased in many Western countries. There are indications that those dying from a PO overdose differ from those dying from other types of overdoses. These differences might pose a challenge as the majority of current preventive measures are tailored toward those with the characteristics of "conventional" overdose deaths. Objective: We investigated differences in the characteristics of persons who died from PO overdoses compared to all other overdoses. Material and methods: Using the Norwegian Cause of Death Registry, we retrieved information on overdoses classified according to ICD-10 and identified PO overdoses (T40.2; T40.4) and all other overdoses (T40.X; T43.6) in 2010-2019. By linking data from nationwide registers, we analyzed data on opioid dispensations and the history of mental and behavioral disorders. 1,224 persons were registered with PO overdoses and 1,432 persons with other overdoses. Results: Persons in the PO overdose group were older and were more frequently women (35.0% vs. 20.5%) than persons with other overdoses. They had a higher prevalence of chronic pain (35.8% vs. 13.2%), history of cancer (8.1% vs. 1.8%), filled prescriptions of analgetic opioids more frequently the month before death (38.8% vs. 12.0%), and used threefold higher doses of prescribed opioids compared to individuals in all other overdose group (66 vs. 26 oral morphine equivalents/day). In the PO overdose group, oxycodone and fentanyl were more frequently dispensed, while codeine was more frequently dispensed in the other overdose groups. A lower proportion of those in the PO overdose group had recorded diagnoses of substance use disorders, schizophrenia, and hyperkinetic disorder compared to the other overdose groups. Conclusion: Persons dying from overdoses on POs often differ from the population targeted by existing prevention strategies, as they are more frequently older women with chronic pain and using high doses of prescription opioids.

• Hamina, Aleksi; Hjellvik, Vidar; Handal, Marte; Odsbu, Ingvild; Clausen, Thomas & Skurtveit, Svetlana Ondrasova (2022). Describing long-term opioid use utilizing Nordic Prescription Registers - A Norwegian example. Basic & Clinical Pharmacology & Toxicology. ISSN 1742-7835. 130(4), p. 481–491. doi: 10.1111/bcpt.13706. Full text in Research Archive Show summary

  Previous studies have defined long-term opioid use in varying ways, decreasing comparability, reproducibility and clinical applicability of the research. Based on recommendations from recent systematic reviews, we aimed to develop a methodology to estimate the prevalence of use persisting more than three months utilizing one of the Nordic prescription registers. We used the Norwegian Prescription Register (NorPD) to extract data on all opioid dispensations between 1 January 2004 and 31 October 2019. New users of opioids (washout 365 days) were defined as long-term users if they fulfilled two criteria: (1) they had ≥2 dispensations of opioids, 91–180 days apart; (2) days 0–90 included ≥90 dispensed administration units (e.g., tablets) of opioids. Overall, there were 2,543,224 new users of opioids during the study period. Of these, 354,666 (13.9%) fulfilled the criteria for long-term opioid use at least once. Compared with those who did not fulfil the criteria (short-term users), long-term users were older, more likely women and used tramadol, oxycodone and buprenorphine more frequently as their first opioid. In conclusion, we found that 1/7 of opioid users continued use longer than 3 months. Future outcome research should identify the clinically most important dose requirements for long-term opioid use criteria.

• Eide, Desiree; Lobmaier, Philipp Paul & Clausen, Thomas (2022). Who is using take-home naloxone? An examination of supersavers. Harm Reduction Journal. 19(1). doi: 10.1186/s12954-022-00647-z. Full text in Research Archive Show summary

  Background As the opioid overdose crisis persists and take-home naloxone (THN) programmes expand, it is important that the intervention is targeted towards those most likely to use it. We examined THN program participants to 1) describe those that return for refills, specifically those that reported multiple use (supersavers), and 2) to examine what rescuer characteristics were associated with higher rates of THN use. Methods This study included a cohort of consenting THN recipients from June 2014–June 2021 who completed initial and refill questionnaires from a widespread program in Norway. Age, gender, number of witnessed and experienced overdoses were assessed for associations with higher reported rates of THN use. ‘Supersavers’ reported 3 or more THN uses. Results A total of 1054 participants returned for a THN refill during the study period. Of these, 558 reported their last THN to have been used on an overdose. Supersavers (those that reported 3 or more THN uses) were younger, primarily reported current opioid use, and had witnessed higher rates of overdoses at the time of initial training when compared to non-supersavers (those that reported 0–2 THN uses). Conclusions THN programs should continue to emphasize and prioritize THN for people actively using drugs, particularly those who have witnessed overdoses previously.

