Shifting focus in substitution treatment in the Nordic countries

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1 Astrid Skretting & Pia Rosenqvist Research report Shifting focus in substitution treatment in the Nordic countries Introduction The responsibility for the provision of social and medical treatment to substance abusers rests with the public authorities at central, county or municipal level in the four Nordic countries Denmark, Finland, Norway and Sweden. Other important providers in addition to public agencies are NGOs and private foundations, which are primarily funded from the public purse. In some cases, treatment responses are specially targeted at drug abusers, while in others, treatment facilities are intended for substance abusers in general. In Denmark drug treatment facilities are organised separately from alcohol treatment facilities, whereas in Finland, Norway and Sweden they are part of the same system. Services also differ in terms of their medical or social orientation, and in terms of whether treatment for drug abuse is provided by specialised treatment centres or by the general health or social service system. Historically, all the Nordic countries have mostly placed their drug treatment systems within the social sector, either completely or under the guidance Submitted Initial review completed Final version accepted A B S T R A C T A. Skretting & P. Rosenqvist: Shifting focus in substitution treatment in the Nordic countries The article compares the development of substitution treatment in Denmark, Finland, Norway and Sweden. The focus is on the official guidelines: under what conditions, for whom and by whom should substitution treatment be organised? For many years, substitution treatment was fiercely opposed in Finland, Norway and Sweden, all of which had a restrictive drug policy and relied on social work rather than medicine. The debate cut through the professions and was at times the main political issue. Methadone treatment started in Denmark and Sweden in the 1960s, and while Finland and Norway did not give the go-ahead until the latter part of the 1990s, they have today expanded their substitution treatment considerably. In all four countries, substitution treatment has become an accepted and established part of treatment responses to abuse problems. The guidelines have become less strict even if the regimes in practice include various kinds of control measures. The thresholds of substitution treatment have remained the lowest in Denmark where this treatment mode is more geared toward harm reduction than in the other countries. Key words Drug users, substitution treatment, Nordic countries NORDIC STUDIES ON ALCOHOL AND DRUGS VOL

2 of social workers, but today they have by and large increased the role and influence of medicine and doctors in the treatment field. This process has been most visible in Norway, where all treatment for substance abuse problems has been transformed from a separate social care treatment system to becoming part of specialised health care (Skretting 2007). There are also country variations in the extent to which treatment services meet the actual needs of treatment, even if all four countries have introduced some kind of treatment guarantee. A wide range of measures aimed at reducing the harms related to substance abuse are also offered within the treatment system and as separate ventures in all the countries, but less so under a harm reduction rubric in Sweden. As a segment of the treatment system, long-term substitution treatment for heroin addicts has gained ground in the four countries during the last years. The history of such treatment nevertheless differs quite widely. Methadone treatment started in Denmark and Sweden in the 1960s as a result of psychiatrists visiting the Dole-Nyswander methadone programme in the US, and indeed they were the first countries in Europe to provide methadone treatment. In contrast, Finland and Norway only went ahead with methadone treatment in the late 1990s but have expanded it considerably ever since. In addition, while substitution treatment in Sweden used to be an exception to the social services approaches, to long-term therapeutic treatment and to educational approaches in treatment centres, it is now a more accepted way of dealing with opiate misuse problems. In all the four countries, substitution treatment now mostly refers to long-term treatment, although short-term treatment aimed at detoxification is also available. In this article we will describe and compare the main features and the development of substitution treatment in the four Nordic countries. We will discuss the growth and the key characteristics of this treatment in the light of the national drug policies. We will focus on the official guidelines, examining under what conditions, for whom and by whom substitution treatment should be organised and will look at the changes in these guidelines over the years. There are variations within each country in how the guidelines are managed. Seen from an international perspective, the Nordic drug policies are fairly similar: they are restrictive and build on a non-acceptance of illegal drugs. Drug use has not been legalised in any of these countries. The main approach has been preventive and punitive, as criminal sanctions commonly apply to the use of, and dealing with, illicit drugs in general. In practice, Denmark has traditionally been the most liberal, permissive country in terms of both attitudes to drugs and enforcement of rules and restrictions. The three other countries have to some degree underscored the goal of drug policy as aiming at a society without drug-related harms or even, as is the case with Sweden, a drug-free society. Treatment policies have in this context, one could argue, been subsumed under a restrictive drug policy framework of what used to be seen as the three-pillar approach to drug problems; prevention, treatment and control. 582 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

