A restrictive drug policy on shaky ground?
Several aspects of Norwegian drug policy are presently challenged. The public health services and the social services have had a decades-long statutory responsibility for treating substance use disorders. Since the Vagrancy Act was abolished in 2006, there has been no legal basis on which to impose criminal sanctions for intoxicated behaviour. There has long been widespread agreement that the health and care services are responsible when substance abuse results in ill health. Drug dependent subjects should be treated, not punished. Therefore, the key issues are not whether a person with substance use disorder should be treated, but when and how. Some signals from the political sphere and professional field give cause for concern.
One such signal is that several important politicians seem to want to decide how drug-assisted rehabilitation (DAR) should develop. The Norwegian government states in its current political platform that it wishes to include more medications and ensure greater freedom of choice in DAR, as well as conduct trials with heroin-assisted treatment within DAR (3). The drug users are supposed to have more influence over which medications should be prescribed for them. It is not clear what this means, but the fundamental conditions underlying DAR are not mentioned. The most important aspect is that the drug-dependent patient can be stabilised with a medication that works so slowly over such a long period of time that he or she can be treated with a drug that is taken once every 24 hours. The goal is that the patient can live his or her life in society without being dominated by swings between abstinence and intoxication.
Norway currently uses methadone and buprenorphine, two internationally approved and recommended drugs. One possible option is slow-release morphine, which is used in Austria and some other countries (4). Treatment results from this are on par with methadone, and some patients report a slightly improved quality of life (5). However, the drug is more difficult to manage and much more expensive. Treatment with short-term drugs such as heroin (diacetylmorphine) requires 2–3 doses per day, and clinics must therefore be established where patients come several times a day, seven days a week, for an unlimited period of time (6). DAR is currently being imposed as a cost-reduction regime, and there is no indication that more resources will accompany the new medications.
The user organisations have signalled the expectation that patients will have increased influence on chosen medications, including other opioids such as morphine chloride and oxycodone. However, the immediate subjective high following drug intake is a central motivation in heroin addiction. This craving, which intensifies with repeated use, is critical for understanding a substance use disorder (7). Usually, popular abused drugs have a rapid, intense effect – not a delayed one due to slow absorption and gradual uptake into the brain, such as methadone. This can easily lead to conflict and dissatisfaction between patients and doctors if treatment is developed with the expectation that the user's wishes and experience of the drug's effect will be a determining factor in the choice of medications.
There is also reason to expect difficulties relating to control measures. In Denmark, where control is less stringent, the number of deaths linked to methadone is higher than the number of heroin-related deaths (8). In England, the number of fatal overdoses caused by heroin is lower than the number caused by prescription opioids with methadone as the main contributor (9). The percentage of methadone-related deaths in Norway continued to increase up to 2012 (10). As a result, more emphasis was placed on various types of controls over the drug's distribution and use, and the percentage of methadone deaths has since declined (10). The percentage of heroin-related deaths has also dropped significantly, but mortality resulting from opioid use is still relatively unchanged due to the increase in deaths from other opioids, including medications requested by users (10).
A concern in this regard is that individual doctors have also begun to prescribe other opioids, especially morphine sulphate, as well as oxycodone. An example of this is that the doctor in charge of a low-threshold intervention in Oslo city centre recommends 'drawing on the entire pharmaceutical compendium in the effort to help the most down-and-out users' (11). The expression 'use the entire pharmaceutical compendium' has gained popularity in the media and is heard in political debates as well. But what does this really mean? Like other patients, those with substance use disorders will of course get drug-related help as indicated by their medical condition. By the same token, the risk of complications and issues of safety must be taken into account. However, the expression is often interpreted to mean that people with substance use disorders should be treated with the opioid of their choice based on their own experiences. Some user organisations now also require maintenance treatment for users of CNS stimulants and benzodiazepines. Treatment of alcohol addiction is mentioned in this context as well (12). On this basis, it is not surprising that we are currently seeing an increase in prescriptions for habit-forming drugs, especially opioids such as oxycodone and tramadol (12, 13). Mortality statistics show that these drugs are increasingly contributing to fatal overdoses (10).