• Ericson, Øystein Bruun; Eide, Desiree; Lobmaier, Philipp Paul & Clausen, Thomas (2022). Risks and overdose responses: Participant characteristics from the first seven years of a national take-home naloxone program. Drug and Alcohol Dependence. ISSN 0376-8716. 240:109645, p. 1–7. doi: 10.1016/j.drugalcdep.2022.109645. Full text in Research Archive Show summary

  Background In 2014, the Norwegian government funded a large-scale take-home naloxone (THN) program to address high overdose mortality rates. The aims of this study are to describe characteristics among persons trained to receive THN, describe actions taken following THN use at an overdose event and to explore factors associated with naloxone use. Methods This was a prospective cohort study of individuals who received THN from 2014 to 2021. Descriptive characteristics were collected at initial training. When returning for refill, participants reported on their previous naloxone use. In a multivariable logistic regression model exploring associations with naloxone use: gender, age, opioid use history, concomitant drug use, injecting, history of experienced or witnessed overdose were included. Results In total, 3527 individuals were included in this study. There were 958 individuals who returned for refills 2303 times. Most participants were male (63.6%), with a history of opioid use (77.5%). Those who reported naloxone use were more likely to have a history of opioid use (aOR= 4.1; 95% CI=2.77,6.1), were younger (aOR=0.98; 95% CI=0.97,0.99) and had witnessed overdoses (aOR=3.3; 95% CI=1.98,5.34). Among current opioid users, the odds were higher for injectors (aOR=1.57; 95% CI=1.18,2.1). Naloxone use was reported 1282 times. Additional actions such as waking the person and calling the ambulance were frequently reported. Survival was reported in almost all cases (94%). Conclusion People who use drugs are a suitable target group for THN-programs, as they seem to be willing and capable to reverse overdoses effectively. Given their personal risk factors for overdosing, recipients will likely also benefit from overdose prevention education.

• Welle-Strand, Gabrielle; Gjersing, Linn; Olsen, Ida Keihl & Clausen, Thomas (2022). A COVID-19 Survey among People Who Use Drugs in Norway. International Journal of Environmental Research and Public Health (IJERPH). ISSN 1661-7827. 19(12). doi: 10.3390/ijerph19127002. Full text in Research Archive Show summary

  Background: to combat the COVID-19 pandemic, adherence to COVID-19 recommendations and vaccination against COVID-19 have been important. Among people who use drugs (PWUD), little is known regarding compliance towards COVID-19 recommendations, COVID-19 testing, or attitudes towards COVID-19 vaccination. We aimed to examine these issues in a sample of PWUD. Methods: a cross-sectional study was conducted between January and March 2021. Through users’ organizations and different low-threshold services for substance users, we recruited former drug users and professionals to include participants and perform the interviews. Participants completed an interviewer-administered questionnaire. Any person above 16 years of age who used substances were recruited. Results: 477 Norwegian PWUD participated in the study. The mean age was 43.8 (SD 12.8) years and 77% were males. Thirty-four percent had injected drugs the past four weeks. Alcohol (41%) and cannabis (41%) were the most common drugs used the past four weeks, followed by tranquilizers (37%), central stimulants (35%) and opioids (30%). The majority (90%) had washed their hands frequently, used alcohol sanitizer during the past two weeks, had used face masks, kept one-meter distance to other people and stayed at home if feeling unwell. Fifty-four percent had been COVID-19 tested. More than half the sample (58%) had positive attitudes to COVID-19 vaccination, while 26% were fairly or very unlikely to accept vaccination. Those older (OR = 0.96, 95% CI 0.94; 0.98) and using face masks (OR = 0.49, 95% CI 0.30; 0.79) were more likely to have positive attitudes towards vaccination, while those reporting low life-satisfaction (OR = 3.86, 95% CI 1.43; 10.40), using opioids (OR = 2.97, 95% CI 1.43; 6.18) or almost never staying at home when feeling unwell (OR = 2.76, 95% 1.39; 5.45) expressed more negative attitudes towards vaccination. Conclusion: there was generally a high compliance towards COVID-19 recommendations, but one quarter of the sample was sceptical towards COVID-19 vaccination. This indicates a need for targeted and tailored information and well-designed vaccination roll-out programs to reach all PWUD.

• Odsbu, Ingvild; Handal, Marte; Hjellvik, Vidar; Borchgrevink, Petter Chr.; Clausen, Thomas & Nesvåg, Ragnar [Show all 7 contributors for this article] (2022). Vedvarende bruk av opioider og samtidig bruk av andre vanedannende legemidler. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. 142(3), p. 1–8. doi: 10.4045/tidsskr.21.0659. Full text in Research Archive Show summary

  BAKGRUNN<p> Vedvarende bruk av opioider kan ha uheldige konsekvenser. Vi har undersøkt vedvarende opioidbruk i pasientgruppersom fikk forskrevet opioider på ulike indikasjoner(langvarig smerte, palliativ behandling, andre (hvitresept)),samt gruppenessamtidige bruk av enkelte andre vanedannende legemidler.<p> MATERIALE OG METODE<p> <p>Personer med minst én utlevering av et opioid i Reseptregisteret i perioden 2011–19 ble inkludert. Vedvarende bruk i et kalenderår ble definertsom uthenting av > 180 definerte døgndoser eller > 4 500 mg orale morfinekvivalenterfordelt på minst tre kvartaler.<p> <p>RESULTATER Antall vedvarende opioidbrukere var 50 422 i 2011 og 59 996 i 2019 (10,1 % og 10,7 % av alle opioidbrukere). I perioden økte antalletsom fikk opioider på blå resept forlangvarige smerter, med 9 952 personer, men flertallet (n = 38 006, 63,3 %) fikk fortsa utlevert opioider utelukkende på hvitresept i 2019. Henholdsvis15 623 (41,1 %) og 14 881 (39,2 %) av de vedvarende opioidbrukerne som fikk utlevert opioider kun på hvitresept i 2019, fikk også utlevert benzodiazepiner og z-hypnotika samme år. Av de 23 967 vedvarende brukerne som også fikk utlevert benzodiazepiner, fikk 88 % utlevert opioider og benzodiazepiner på samme dag minst én gang i løpet av 2019.<p> <p>FORTOLKNING Vedvarende forskrivning av opioider på hvitresept og samtidig forskrivning av andre vanedannende legemidler kan tyde på uheldig bruk uten klarindikasjon.