3 Denmark Substitution treatment was introduced in Denmark in the mid-1960s, but the misuse of heroin was not really seen as a problem until the 1970s and 1980s. The first estimates on the number of problem drug users were made in 1994, and in 2005 the figure of injecting drug users was estimated at 13,000. The majority of these inject heroin (National Board of Health 2009). For about 30 years, methadone was prescribed by GPs in Denmark even if there was much critique against such practice. There was opposition within the treatment system against the use of methadone as such, but also to GPs practices which often did not involve any other treatment or support than the prescription itself (Winsløw 1984). Twice a committee formed by the National Board of Health voiced such critique (ibid). The National Board of Health agreed with the committee, but as most treatment centres were not in favour of substitution treatment, the board did not want to interfere with GPs providing long-lasting methadone treatment outside the ordinary treatment system and hence did not restrict the GPs prescription rights. However, problems with overdoses and a general lack of control led to transferring prescription rights to county treatment centres in The reorganisation did not end major variations in treatment practices between and within the counties in, for example, how strictly the clients intake of methadone and their urine samples were supervised, the consequences of side abuse monitored and take home policies assessed (Dahl 2007). In 2007, a new local government reform came into force which transferred the responsibility for all kinds of treatment of drug users from the former counties to 98 new municipalities. As of January 2007, the municipalities are responsible for all kinds of drug-related treatment, be it slow withdrawal, outpatient treatment, substitution treatment or inpatient treatment (Pedersen 2007). Most drug-related treatment is targeted at drug use closely linked with social problems. The municipality must ensure that the medical treatment and the related psychosocial services targeted at the social problems that the drug user may also have are coherent and plausible (Sundhedsstyrelsen 2008). New guidelines The medical treatment of drug use has been an extremely diverse area in Denmark, mainly because of the difference in medical background and the organisational framework of the treatment programmes. This is why the National Board of Health launched a review of the entire field of the medical treatment of drug users receiving substitution treatment. This work resulted in new medical guidelines in June 2007 (Sundhedsstyrelsen 2007), revised in 2008 (Sundhedsstyrelsen 2008). The guidelines seek to support and strengthen the overall action through principles for the substitution treatment itself and a description of the medical core services associated with the treatment. The guidelines are expected to contribute to securing consistent quality on an acceptable level. In the long term, the guidelines and their recommendations are also meant to form the basis for ongoing quality development and constitute the core of organisational planning of treatment in the municipalities. According to the guidelines, substitution treatment is intended to stabilise the NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

4 drug addict pharmacologically, socially and psychologically. The medical treatment shall be followed by psychosocial care, such as managing problems of housing, means of economic support and employment. Substitution treatment is justified by arguably lower mortality rates, reduced risk behaviour in relation to infectious diseases and reduction in crime of gain among drug addicts (ibid). More than rehabilitation, it is harm reduction that seems to be the main focus of substitution treatment in Denmark. However, it is also said that the outcome of substitution treatment depends on the right dosages and on the quality and extent of the accompanying psychosocial treatment. Indications for substitution treatment in Denmark are: Dependency of opioids according to ICD-10 The wish of the drug addict; should be voluntary. Other relevant treatment measures should already have been considered. Pregnant women should be offered substitution treatment if detoxification is unrealistic. Methadone buprenorphine Buprenorphine was introduced in Denmark in However, for several reasons methadone still remains the dominant substitution drug. One important reason is probably the long methadone tradition stretching back to 1960/70. It is also widely thought that buprenorphine is a kind of light methadone, particularly suitable for younger people and individuals who are not too heavily addicted. Furthermore, cost considerations have meant that buprenorphine is primarily used for short-term substitution treatment as it has been up to eight times more expensive than methadone, although in recent years the price has come down somewhat (National Board of Health 2007). The understanding of methadone as more appropriate than buprenorphine is, however, about to change. In the guidelines of 2008, it is recommended that buprenorphine should be prescribed as the first choice, because it has a better safety profile. The guidelines also provide more detailed professional guidance in the initiation of treatment and dosage regimen than the old one. As of 2008, some 8,000 clients have been receiving substitution treatment, about 12 per cent with buprenorphine (National Board of Health 2009). So far, buprenorphine in Denmark is mostly prescribed as Subutex. Heroin treatment In June 2008, it was decided to allow injectable heroin in the treatment of drug addicts who continue their injection of heroin on a daily basis even if they are in methadone programmes and have serious drug-related health problems (Sundhedsstyrelsen 2009). The heroin programme is a result of numerous expert reports, proposals and hearings in the Danish parliament. It is, however, estimated that the programme will be restricted to a rather small number of heroin addicts. The first clients entered the heroin programme in March At national level, five clinics are planned to provide heroin treatment, and only doctors approved by the National Board of Health can prescribe the substance (Diamorphine). Clients are given supervised injections of heroin 584 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

