Nordia's Role in the Treatment of Substance Abuse

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1 ASTRID SKRETTING Treatment reforms Norway From client to patient Will the Norwegian substance abuse treatment reform mean better access to treatment? Is substance abuse an illness or attributable to social factors and personal dispositions? Should treatment for substance abuse be the responsibility of health care or social welfare services? Are substance abusers patients or clients? Opinions vary on the underlying causes of substance abuse and the most appropriate way of going about its treatment. In the Nordic countries there is traditionally a strong social services approach, in many other countries responsibility for the treatment of substance abuse rests mainly with the health sector. There is much current interest in the relative effectiveness of different treatments. In the Nordic countries, the Swedish Council on Technology Assessment in Health Care has compiled a state of the art knowledge of treatments for alcohol and drug problems (SBU 2001), and in Norway a research commission report has recently come out on the effectiveness of measures in the alcohol and drugs field (NOU 2003:4). In the so-called evidence based research literature, conclusions on effectiveness seem primarily to lean in the direction of medically oriented treatments. In Norway, concerns about the increasing need for better services and treatment for substance abusers have their background in the continuing escalation of problems related to substance abuse. The number of drug-related deaths increased dramatically in the latter half of the 1990s (Bryhni 2004). From the late 1980s to the early 2000s, the estimated number of injecting drug users in the country climbed from around 4,000 5,000 to 12,000 15,000 (SIRUS 2003). There is also increasing evidence that large numbers of substance abusers are in seriously poor health (Kurtze & Eide 2003) and that they are not getting the health services they need (Ruud & Reas 2003). Major reforms have swept the Norwegian health care organisation in recent years. In 2001, with the launch of a new family doctor system, all residents in the country were assigned their own GP. In connection with the hospital reform that took effect 167

2 on 1 January 2002, ownership and responsibility for the operation of hospitals and other specialised health care services were transferred from county municipalities to central government. At the same time the country s five health care regions were transformed into five state-owned regional health enterprises, which have a statutory responsibility of ensuring that all the people living in their respective areas have access to specialised health care services. The aim of the hospital reform is to promote the attainment of health policy objectives and to support more effective resource allocation. In the wake of the hospital reform, the substance abuse treatment system has also been upgraded. As from 1 January 2004, responsibility for the treatment of substance abuse has been transferred from county municipalities to the regional health enterprises. The provision of other services to substance abusers, however, remains the responsibility of local municipalities. The new regional health enterprises have the responsibility of the provision of specialised interdisciplinary treatment for substance abuse. The units working to meet this task are no longer governed by social welfare legislation, but legislation on specialised health care. The Ministry of Health and Care Services has recently issued a circular detailing the implications of these changes (Helsedepartementet 2004a). The circular explains the regulations of the Patients Rights Act and how these are to be applied for the specialised interdisciplinary treatment services for substance abuse. Moreover the Ministry has drawn up a strategy document directed to the regional health enterprises, explaining the national perspectives and strategies in the substance abuse treatment reform (Helsedepartementet 2004b). Aims of the reform The substance abuse treatment reform is an ambitious project. The Ministry s strategy document says that the standard of services provided to substance abusers with multiple problems shall be improved. Treatments shall be upgraded into specialised interdisciplinary health services that focus on comprehensive and individual approaches, with equal weight given to the social welfare and health perspectives (Helsedepartementet 2004b). Furthermore, the document specially highlights the rights of substance abusers as patients. It is considered particularly important that substance abusers not only get the help they need with their abuse and addiction problems, but also have better access to specialised health care services with a view to reducing their somatic and mental symptoms. It is a major challenge for regional health enterprises to streamline and coordinate the various components of specialised health services. It has always been a problem for substance abusers that they have been juggled back and forth between different services, that no one has really assumed responsibility. In particular, abusers with mental health problems have not been very readily admitted to psychiatric care. It has also been pointed out that somatic hospitals often are reluctant to provide the help needed by drug abusers. To some extent this has to do with the lack of expertise on the part of the health services concerned, and possibly to some extent with their lack of commitment to meet the needs of these people. On the other hand, it also has to do with the acknowledged fact that substance abusers often are awkward customers. They frequently break the rules, have difficulty sticking to agreements and in general tend to neglect their treatments. It could be asked if the fact that the specialised health services now include treatment for all groups of patients will give substance abusers better access to medical treatment in general. It is obvious that the organisational reforms for improved service provision can do little to resolve the problems of lacking professional competence in substance abuse problems in the psychiatric and somatic specialised health services; and of course equally obvious that they can do nothing to make drug abusers any easier patients. It will therefore only remain to be seen whether 168