• Mcdonald, Rebecca Silvia; Eide, Desiree; Abel-Ollo, Katri; Barnsdale, Lee; Carter, Ben & Clausen, Thomas [Show all 24 contributors for this article] (2022). A rapid assessment of take-home naloxone provision during COVID-19 in Europe. International journal of drug policy. ISSN 0955-3959. 107. doi: 10.1016/j.drugpo.2022.103787. Full text in Research Archive Show summary

  Background In March 2020, the World Health Organization declared COVID-19 a global pandemic. In the following weeks, most European countries implemented national lockdowns to mitigate viral spread. Services for people who use drugs had to quickly revise their operating procedures to rearrange service provision while adhering to lockdown requirements. Given the scarcity of literature published on overdose prevention during COVID-19 in Europe, we aimed to examine how these changes to service provision affected take-home naloxone (THN) programmes and naloxone availability across Europe. Methods Between November 2020 and January 2021, we conducted a rapid assessment with country experts from European countries that provide THN. We sent country experts a template to report monthly THN distribution data (January 1, 2019-October 31, 2020) and a structured 6-item survey for completion. Results Responses were received from 14 of the 15 European countries with THN provision of which 11 participated in the rapid assessment: Austria, Denmark, England, Estonia, Lithuania, Northern Ireland, Norway, Scotland, Spain (Catalonia only), Sweden, and Wales. All reported reduced organisational capacity during COVID-19, and some put into place a range of novel approaches to manage the restrictions on face-to-face service provision. In six countries, the introduction of programme innovation occurred alongside the publication of government guidelines recommending increased THN provision during COVID-19. Eight of the eleven participating countries managed to maintain 2019-level monthly THN distribution rates or even increase provision during the pandemic. Conclusion Through programme innovation supported by public guidelines, many European THN programmes managed to ensure stable or even increased THN provision during the pandemic, despite social distancing and stay-at-home orders affecting client mobility.

• Skeie, Ivar; Clausen, Thomas; Hjemsæter, Arne Jan; Landheim, Anne Signe; Monsbakken, Bent Berntsen & Thoresen, Magne [Show all 7 contributors for this article] (2022). Mortality, Causes of Death, and Predictors of Death among Patients On and Off Opioid Agonist Treatment: Results from a 19-Year Cohort Study. European Addiction Research. ISSN 1022-6877. 28(5), p. 358–367. doi: 10.1159/000525694. Full text in Research Archive Show summary

  Background: Mortality is increased among people with opioid use disorder but reduced while on opioid agonist treatment (OAT). However, the impact of patient and treatment characteristics on mortality and causes of death is insufficiently studied. Objectives: The objective of this study was to explore mortality and causes of death and examine the impact of patient and treatment characteristics on mortality in an OAT cohort with high retention in treatment. Methods: Design: longitudinal cohort study. Setting: Norway. Observation period: time from OAT start as of 1998 until death or end of 2016, 2,508 person-years (PY) in total. Sample: 200 persons starting OAT 1998–2007. Data sources: hospital records, interviews, the Norwegian Cause of Death Registry, Statistics Norway. Results: Retention: 86.4% of the observation period was on OAT, 9.0% off, 4.6% unknown OAT status. All-cause crude mortality rate per 100 PY during the whole observation period was 1.64 (95% CI: 1.19–2.20), for deaths of somatic cause 0.88 (0.56–1.31), for drug-induced deaths 0.44 (0.23–0.76), and traumatic deaths 0.24 (0.10–0.50). Off-versus-on-OAT all-cause mortality ratio was 2.31 (1.00–4.85). On OAT, 58% of the deaths were of somatic cause and 21% drug-induced; off OAT, 38% of somatic cause and 50% drug-induced. Increasing baseline age and rate of somatic hospital treatment episodes were independently associated with increased all-cause mortality risk, while increasing rate of in-patient psychiatric treatment episodes was associated with reduced risk. Increasing duration of nicotine and cannabis use and alcohol dependence as well as increasing severity of polydrug use were associated with increased all-cause and somatic mortality adjusted for age and sex. Conclusion: The long observation period made it possible to demonstrate the importance of long-term retention in OAT to reduce mortality. Further, the preponderance of somatic and reduction of drug-induced causes of death during OAT underlines the need for follow-up of chronic diseases and health-promoting lifestyle changes. These findings add to the knowledge about long-term OAT effects, not least in ageing OAT populations. © 2022 The Author(s). This article is licensed under the Creative Commons Attribution 4.0 International License (CC BY) (http://www.karger.com/Services/OpenAccessLicense). Usage, derivative works and distribution are permitted provided that proper credit is given to the author and the original publisher.