5 twice a day and take-home doses of oral methadone for nights and vacations. The medical indication for heroin treatment has to be reviewed every sixth months. Finland Compared to its Nordic neighbours, Finland long had a less serious drug situation. The comparatively low level of problematic drug abuse was dominated by amphetamines, and the use of heroin and other opiates became more spread as late as the latter half of the 1990s. A register study from 2005 (Partanen et al. 2007) gave an estimate of around 3,700 4,900 opiate users. With the changing drug abuse situation of the 1990s, the Finnish drug policy changed, too, leading to what has been called a dual track policy (Hakkarainen et al. 2007). Along with the considerable increase in harm from narcotic drugs, it has been claimed that the drug issue acquired the status of a social problem. It was no longer seen as a moral issue of young people, but as a serious threat to public health and as a problem involving organised and other crime (Hakkarainen et al. 2007). Measures such as syringe exchange schemes and maintenance treatment were intended to counter the drug-related public health problems but, at the same time, the policies left intact the restrictive drug policy measures built on a kind of nontolerance of drugs. Methadone in maintenance treatment had been used in the 1970s and in detoxification during the early 1990s, but these were exceptions. Substitution treatment was officially introduced in In addition to the worsening epidemiological situation, the decision was propelled by two incidents with private physicians prescribing buprenorphine (Temgesic, Subutex) to their addicted patients (Hakkarainen & Tigerstedt 2005). In the first case, early in the 1990s, neither the authorities nor the professionals were ready to accept substitution treatment, fearing that the drug could be diverted to street use. In the second case, in the latter half of the 1990s, the physician in question appealed to best practice, human rights and patient rights and went public with his views. By the end of the 1990s, the medical establishment as well as the media and the authorities accepted the use of substitution treatment. The development was tied to both ongoing changes in the drug policy and the more general patients rights movement that was gaining strength. Guidelines Since 1997, the regulations have been revised several times and turned from detailed to general guidelines. The painstaking work of deciding, for example, how long a person could be in treatment and setting the goals of treatment reveals that substitution treatment was seen to contradict with the overall aims of having a restrictive drug policy. Even the rights to assess the needs for treatment were in 1997 restricted only to university hospitals and a specialised addiction hospital, but the base was substantially broadened in the year In the 1997 decree, the maximum treatment period was 3 months, but this was prolonged to one year already in In a decree from 2002, treatment for one month or less was considered to be detoxification. Treatment which lasted longer than one month was named either substitution if it aimed at a life free of illicit drug use, NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