3 drug abusers with serious mental and/or somatic illnesses really will get access to better treatment, and whether the reform really will create a more coherent and effective system of specialised health services and municipal social welfare and health services. In connection with the substance abuse treatment reform all units were obliged to advise municipal social welfare services about patients who were being discharged from treatment. The question that this raises, however, is whether drug abusers no longer will be discharged from treatment institutions unless the local authorities can guarantee further care for them? What is good treatment? The substance abuse treatment reform is motivated by concerns of improving the quality of care and treatment for substance abusers. It is particularly stressed that the interventions offered shall be knowledge-based (Helsedepartmentet 2004b). It is a huge challenge for the regional health enterprises to develop their services in line with the results of national and international research. Given the marked variation in the duration of different treatments, one would also expect to see greater effort invested in distinguishing between specific treatment needs, on the one hand, and long term social care and rehabilitation needs, on the other. One of the key goals of the reform is to provide for better targeted and better balanced combinations of institutional/ non-institutional treatments provided by the regional health enterprises and services provided by the local municipalities. Regional health enterprises will be in the position to restructure and design treatments and services on the basis of the best information available and on the basis of what are thought to be the most pressing needs. The changeover to specialised health care services is expected to facilitate the provision of specialised somatic and psychiatric health services to substance abusers. At the same time, though, the reform will also imply a stronger health care orientation at units that provide specialised interdisciplinary care for substance abusers. Until now it has been rather difficult to get qualified health care personnel to work in the care of substance abusers. This has been particularly true of doctors and to some extent of psychologists. Against this background it will be interesting to see whether and to what extent there will indeed by changes in the availability of treatment in different areas of health care. Will the reform succeed in creating greater consensus on what kind of treatment to offer and in streamlining and coordinating treatments provided by specialised health care services and the local municipalities? Will the reform manage to bring in more health care staff to work with substance abusers? Will it succeed in placing greater weight on the health aspect and still manage to retain the social welfare component? Growing demand on private treatment Private sector organisations have traditionally played a major role in the provision of services and treatment for substance abusers in Norway. Many of these organisations had formal agreements of cooperation with one or more county municipalities, which now have been taken over by regional health enterprises. In the wake of the substance abuse treatment reform private organisations will continue to provide their services alongside public sector care providers, and the quality criteria applied to the treatments offered by both private and public service providers will also remain the same (Helsedepartementet 2004b). With the treatment of substance abuse now organised as part of specialised health care services, both public and private operators will no doubt feel that the demands and expectations with respect to quality and outcomes are greater than before. However their chances of responding to these demands and expectations are clearly different. Public sector units will not take the same risks as private operators to be excluded, although they could undoubtedly also be asked to change their treatment profile. 169

4 Changes in referral practices and the assessment of treatment needs In the pre-reform era when the treatment of substance abuse was governed by social services legislation, referrals to care were made through municipal social services and the local council paid a basic amount on each customer (NOK 12,500 in 2003). With the changeover which shifted responsibility for substance abuse treatment to specialised health care services, it would have been logical for medical doctors to assume responsibility for all referrals; this is common practice in specialised health care services. However since many substance abusers have only limited contact with health care services, the Norwegian Parliament decided that both social services and medical doctors shall have the same rights to refer these people to specialised interdisciplinary care, whether institutional or non-institutional. Social services do not, however, have the right to refer clients to specialised somatic or psychiatric care. While previously clients were referred directly to the unit concerned, regional health enterprises have now assigned units to admit these people and assess their need for care; or their need to receive necessary health care through specialised health services (Helsedepartementet 2004a). These assigned units are outpatient clinics commissioned by regional health enterprises to provide treatment for substance abuse problems, and psychiatric outpatient clinics. The Ministry has stressed that better assessments of treatment needs and closer diagnosis of substance abusers health and psychosocial life situation are crucial if the reform target of an improved quality of care is to be met (Helsedepartementet 2004b). All five regional health enterprises have been working to develop better procedures for the assessment of treatment needs and to define the content of these assessments. The Norwegian Patients Rights Act guarantees every citizen in the country the right to a health assessment within 30 working days of referral. In cases where the assessment concludes that the patient has the right to specialised health care services, the statement must detail the patient s specific need for treatment (further examinations, detoxification, outpatient treatment, institutional treatment) and indicate the date by which the patient s treatment at latest shall be started. If the patient and the person making the referral disagree on the results of the assessment, the patient has the right to ask a second opinion. According to the Act on Specialised Health Services, this right only applies once to the same health condition. Not all assigned units have the necessary competence to carry out comprehensive health assessments or evaluations of the need for treatment. As was pointed out, many of these units are psychiatric outpatient clinics. There is obviously much variation in terms of how far they have the competencies to conduct systematic reviews and to assess substance abuse problems and somatic complaints. In the same way there is much variation between outpatient clinics that provide treatment for substance abuse problems, both in terms of the traditions of assessing and reviewing psychiatric and somatic complaints and in terms of the necessary competencies. The right to choose one s place of treatment? All patients in Norway have the right to choose the hospital where they want to receive treatment. The same right is extended to substance abusers, who may choose not only where their initial assessment of need for referral shall be done, but also where their assessment proper shall be carried out and where they shall be admitted for treatment. This freedom of choice extends to all treatment units under the system of regional health enterprises throughout the country, regardless of the patient s place of residence. It does not, however, give the patient any say on the level of treatment. For example, a patient who has been granted the right to receive treatment for substance abuse is not 170