• Bjørnestad, Endre Dahlen; Vederhus, John-Kåre & Clausen, Thomas (2022). High smoking and low cessation rates among patients in treatment for opioid and other substance use disorders. BMC Psychiatry. 22(1), p. 1–8. doi: 10.1186/s12888-022-04283-6. Full text in Research Archive Show summary

  Background: Smoking is a well-documented cause of health problems among individuals with substance use disorders. For patients in opioid maintenance treatment (OMT), the risk for somatic health problems, including preventable diseases associated with tobacco smoking, increases with age. Our aim was to describe smoking among patients entering substance use disorder (SUD) treatment, investigate changes in smoking from the start of treatment to 1-year follow-up, and explore factors related to smoking cessation. Methods: We employed data from the Norwegian Cohort of Patient in Opioid Maintenance Treatment and Other Drug Treatment Study (NorComt). Participants were 335 patients entering SUD treatment at 21 participating facilities across Norway. They were interviewed at the start of treatment and at 1-year follow-up. The main outcomes were smoking and smoking cessation by treatment modality. A logistic regression identified factors associated with smoking cessation. Results: High levels of smoking were reported at the start of treatment in both OMT (94%) and other SUD inpatient treatment patients (93%). At 1-year follow-up most patients in OMT were still smoking (87%), and the majority of the inpatients were still smoking (69%). Treatment as an inpatient was positively associated and higher age was negatively associated with smoking cessation. Most patients who quit smoking transitioned to smokeless tobacco or kept their existing smokeless habit. Conclusion: As illustrated by the high smoking prevalence and relatively low cessation levels in our sample, an increased focus on smoking cessation for patients currently in OMT and other SUD treatment is warranted. Harm-reduction oriented smoking interventions may be relevant.

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• Gjersing, Linn; Clausen, Thomas; Edvardsen, Hilde Marie Erøy; Bergem, Anne Kristine; Buvik, Kristin & Eide, Desiree [Show all 21 contributors for this article] (2025). Overdoseboka. En helhetlig gjennomgang. Cappelen Damm Akademisk. ISBN 9788202852610. 284 p. doi: https:/www.cappelendamm.no/boker/overdoseboka-9788202852610. Full text in Research Archive Show summary

  Boken omhandler et bredt spekter av temaer knyttet til overdoseproblematikk. Den går i dybden på rusmidlers virkning, risikofaktorer og relaterte helseutfordringer. Politikkens og myndighetenes rolle i forebygging og behandling presenteres. Boken utforsker også skadereduksjon og oppfølging i tjenesteapparatet, og gir et innblikk i brukeres, pårørendes og helsepersonells opplevelser og erfaringer. Videre belyses politiets arbeid, obduksjoner og registrering av dødsfall. Målet er at boken kan bidra til en mer helhetlig forståelse, og dermed bedre tjenester og en reduksjon av overdoser.

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• Bukten, Anne; Mehlum, Lars; Fazel, Seena; Lokdam, Nicoline Toresen; Skurtveit, Svetlana Ondrasova & Ericson, Øystein Bruun [Show all 11 contributors for this article] (2026). Risikofaktorer for selvmord under fengsling og etter løslatelse. Full text in Research Archive
• Bukten, Anne; Mehlum, Lars; Fazel, Seena; Lokdam, Nicoline Toresen; Tverborgvik, Torill & Skurtveit, Svetlana Ondrasova [Show all 12 contributors for this article] (2026). Psykisk helse i fengsel. Risikofaktorer for selvmord under fengsling og etter løslatelse. doi: https:/www.fagligforum.no/event/rus-og-psykisk-helse-2026/. Full text in Research Archive
• Bukten, Anne; Mehlum, Lars; Lokdam, Nicoline Toresen; Fazel, Seena; Tverborgvik, Torill & Skurtveit, Svetlana Ondrasova [Show all 12 contributors for this article] (2025). Suicides among people in prison. Full text in Research Archive
• Bukten, Anne; Stavseth, Marianne Riksheim; Tverborgvik, Torill; Clausen, Thomas; Lothe, Johan & Havnes, Ingrid Amalia [Show all 8 contributors for this article] (2024). Rus og psykisk helse. Full text in Research Archive
• Stavseth, Marianne Riksheim; Tverborgvik, Torill; Skardhamar, Torbjørn; Clausen, Thomas; Lothe, Johan & Havnes, Ingrid Amalia [Show all 8 contributors for this article] (2024). Rus og psykiske lidelser. Full text in Research Archive
• Comiskey, Catherine; Bergeron, Henri; Clausen, Thomas; Colman, Charlotte; Ferrer-Wreder, Laura & Fischer, Gabriele [Show all 15 contributors for this article] (2024). The importance of co-produced, multi-method, independent scientific evidence in times of alternative truths and global policy debates. doi: 10.1016/j.drugpo.2024.104481. Full text in Research Archive
• Myklebust, Lars Henrik Ryther; Eide, Desiree; Arnevik, Espen Ajo; Dadras, Omid; Pirro, Silvana De & Ellefsen, Rune [Show all 14 contributors for this article] (2024). Evaluation of heroin-assisted treatment in Norway: protocol for a mixed methods study. BMC Health Services Research. 24(1). doi: 10.1186/s12913-024-10767-w. Full text in Research Archive Show summary