6 or maintenance, if it aimed at minimising the harms and improving the life conditions of the person for whom cure was not seen as possible. The latest decree from 2008 gives no time limits whatsoever but the preparatory work emphasises that treatment should follow the needs of each individual patient (Social- och hälsovårdsministeriet 2008). The 2008 decree does not specify in detail the content of treatment. Treatment is rather conceived as a kind of framework, building on best available knowledge. The underlying working document, however, emphasises that the mere substitution of an illicit drug or an illicit use with a legal prescription is not enough. Other measures are also needed. Methadone or buprenorphine are used either in detoxification in order to get a person drug free or in substitution treatment. Substitution should aim at rehabilitation or reducing harms or improving the quality of life. Harm reduction is thus accepted as a goal as is rehabilitation or detoxification. The criteria for admittance to treatment have also been slackened since the end of the 1990s. The main criteria include diagnosed opiate dependence in accordance with the ICD-10 classification. Earlier attempts to become detoxified with the help of other accepted treatment forms are no longer a requirement, even though substitution treatment should be used only when the patient has not managed to become detoxified. The concomitant use of opioids and other drugs is not dealt with nor are there any age limits or duration of dependency as access criteria. Substitution medicine dispensation should normally be supervised from the treatment unit. A treatment commitment and plan, including psychosocial support and rehabilitation activities, should be drawn up. Specific regulations or recommendations concerning these activities have not been indicated. The 2008 decree, however, opened up a new possibility by allowing that when a compound medicine of buprenorphine and naloxone (Suboxone) is prescribed, it can be delivered from the pharmacies, but still under the supervision of the clinic. According to the 2008 regulations, both the evaluation and admission to treatment and the treatment itself can (and should) be started on an outpatient basis. Only the more demanding cases should be transferred to specialist inpatient care. Substitution treatment is thus carried out mainly as outpatient care, either in the specialised clinics or as part of normal substance abuse treatment or in health care clinics. Methadone/ buprenorphine The most striking feature of the Finnish situation is that almost all the patients now receiving substitution treatment do so because of an illegal use of buprenorphine. Information from the Finnish drug treatment information system (Drug Situation 2008) shows that the percentage of the patients who have named buprenorphine as their foremost problem has clearly increased during the last six years (33 per cent in 2007), and only a few report heroin as their main drug (2 per cent in 2007). Since 2004, the combined preparation Suboxone has been used as substitution medication. The guidelines from 2008 reserved the use of (simple) buprenorphine only to exceptional cases (such as pregnant drug users). In 2008, around half of all patients in substitution treatment re- 586 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

7 ceived buprenorphine, mostly in the form of Suboxone (ibid.). Because of its lower toxicity, buprenorphine has been seen as a safer drug than methadone, but in fact the share of methadone has increased somewhat during the last 3 4 years (Drug Situation 2008; 2009). The fact that methadone as the substitution drug is used more in treatment than before may also indicate that many patients have already been in the programme for some years (ibid). According to Tourunen (2007), that patients stay longer has caused some organisational and ideological problems; what should be done, and for how long, with this new kind of client group that settles somewhere between the normal/traditional rehabilitation clients and drug addicts in the streets. As the use of buprenorphine is fairly strictly controlled in the treatment centres, few believe that the illegal market is furnished with leakages through this system. Probably most of the street-used buprenorphine is smuggled into the country, previously from France, later from the Baltic countries, although this route has been closed since the Baltic countries joined the Schengen agreement). Organised trips made by the addicts themselves play a role as well. The involvement of buprenorphine in drug-related deaths has caused concern. Findings in autopsies show that buprenorphine was present in 7 cases in 2000 and in 97 cases in 2007 (Drug Situation 2009). Norway The estimated number of injecting drug users in Norway increased until 2001, declined until 2003 and then flattened out. In 2008, the numbers were estimated at 8,600 12,600, of whom about 90 per cent are estimated to inject heroin (www.sirus.no). Throughout the 1970s and 80s, the use of medication in Norway in the treatment of substance abuse was largely viewed with scepticism. When the idea of substitution or methadone treatment was aired, it was also widely dismissed. The most important arguments against substitution treatment in Norway used to be: A strong belief in the possibility of ending addiction by drug-free treatment Methadone was symptomatic of a degrading attitude to one s fellow men, of a loss of faith in substance abusers and their ability to change Methadone condemns abusers to lifelong dependency (Sosial- og helsedepartementet 1997) Argumentation against substitution treatment can also be seen as a reflection of the minor part played by the medical profession in substance abuse treatment. It has been an area dominated instead by social workers and, to a lesser degree, psychologists. However, in 1994 a three-year pilot project for providing methadone to opiate abusers was set up in Oslo. Initially, 50 opiate-dependent substance abusers were enrolled into the trial based on a Swedish design and monitored and evaluated with particular care (Ervik 1997; Frantzen 2001; Skretting 1997). To be eligible for the programme, applicants had to be thirty years of age or over, have used opiates for at least ten years, undergone a reasonable amount of drug-free treatment, and have no pending legal issues with the police or courts. In 1997, the Parliament decided that substitution treatment for heroin abusers NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