5 eligible for institutional treatment if the referral is for outpatient treatment only. Units that provide treatment for substance abusers vary widely in terms of the care and services they offer; a good example is provided by the duration of in-patient care. In the current situation where patients have such extensive freedom of choice with respect to their place of treatment, it has also been necessary for regional health enterprises to agree on a common set of norms for treatment levels. These are now defined as follows: 1. Outpatient care 2. Detox/Abstinence treatment 3. In-patient care less than 6 months 4. In patient care more than 6 months The patient s right to choose a place of treatment only applies in so far as the unit concerned offers the type of treatment that the patient is thought to require and the unit can accommodate the patient. Under the Patients Rights Act all substance abusers who are granted the right to receive treatment shall also have a deadline set for the commencement of their treatment. If the unit fails to meet this deadline, the Patients Rights Act stipulates that alternative treatment shall be made available without delay, i.e. as soon as the deadline has expired. The Act also says that if necessary, the treatment may be provided through a private organisation or a service provider based in another country (Helsedepartementet 2004a). In other words the substance abuser must immediately receive an offer for equivalent treatment in a private unit outside the regional health enterprise or in a treatment unit abroad if for reasons of inadequate resources the treatment plan cannot be put into effect within the time scale indicated. How does substitution treatment fit in? Substitution treatment for heroin abusers in Norway is organised through state-funded regional centres approved by the Ministry of Health and Care Services. In connection with the substance abuse treatment reform these centres were also brought under regional health enterprises and redefined as specialised health care services. All decisions on who shall be offered substitution treatment are now confined to these centres. Given the importance of comprehensively assessing treatment needs, this arrangement is obviously less than ideal. For the time being it remains unclear exactly how this problem will be resolved. Regional health enterprises have however been charged with providing a comprehensive assessment of what kind of treatment shall be offered to patients who are judged to be in need of substitution therapy (Helsedepartementet 2004b). Patients who are referred to substitution treatment but who for whatever reasons substitution treatment is not seen to be appropriate, shall be offered some other form of specialised interdisciplinary treatment if they are considered eligible for necessary health care. Furthermore the regional health enterprises are asked to integrate substitution treatment with other specialised treatment for substance abuse (Helse- og omsorgsdepartementet 2005). Can treatment for substance abuse compete for budget resources? In connection with the substance abuse treatment reform, regional health enterprises were granted resources equivalent to the amounts spent by county and local municipalities on the treatment of substance abuse in In addition, they received special state subsidies for substitution therapy in These resources were allocated between the five regional health enterprises in proportion to spending levels in each region in Furthermore, the corporations were granted extra subsidies. As from the beginning of 2005, however, the monies allocated to specialised interdisciplinary treatment, including substitution therapy, were included as part of the general appropriations granted to regional health enterprises. Regional health enterprises have complete independence with regard to how they spend their annual appropriations so that they can meet the tasks they have been assigned and provide adequate somatic and psychiatric 171