  Background Opioid agonist treatment (OAT) for patients with opioid use disorder (OUD) has a convincing evidence base, although variable retention rates suggest that it may not be beneficial for all. One of the options to include more patients is the introduction of heroin-assisted treatment (HAT), which involves the prescribing of pharmaceutical heroin in a clinical supervised setting. Clinical trials suggest that HAT positively affects illicit drug use, criminal behavior, quality of life, and health. The results are less clear for longer-term outcomes such as mortality, level of function and social integration. This protocol describes a longitudinal evaluation of the introduction of HAT into the OAT services in Norway over a 5-year period. The main aim of the project is to study the individual, organizational and societal effects of implementing HAT in the specialized healthcare services for OUD. Methods The project adopts a multidisciplinary approach, where the primary cohort for analysis will consist of approximately 250 patients in Norway, observed during the period of 2022–2026. Cohorts for comparative analysis will include all HAT-patients in Denmark from 2010 to 2022 (N = 500) and all Norwegian patients in conventional OAT (N = 8300). Data comes from individual in-depth and semi-structured interviews, self-report questionnaires, clinical records, and national registries, collected at several time points throughout patients’ courses of treatment. Qualitative analyses will use a flexible inductive thematic approach. Quantitative analyses will employ a wide array of methods including bi-variate parametric and non-parametric tests, and various forms of multivariate modeling. Discussion The project’s primary strength lies in its comprehensive and longitudinal approach. It has the potential to reveal new insights on whether pharmaceutical heroin should be an integral part of integrated conventional OAT services to individually tailor treatments for patients with OUD. This could affect considerations about drug treatment even beyond HAT-specific topics, where an expanded understanding of why some do not succeed with conventional OAT will strengthen the knowledge base for drug treatment in general. Results will be disseminated to the scientific community, clinicians, and policy makers. Trial registration The study was approved by the Norwegian Regional Committee for Medical and Health Research Ethics (REK), ref.nr.:195733.

• Ericson, Øystein Bruun; Eide, Desiree; Lobmaier, Philipp Paul & Clausen, Thomas (2024). Correction: Staff preferences towards electronic data collection from a national take-home naloxone program: a cross-sectional study (Substance Abuse Treatment, Prevention, and Policy, (2022), 17, 1, (13), 10.1186/s13011-022-00440-y). Substance Abuse Treatment, Prevention, and Policy. 19(1). doi: 10.1186/s13011-024-00609-7. Full text in Research Archive
• Borchgrevink, Petter Christian & Clausen, Thomas (2024). Advares mot langvarig bruk av sterke opioider som oksykodon ved kronisk smerte. Thomas Clausen og Petter Borchgrevink fra POINT-prosjektet intervjuet av TV2 Nyheter 07.05.24. [Journal]. TV2.no. Full text in Research Archive
• Eide, Desiree; McDonald, Rebecca & Clausen, Thomas (2024). Overdoses in the drug consumption room: route of administration matters! Full text in Research Archive
• Eide, Desiree; Pirro, Silvana De; Myklebust, Lars Henrik Ryther; Melis, Francesca; Oldervoll, Ann & Clausen, Thomas (2024). Norway's first heroin-assisted treatment clinics: initial impact of the intervention. Full text in Research Archive
• Eide, Desiree; Ericson, Øystein Bruun & Clausen, Thomas (2024). Update on Drug Checking. Full text in Research Archive
• Clausen, Thomas & Skurtveit, Svetlana Ondrasova (2024). Bruken øker kraftig blant unge. Ingen vet hvorfor. [Internet]. TV2. Full text in Research Archive
• Nesse, Linda; Mcdonald, Rebecca Silvia; Bech, Anne Berit & Clausen, Thomas (2023). Medborgerskap: Et perspektiv for brukermedvirkning i LAR. Rus & samfunn. ISSN 1500-8614. Full text in Research Archive
• Clausen, Thomas (2023). Når det går galt. Full text in Research Archive
• Skurtveit, Svetlana Ondrasova & Clausen, Thomas (2023). Hun kjemper mot abstinensene smertene og skammen har norge en opioid krise. [Journal]. A-magasinet : uketillegg til Aftenposten. Full text in Research Archive
• Skurtveit, Svetlana Ondrasova & Clausen, Thomas (2022). Flere kvinner dør av smertestillende piller. [Journal]. Aftenposten (morgenutg. : trykt utg.). Full text in Research Archive
• Clausen, Thomas (2022). OxyContin: – Det er jeg som hører at hun gråter om natten. [Internet]. NRK Nyheter. Full text in Research Archive
• Mcdonald, Rebecca Silvia & Clausen, Thomas (2022). Revised service delivery of opioid agonist treatment in Norway in 2021, the second year of the pandemic: a national cross-sectional study of treatment provider experiences. Full text in Research Archive
• Bjørnestad, Endre Dahlen; Vederhus, John-Kåre & Clausen, Thomas (2022). High smoking and low cessation rates among patients in treatment for opioid and other substance use disorders. Full text in Research Archive
• Uleberg, Oddvar; Kristiansen, Thomas; Nordseth, Trond; Stenehjem, Jo S.; Gran, Jon Michael & Clausen, Thomas [Show all 8 contributors for this article] (2022). Skader etter vold og ulykker - den glemte pandemi? 142(8), p. 678–679. doi: 10.4045/tidsskr.22.0261. Full text in Research Archive
• Gjerde, Line Cecilie; Handal, Marte; Nesvåg, Ragnar; Clausen, Thomas; Lid, Torgeir Gilje & Hamina, Aleksi [Show all 8 contributors for this article] (2022). A nationwide registry-linkage study of mental disorders in chronic pain patients: Characteristics of users of opioid versus non-opioid analgesics. Full text in Research Archive
• Hamina, Aleksi; Odsbu, Ingvild; Hjellvik, Vidar; Gjersing, Linn; Lid, Torgeir Gilje & Clausen, Thomas [Show all 7 contributors for this article] (2022). Fatal overdoses in a cohort of chronic pain patients. Full text in Research Archive
• Odsbu, Ingvild; Handal, Marte; Borchgrevink, Petter Chr.; Clausen, Thomas & Skurtveit, Svetlana Ondrasova (2022). Endringer i opioidbruken i Norge må tas på dypeste alvor. Tidsskrift for Den norske legeforening (Tidsskriftet). ISSN 0029-2001. doi: 10.4045/tidsskr.21.0909. Full text in Research Archive
• Clausen, Thomas (2022). Dagsrevyen Avhengig av medisiner. [TV]. NRK Dagsrevyen. Full text in Research Archive
• Bukten, Anne; Lokdam, Nicoline; Skjærvø, Ingeborg; Ugelvik, Thomas; Skurtveit, Svetlana Ondrasova & Gabrhelík, Roman [Show all 20 contributors for this article] (2022). PriSUD-Nordic—Diagnosing and Treating Substance Use Disorders in the Prison Population: Protocol for a Mixed Methods Study. JMIR Research Protocols. 11(3). doi: 10.2196/35182. Full text in Research Archive Show summary