8 should be a part of the treatment system. Available at the national level since 1998, the system has so far been based on specialised regional centres. Follow-up is, however, in most cases the responsibility of the municipal health and social services. New, revised guidelines were put in place in 2010 (Helsedirektoratet 2010), which state that substitution treatment should be an integrated part of the ordinary specialised treatment services for substance abuse. The objective of substitution treatment in Norway is to provide assistance and treatment for opiate abuse and social and health problems. Drug users who receive substitution treatment are to be offered social assistance in their home municipality. In the old guidelines, the patients were in principle expected to stop using illicit drugs, while the new guidelines are more geared toward increasing the clients life quality and harm reduction. The Norwegian criteria for admission into medically assisted rehabilitation have been relatively strict: between 1998 and 2010, the drug user had to be at least 25 years old, heavily addicted to an opiate despite reasonably extensive treatment, and have a history of several years of opiate addiction (Sosial- og helsedepartementet 2000). It was, however, possible to waive these criteria as a result of an overall evaluation of health and social problems. The new guidelines are less strict and give no age limit. At the same time, they are more detailed in presenting how substitution treatment as a whole should be carried out. Referral for admission to treatment has to come from a medical doctor or a municipal centre of social services. An action plan should be prepared that describes the patient s existing problems as well as the cooperation proposed to remedy these problems. It is also possible to start treatment while in prison. The referral should be sent to and approved by a substance abuse treatment centre in the specialist health care services. Treatment starts under the auspices of or in the treatment centre with detoxification from other drugs, the necessary examinations and the stepping up of medication. The medication is prescribed by the centre or by GPs cooperating with the centre. Unless there are special requirements, the treatment will mainly be ambulant, with medication supplied by chemists or through the centre. Inpatient treatment may take place for detoxification purposes, crisis intervention or treatment of specific conditions. During the ten years or so that substitution treatment has been available, the number of patients has increased steadily. It now exceeds 5,000. Psychosocial assistance interventions are based on individual action plans, which outline the targeted measures for dealing with the problems present. Interdisciplinary groups should be established for patients with multiple problems, with the social consultant and regular GP sharing principal responsibility with the specialised centre. The system aims at a rather high degree of control. Medication should only be provided if there is close follow-up including regular supervised urine samples. Generally the system works very well when the treatment centre is in charge of the follow-up and, if applicable, handing out medication (Waal et al. 2010). Methadone and Subutex have, however, been seen on the illegal drug market. 588 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

9 Methadone buprenorphine In Norway, both methadone and buprenorphine are currently approved for substitution treatment. In 2009, buprenorphine was given to 44 per cent of the nearly 5,400 patients (Waal et al. 2010). With both methadone and buprenorphine, the medication must be taken daily under supervision until the patient is deemed to be stable and to have sufficient mastery of his/her drug problem. Permission for home use can then be granted to an increasing degree. Medication can be collected for a maximum of one week at a time. The new guidelines suggest that buprenorphine prescribed as Suboxone should be given as a first choice (Helsedirektoratet 2010). Sweden The most recent estimate of the number of hard drug users in Sweden dates back to 1998, when some 26,000 persons were calculated to use an illegal drug or inject any illegal substance daily or almost daily. An estimate based on inpatient data from 2004 yielded about the same result, which indicates that the level of hard drug use had not risen from 1998 to 2004 and that the situation seems to have stabilised (CAN 2009). Traditionally, the use of amphetamines has been more spread than that of opiates, which were, however, gaining ground especially in the 1990s. At the end of the 1990s, around 28 per cent of the heavy drug users reported heroin as their main drug (ibid). Until the end of the 1980s, nearly all treatment for drug abuse was seen as drugfree treatment. Involuntary treatment has been used for young people under the age of 18 as well as for substance abusers over 18. Involuntary treatment takes place in special treatment institutions. Moreover, the (medical) health services, organised regionally, have offered specialised treatment at in- or outpatient addiction clinics, mostly under psychiatric hospitals/ services. The main responsibility for the treatment of drug abusers has been with municipal social services. Bearing in mind the overall goals of drug treatment in Sweden, substitution treatment was developed as something of an exception to the rule. Based on the Dole-Nyswander model, it was introduced as early as 1966 in Uppsala. Guidelines for the programme were issued by the National Board of Health and Welfare. Patients spent their first six months after detoxification (about one month) in a day care methadone treatment centre and received their dose of methadone. They were required to take part in training programmes. Urine screenings were carried out to ascertain that the patients did not use illegal drugs and also to prevent leakage from the programme. After the first six months, the patients were allowed to visit the centre at progressively greater intervals. If they managed this properly, they were allowed to get their methadone dose at a pharmacy under supervision from the programme. There was persistent opposition and criticism against methadone treatment in Sweden for many years (Johnson 2003). It was regarded by many as a form of legal abuse. Much of that attitude changed with the HIV epidemic, however, albeit not immediately. As the number of heroin abusers continued to increase and the programme in Uppsala was unable to take on more patients, there was growing approval NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