6 care and treatment for substance abusers. Having said that, the Ministry of Health and Care Services does set out its own priorities that the regional authorities are expected to heed. In 2005, for example, special funds have been earmarked for purposes of increasing the capacity of substitution therapy (Helse- og omsorgsdepartementet 2005). Regional health enterprises carry a heavy burden of responsibility. The health sector will always be a bottomless pit suffering from a chronic scarcity of financial resources. As treatments for different conditions are continuing to improve and develop, people s expectations with respect to the standard of specialised health services are also rising. Although treatment for substance abusers currently enjoys something of a priority status, this is a weak patient group who very much depend on help from other people. As the focus of political and media attention today can swing very easily and unpredictably, the whole situation may change quite suddenly in favour of other, stronger patient groups. Overall it is very difficult to predict how regional health enterprise will prioritise the treatment of substance abuse in comparison with other patient groups. Will the substance abuse treatment reform reach its goals? There is no real reason to doubt the government authorities sincerity and commitment to improving the standard of services and treatments offered to drug abusers. The integration of substance abuse treatment with specialised health care services and the promotion of substance abusers to the status of patients can hardly be interpreted in any other way. The whole initiative came from Parliament and the government, and they have also been the driving force behind the reform, as well as keeping a close eye on its progress. The organisational changes have also been closely monitored from an economic point of view. Nonetheless the reform presents a host of major challenges and raises a number of problems. The new area of specialised health care services has been dubbed specialised interdisciplinary treatment for substance abuse the idea being to emphasise that even though the health care aspect is prominent, the social welfare side of treatment will also continue to remain in place and indeed be further developed. This, however, is the critical issue: Will the social welfare aspect really survive, or will it be overshadowed by the health component in a system that after all is organised around specialised health services. Another issue that deserves our attention here is the true practical extent of patients rights. Although the law says that substance abusers shall receive the same treatment as other patient groups, there is no escaping the fact that this is a group who present numerous problems to the health care system and who require special attention. Many would argue that it is a common characteristic of the substance abuser s illness profile that they do not always stick to agreements and treatment regimes. Nevertheless opinions will differ on how far specialised health care services shall be applied to individual patients. In terms of the Patients Rights Act, the right to necessary health care from specialised health services only applies if there is reason to expect, that the care will be beneficial and if its costs are reasonable when weighed against the benefits (Helsedepartementet 2004a). This obviously leaves much room for interpretation in assessing the right of substance abusers to care and treatment. The legal requirement that the patient expect benefits from the treatment is clearly grounded in experiences of cases where abusers have received recurring treatment with no visible impact. Given the eternal problem of scarce resources, it could be argued in these situations to give priority to patients who it is felt will benefit most from the treatment. Another problem has to do with the provisions in the Patients Rights Act regarding the right to an assessment and reassessment of one s health by specialised health services. A reassessment will only be made one time 172

7 for one and the same health condition. How will these rules be applied to drug abusers who time and again come back to get treatment for their abuse problems? Treatment units have different kinds of treatment plans and programmes that vary in duration. For example, clinics that specialise in the treatment of people with alcohol problems have much shorter programmes than do in-patient units that provide treatment for drug abuse. In the latter case many treatment centres have integrated treatment and aftercare, which basically is the responsibility of municipal authorities. It is too early to say to what extent regional health enterprises will continue to offer these long-term treatments. Nonetheless there is reason to believe that treatment proper will increasingly become just that proper treatment as it is integrated with specialised health care services than it is in the case where treatment is seen as a social care effort. Inevitably, then, this changeover to specialised health care services will put an end to long-term institutional care. As a consequence, municipalities will have to assume greater responsibility for providing services to substance abusers that were previously provided by a large number of in-patient institutions. Social services have retained the right to refer patients to interdisciplinary specialised treatment for substance abuse, even though the specialised health care service normally reserves this right to medical doctors. So far it seems the system is working, however, because social services have greater competence than doctors in planning treatments for substance abusers. Whether this situation will change as doctors continue to gain experience and the treatment of substance abuse is integrated more closely with other specialised health care services, remains to be seen. As we have seen, the substance abuse treatment reform in Norway involves a number of problems. The evaluation of the reform at the end of 2006 will provide important clues on the direction in which it is heading. However it will take a few years before we will see how far the changeover to specialised health services has helped to give substance abusers better treatment and to produce better treatment results. Translation: David Kivinen Astrid Skretting, researcher, SIRUS, POB 565 Sentrum, N-0105 Oslo as@sirus.no REFERENCES Bryhni, Anders (ed.) (2004): Rusmidler i Norge (Alcohol and drugs in Norway). SIRUS Helsedepartementet (2004a): Rundskriv (I 8/2004): Rusreformen pasientrettigheter og endringer i spesialisthelsetjenesteloven (Ministry of Health: The rights of patients and changes in specialised health services). Helsedepartementet (2004b): Bedre behandlingstilbud til rusmiddelmisbrukere. Perspektiver og strategier (Better treatment for substance abusers. Perspectives and strategies) Helse- og omsorgsdepartementet (2005): Bestillerdokument 2005 (Ministry of Health and Care: Purchase document) Kurtze, Nanna & Eide, Arne H. (2003): Helsetilstand hos tunge rusmiddelmisbrukere (Heavy substance users health status). SINTEF Unimed NOU (2003): Forskning på rusmiddelfeltet. En oppsummering av kunnskap om effekt av tiltak. Norges offentlige utredninger 2003:4 (Research on alcohol and drugs. Review of evidence on prevention and treatment) Ruud, torleif og Reas Deborah (2003): Helsetjenester for tunge rusmiddelmisbrukere (Health service for heavy substance abusers). SINTEF Unimed SBU (2001): Behandling av alkohol- och narkotikaproblem. En evidensbaserad kunskapssammanstälning (Treatment of alcohol and drug problems). Stockholm SIRUS (2003): Narkotikasituasjonen i Norge (Drugs in Norway). 173