  Background: A large proportion of the prison population experiences substance use disorders (SUDs), which are associated with poor physical and mental health, social marginalization, and economic disadvantage. Despite the global situation characterized by the incarceration of large numbers of people with SUD and the health problems associated with SUD, people in prison are underrepresented in public health research. Objective: The overall objective of the PriSUD (Diagnosing and Treating Substance Use Disorders in Prison)-Nordic project is to develop new knowledge that will contribute to better mental and physical health, improved quality of life, and better life expectancies among people with SUD in prison. Methods: PriSUD-Nordic is based on a multidisciplinary mixed method approach, including the methodological perspectives of both quantitative and qualitative methods. The qualitative part includes ethnographic fieldwork and semistructured interviews. The quantitative part is a registry-based cohort study including national registry data from Norway, Denmark, and Sweden. The national prison cohorts will comprise approximately 500,000 individuals and include all people imprisoned in Norway, Sweden, and Demark during the period from 2000 to 2019. The project will investigate the prison population during three different time periods: before imprisonment, during imprisonment, and after release. Results: PriSUD-Nordic was funded by The Research Council of Norway in December 2019, and funding started in 2020. Data collection is ongoing and will be completed in the first quarter of 2022. Data will be analyzed in spring 2022 and the results will be disseminated in 2022-2023. The PriSUD-Nordic project has formal ethical approval related to all work packages. Conclusions: PriSUD-Nordic will be the first research project to investigate the epidemiology and the lived experiences of people with SUD in the Nordic prison population. Successful research in this field will have the potential to identify significant areas of benefit and will have important implications for ongoing policy related to interventions for SUD in the prison population.