10 for plans to expand the scheme. New units were consequently established in other locations: in Stockholm 1988, in Lund 1990, in Malmö 1992 and two more as late as in 2004 (Helsingborg and Gothenburg). The maximum number of patients that could be taken into the programme was centrally determined. In 1983, the limit was 150 patients, but by 2004 the limit had been raised six times, finally reaching 1,200 patients. and be continued for some years in the otherwise restrictive Swedish drug policy and drug-free treatment regime has been explained by the worsening heroin situation, increasing drug mortality, shortage of treatment offers and long waiting lists to methadone treatment (Johnson 2007). The medical establishment also voiced opposition to attempts to regulate buprenorphine prescriptions in the same restrictive way as had been done with methadone. Methadone/buprenorphine Until just a few years ago, methadone was the only substitution medicine offered in Sweden. In 1999, buprenorphine was accepted by the relevant medical products agency as a medicine to be used for addiction problems. This was a decision which did not involve the National Board of Health and Welfare, the agency having the overall responsibility for substitution treatment. Physicians of any specialist competence were now allowed to prescribe buprenorphine. It was recommended that prescriptions should only be issued at drug treatment units, but other than that, no permissions were needed nor criteria or guidelines given. The approval of buprenorphine considerably expanded the possibilities of getting substitution treatment outside the ordinary system (Engdahl et al. 2006). In 2004, there were more than 1,300 patients receiving buprenorphine in Sweden compared to the maximum number of 1,200 methadone patients. For some years, the more liberal way of prescribing buprenorphine co-existed side by side with the very strictly run methadone programmes. The fact that the prescription regime could at all come about New system The two sets of rules were unified in 2004 by a decree that went into effect on January 1, The regulations, still strict, changed the overall structure of substitution treatment in Sweden. Substitution treatment has to be arranged within addiction clinics under the supervision of specialised doctors (psychiatrists) but it is not restricted to specific programmes or to any special permission from the state. A new set of regulations came into force on March 1, While the minimum time of prior history of opiate drug use was reduced from four to two years in 2005, the new guidelines brought the limit down to one year (Socialstyrelsen 2009). As before, however, the patient should be at least 20 years old, even if exceptions are possible. On the other hand, those addicted to alcohol or narcotic substances other than opiates cannot be accepted for substitution treatment. This means that those who misuse buprenorphine, as is the case in Finland, will not get access. The main goals are intact: treatment should aim at sobriety and to improving the health and social circumstances of the patient. The patient should also be followed closely, be regularly tested for the 590 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

11 use of illicit drugs and excluded if it turns out that side use is considerable. Moreover, if a patient is excluded from the treatment programme, he/she cannot enter a new programme for a period of 3 months. A treatment plan should be set up, and the patient should have access to personnel trained in both social affairs and therapeutic interventions. In practice, there are big differences between different programmes in how the regulations are implemented (Communication 2010). The debates on the criteria for receiving substitution treatment, whether methadone or some other drug should be used as medication and under what circumstances a patient might be expelled from the programme continue lively in Sweden. In the spring of 2008, recommendations were formulated on the use of Suboxone rather than (simple) buprenorphine. Discussion The scenarios of how and when substitution treatment was instituted vary in the four Nordic countries of Denmark, Finland, Norway and Sweden depending on the need for such treatment. This need, then, was determined by the size of the drug-using population and by the main problem drug, but was also conditioned by the dominant drug policy. In Denmark and Norway, the population of problem drug users has been dominated by heroin misuse (or heroin in combination with other drugs), for which methadone could have been used. From the very beginning, Denmark chose to provide substitution treatment while in Norway the use of medication for treating substance abuse was largely viewed with scepticism. There was a strong belief in drug-free treatment. Methadone treatment was seen in terms of losing faith in substance abusers and in their ability to change, which would condemn them to life-long dependency. In Sweden, amphetamines have traditionally been the dominant drug among problem drug users, whereas the misuse of opiates did not increase until the late 1990s. This was also the case for Finland. Until recent years, both these countries managed to isolate substitution treatment into special programmes or trials. Sweden instituted an exception programme for heroin users in 1966, which remained somewhat unchanged until Finland had a small programme in the 1970s for wartime addicts, but it was not until the late 1990s that Finland actually instituted substitution treatment. The history of substitution treatment in Sweden and Finland exhibits interesting and innovative ways of expanding the narrow frames of the existing programmes in order to meet new needs: in Sweden through the unrestricted possibility for GPs to prescribe buprenorphine in and in Finland through individual doctors prescribing Dolorex, Temgesic and Subutex for some time in the 1990s. In terms of the drug policy, there has traditionally been a dividing line between Denmark and the rest of the Nordic countries. Denmark has clearly been more lenient toward drugs. In Finland, Sweden and Norway, the introduction of substitution treatment was fiercely opposed for many years. A restrictive drug policy and a reliance on social work rather than medicine were common for these three countries. Battles were fought around the establishment of NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