• Hamina, Aleksi; Odsbu, Ingvild; Clausen, Thomas & Skurtveit, Svetlana Ondrasova (2022). Intentional overdoses and associated mental health challenges, an overlooked sub-population of overdoses. Full text in Research Archive
• Eide, Desiree; Ericson, Øystein Bruun & Clausen, Thomas (2025). Et forslag til plan for rusmiddeltestingstjenester i fire norske byer; på oppdrag fra Helsedirektoratet. Universitetet i Oslo. doi: https:/www.med.uio.no/klinmed/forskning/sentre/seraf/publikasjoner/rapporter/2025/seraf-rapport-1-2025---forslag-til-plan-rusmiddeltesting.pdf. Full text in Research Archive
• McDonald, Rebecca Silvia; Bech, Anne Berit & Clausen, Thomas (2025). Evaluering av implementeringen av revidert nasjonal faglig retningslinje for legemiddelassistert rehabilitering (LAR) ved opioidavhengighet. Universitetet i Oslo. doi: https:/www.med.uio.no/klinmed/forskning/sentre/seraf/publikasjoner/rapporter/2025/seraf-rapport-2-2025---evaluering-av-implementeringen-av-revidert-nasjonal-faglig-retningslinje-for-lar.pdf. Full text in Research Archive
• Bukten, Anne; Lillevold, Pål Henrik; Skeie, Ivar & Clausen, Thomas (2025). SERAF rapport nr 5/2025 Statusrapport 2024. Universitetet i Oslo. doi: https:/www.med.uio.no/klinmed/forskning/sentre/seraf/publikasjoner/rapporter/2025/seraf-rapport-nr-5-2025-statusrapport-2024.pdf.pdf. Full text in Research Archive
• Lunde, Rose Elisabeth; Oldervoll, Ann; Clausen, Thomas & Eide, Desiree (2025). Evaluering av brukerrom i Oslo og Bergen. Senter for rus- og avhengighetsforskning. doi: https:/www.med.uio.no/klinmed/forskning/sentre/seraf/publikasjoner/rapporter/2025/seraf-rapport-4-2025-evaluering-av-brukerrom-i-oslo-og-bergen.pdf. Full text in Research Archive Show summary

  Brukerromsordningen tilbyr hygieniske og trygge rammer for inntak av illegale rusmidler. Formålet med ordningen er å redusere skader knyttet til rusbruk, samt redusere faren for overdose og smittespredning. Det første brukerrommet i Norge ble åpnet i 2005 i Oslo. I årene som har gått, har det skjedd betydelige fremskritt på feltet, blant annet gjennom lovendringer og en utvidelse av tilbudet til å inkludere andre rusmidler enn heroin og andre inntaksformer enn injisering. I dag finnes det brukerrom både i Oslo og Bergen. Tidligere evalueringer, utført av Statens institutt for rusmiddelforskning (SIRUS) i 2007 og 2009, belyste utfordringene ved oppstarten av brukerromsordningen og ga flere anbefalinger. Denne evalueringen er utført etter oppdrag fra Helsedirektoratet og har som mål å bidra med økt og oppdatert kunnskap på feltet. Dette gjøres gjennom å analysere sentrale utviklingsområder og ved å inkludere perspektivene til både ansatte og brukere. Evalueringen har tatt i bruk et blandet metodedesign («mixed methods»). Metodologien inkluderer kvantitativ data om drift, trender og erfaringer i brukerrommene, samlet inn via spørreskjemaer besvart av ledelse og ansatte. I tillegg ble det gjennomført dybdeintervjuer med registrerte brukere ved Prindsen mottakssenter i Oslo. Sistnevnte gir et kvalitativt innblikk i brukernes perspektiver og erfaringer.

• Melis, Francesca; Clausen, Thomas; Thylstrup, Birgitte; Tjagvad, Christian & Eide, Desiree (2025). Evaluering af behandling med lægeordineret heroin i Danmark. University of Oslo (UiO). doi: https:/www.med.uio.no/klinmed/forskning/sentre/seraf/aktuelt/aktuelle-saker/2025/seraf-rapport-2025.pdf. Full text in Research Archive Show summary

  The purpose of the report is to conduct an evaluation of the Danish HAT program. The report includes how the program has evolved since its implementation in 2010, program challenges from different perspectives and potential areas for improvement, particularly as it relates to patient dignity. The evaluation offers insights into patient outcomes while in treatment, staff and patient impressions on treatment, staff opinions on the treatment guidelines, and operational differences between the five clinics. This evaluation did not conduct a cost-benefit analysis, nor does it offer recommendations for how to update clinical practices guidelines. Such evaluations are outside the scope of this report.

• Eide, Desiree; Bjørnestad, Ronny; Brummer, Julie Elizabeth; Dadras, Omid; Pirro, Silvana De & Ellefsen, Rune [Show all 17 contributors for this article] (2024). Midtveisrapport om heroinassistert behandling fra 2022-2023 (SERAF rapport 4/2024). Senter for rus- og avhengighetsforskning. Full text in Research Archive Show summary

  Denne midtveisrapporten tar for seg de to første årene av Norges første heroinassisterte behandlingsprogram (HAB) som er planlagt å vare ut 2026 som et tidsavgrenset klinisk forsøksprosjekt. Forsøksprosjektet HAB ble etablert som del av legemiddelassistert rehabilitering (LAR) i Oslo og Bergen. Fra 1. januar 2022 til 31. desember 2023 ble 92 av totalt 97 pasienter inkludert i forskningsprosjektet som skal evaluere de to nyetablerte HABklinikkene. Denne rapporten beskriver etableringen av klinikkene, pasienterfaringer og pasientrapporterte resultater mens de var i heroinassistert behandling. Denne rapporten gir en midtveisevaluering av forsøksprosjektet. En endelig og utvidet evalueringsrapport vil bli levert i løpet av første halvdel av 2026.

• Nesse, Linda; Lobmaier, Philipp Paul; Skeie, Ivar; Lillevold, Pål Henrik & Clausen, Thomas (2024). Statusrapport 2023: Tjuefem år med legemiddelassistert rehabilitering (LAR). Universitetet i Oslo. Full text in Research Archive
• Nesse, Linda; Lobmaier, Philipp Paul; Skeie, Ivar; Lillevold, Pål Henrik & Clausen, Thomas (2023). Statusrapport 2022: Første år med nye LAR-retningslinjer. Universitetet i Oslo. Full text in Research Archive Show summary

  SERAF utarbeider en årlig nasjonal statusrapport for legemiddelassistert rehabilitering (LAR) på oppdrag fra Helsedirektoratet. Statusrapportenen er basert på en kartlegging som alle LAR-tiltakene gjennomfører en gang i året. Formålet er å kartlegge pasientenes situasjon, behandling, og behandlingsutfall i LAR. Denne spørreundersøkelsen har blitt gjennomført gjennom de siste 23 årene, og har vist at LAR over tid har utviklet seg til å være en godt etablert, standardisert behandling for de fleste med opioiddominert avhengighet. I statusrapporten oppsummeres sentrale funn om situasjonen til pasienter i LAR, aktuell behandlingsstatus, medikamentell behandling (inkludert valg av medikament og dosering), psykososial oppfølging (som behandlingsmål, individuell plan, ansvarsgruppemøter og behandling for psykiske helseproblemer), psykiske helseproblemer og rusbruk siste fire uker, og rusbruk og helserelaterte forhold siste år, og tilfredshet med behandlingen. I tillegg presenteres funn om dødsfall blant pasienter i LAR siste år. Ivar Skeie har analysert mortalitetsdata og har fulgt LAR-tiltakene tett for å kunne inkludere komplette tall på overdoser, suicid og naturlige dødsfall. Årets statusrapport bygger på svar fra 18 ulike LAR-tiltak fordelt på fem regioner. Innføringen av det elektroniske journalsystemet Helseplattformen ved St. Olavs hospital og i Nord-Trøndelag har medført utfordringer som har gjort at disse LAR-tiltakene ikke har hatt mulighet til å gjennomføre statusundersøkelsen. Dette innebærer at tallene som presenteres for region Midt ikke kan sammenlignes med fjorårets tall for samme region, og at nasjonale gjennomsnitt ikke inkluderer St. Olavs hospital og Nord-Trøndelag. I 2022 ble det innført nye LAR-retningslinjer, og dette er den første statusrapporten som er gjennomført etter dette. I tillegg inneholder årets statusrapport flere nye elementer. LAR-tiltak som benytter det elektroniske journalsystemet DIPS Arena har besvart en noe videreutviklet versjon av statusundersøkelsen som inkluderer nye tilleggsopplysninger. Tiltakene det gjelder er Oslo, Bergen, Fonna og Førde. De nye spørsmålene omhandler blant annet opplevde bivirkninger av LAR-medikament, og ulike spørsmål om fysisk helse, sykdommer og behandling siste år. Spørsmålene er besvart av omtrent 1 av 4 pasienter i LAR, og bidrar til å videreutvikle kunnskap om behandlingen og om pasientenes situasjon. Samtidig er det første gang pasienter som er i heroinassistert behandling (HAB) deltar i statsundersøkelsen. I et av kapitlene oppsummeres hovedfunn for pasienter i HAB. Vi ser at økningen av gjennomsnittsalderen i LAR fortsetter også i år. Vi minner om at en aldrende LAR-populasjon er å anse som en suksess i seg selv. LAR har medført at mange personer med opioidavhengighet kan eldes med sykdommen. Samtidig ønsker vi i fremtiden å styrke forutsetninger for gode levevaner, tilgjengelig utredning og behandling for psykiske lidelser, utredning og behandling for somatiske sykdommer som hepatitt C, og regelmessige legeundersøkelser. Det er viktig at LAR fortsetter å være en behandlingsmodell som oppleves tilgjengelig, til å leve godt med over tid, med høy faglig kvalitet og forsvarlighet. Samtidig er det viktig å støtte majoriteten av pasientene i å ha en rimelig god rusmestring. Denne balansegangen utgjør hverdagen til pasienter og behandlere i LAR. Denne rapporten er resultatet av betydelig innsats i hvert LAR-tiltak. Vi takker for innsatsen fra pasienter i LAR som har besvart statusundersøkelsen, LAR-ansatte over hele landet for arbeidet med innsamling av svar, og for et godt samarbeid med LAR-tiltakene og med Helsedirektoratet.

• Bech, Anne Berit; Clausen, Thomas & Lillevold, Pål Henrik (2022). SERAF rapport 1/2022 - Forebygging og håndtering av covid-19 i LAR-tiltakene i spesialisthelsetjenesten 2021 - Erfaringer og tiltak. 7Letras. Full text in Research Archive
• Bech, Anne Berit; Bukten, Anne; Lobmaier, Philipp Paul; Skeie, Ivar; Lillevold, Pål Henrik & Clausen, Thomas (2022). SERAF RAPPORT 2/2022 Statusrapport 2021-Siste år med gamle LAR-retningslinjer. 7Letras. Full text in Research Archive

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