12 substitution treatment, but in none of the countries was there any clear-cut division between the good and the bad guys. The debates cut through the professions of medical doctors and social workers, for example, and at times substitution treatment was fiercely disputed in party politics. To a lesser degree, this was also the case in Denmark. From a drug policy perspective, Norway and Sweden have been close to one another. The similarities start from the terms used to describe substitution treatment (table 1). Medically assisted reha- Table 1. Substitution treatment goals and principles Term used When started/ Criteria for eligibility Goals of substitution changes introduced treatment Denmark Substitution Mid-1960s Opioid dependency Harm reduction treatment Other treatment Pharmacological, psy- New regulations measures should be chological and social 1996, 2007, 2008, considered stabilisation (2009 heroin) Pregnancy Finland Detoxification 1995, first regulation Opioid dependency Detoxification & substitution 1997 Not been able to be Rehabilitation or treatment detoxifyed harm reduction New regulations 1998, 2000, 2002 & 2008 Norway Medically 1994 Trial Opioid-dominated Increase life quality assisted 1998 Nationwide misuse Take advantage of rehabilitation Drug-free treatment psychosocial treatment New regulations should be considered measures 2000, 2003, 2010 Harm reduction Sweden Medically assisted maintenance treatment 1966 Trial 1983 Permanent New regulations 2005, 2010 Age over 20 1 years 1 year s opiate dependency Substitution treatment should not be provided if: the patient is depend- Stop misusing drugs Improved health and social situation ent of other substances implying a medical risk, the patient has been excluded from such treatment within the last 3 months, the patient is in compulsory treatment 1 Age under 20 years may be considered in special cases. 592 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

13 Table 2. Substitution treatment patients, access and control Denmark 2008 Finland 2008 Norway 2008 Sweden 2007 Number of persons in substitution treatment (Methadone) (Buprenorphine) 60 (Heroin, 2010) 550 (Methadone) 500 (Suboxone) 150 (Subutex) (Methadone) (Buprenorphine) (Methadone) (Buprenorphine) Waiting lists Controls by urine sampling Exclusion criteria No Rarely Treatment is seen as fruitless Violence or threatening of violence Yes Yes Yes Yes In the new guidelines (2010) exclusion from substitution treatment is restricted to situations when the treatment is no longer seen as defensible. Yes Yes Been out of treatment for more than one week Repeated relapse Misuse of alcohol Repeated manipulation of urine tests Sentence of drug crime bilitation/maintenance treatment allocates medicine a secondary position in the treatment or rehabilitation process. These two countries have also had age among the eligibility criteria: in Norway it used to be 25 years and in Sweden it still is 20. Both Norway and Sweden also used to demand long-term opioid/opiate dependency as a prerequisite, whereas Denmark and Finland have had no such criteria. Another dividing line can be drawn as to the aims of treatment, whether short-term detoxification or long-term substitution or even maintenance. Substitution treatment in Denmark has from the start been more directed at reducing harms than at getting people off drugs, while Norway and Sweden have emphasised rehabilitation as the main goal, in harmony with their general drug policies. In Finland, again, the difficulty in determining the treatment goals was expressed by the varying time limits: first set, the time limits were then prolonged and finally lifted. Finland, and for some years now also Norway insist on harm reduction as a goal for substitution treatment. The number of patients receiving substitution treatment has remained at about the same level in the last years in Denmark, but in Finland, Norway and Sweden the numbers have grown dramatically. By 2008, the estimated number of patients was around 8,000 in Denmark, around 1,200 in Finland, some 5,000 in Norway and around 3,100 in Sweden. Until the NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

14 end of the 1990s, methadone was the selfevident medicine to be used in substitution treatment in all the four countries, but buprenorphine (initially as Subutex, today as the mixed substance Suboxone) has since acquired a firm position. At the moment, different buprenorphine products are recommended to younger drug addicts or those with a relatively short history of opiate/opioid misuse. In the future, buprenorphine will probably be the dominant substitution drug. With a strong methadone tradition, Denmark may be an exception, even if the 2008 regulations clearly recommend buprenorphine as a first choice. While substitution treatment has expanded, with the exception of Denmark, most drug addicts referred and accepted to treatment face certain waiting periods (Table 2). How long a patient accepted for substitution treatment has to wait depends on the capacity of the medical or the social arm of the treatment system. It varies regionally, too. Patients are also controlled by urine tests as a way of keeping track of misuse of other drugs. In Finland, Norway and Sweden urine tests are used regularly, in Denmark only rarely. To what extent urine tests are used to control the patients or whether they serve as a therapeutic tool for the medical doctors/therapists in the treatment process is a much-debated issue. In Sweden, manipulation of urine tests may serve as grounds for involuntary exclusion from treatment, whereas this is rarely the case in the other countries. Sweden is also different from Denmark, Finland and Norway in listing other causes as possible reasons for being excluded from a programme. Table 3 gives an overview of how substitution treatment is organised in the four Nordic countries. There is no longer any questioning of the existence of this kind of treatment, but rather the discussions focus on access to treatment, how it should be organised, whether it should aim at sobriety or harm reduction and to which extent social services should be attached. Views are split on whether general practitioners should be allowed to initiate substitution treatment and to what extent special- Table 3. Substitution treatment decision on admittance to treatment and regulation Organisation Special conditions Phasing out plan Denmark Municipal or regional Medical treatment plan Yes employed doctors Social action plan Finland Health care centres, Social action plan addic.units. hospitals in special cases Norway Treatment centres for Social action plan Not always drug misuse within the spesialist health care Sweden Psychiatric or addiction Social action plan Yes centres 594 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

15 ist services and various support services should be involved. Denmark seems more obviously than the others to make a distinction between the medical and the social treatment. However, in the end it is the medical sector, the doctors, who are in charge and bear the responsibility in all the countries on whether substitution treatment should be provided. In Finland up to the 1990s, people addicted to heroin/opiates had not been seen in the treatment system to any larger extent. As the treatment system was not very strong, money and a changing (contracting) welfare state favoured what one thought would be quick medical fixes provided by hospitals. The 2008 guidelines illustrate, however, that substitution treatment could last for longer periods, and today health care centres or specialised clinics are the main providers. Substitution treatment in Norway was from the very beginning organised through regional centres parallel to the social treatment system. However, as of 2004 all kinds of treatment of substance abuse have been moved to the medical sector. In Sweden, substitution treatment used to be provided within a psychiatric hospital and continues to be a part of the medical establishment whereas non-medical treatment is given by the social sector. All four countries require a social action plan for patients in substitution treatment. There will, however, be great variations to what extent such plans actually are in place and constitute a substantial part of the treatment. Conclusions Substitution treatment has become an accepted and established response to abuse problems in the four Nordic countries of Denmark, Finland, Norway and Sweden. All of them now have less stringent restrictions on under what circumstances, by whom and to whom substitution treatment can be delivered. In practice, the regimes include control measures of various kinds. The thresholds for getting substitution treatment have remained the lowest in Denmark where this treatment mode, more geared toward harm reduction, also suited the prevalent drug policy concerns better than in the three other countries. The rapid expansion of the substitution treatment systems in Finland, Norway and Sweden has made it difficult to observe the intended standards in practice. This applies to provisions such as suitable accommodation, employment and additional supportive therapy. One could argue that the ideal of a comprehensive treatment including medical as well as psychosocial care and support has in many cases been replaced by one-sided medical treatment only. One could ask whether we are witnessing a shift in the aims of substitution treatment, one facet of which is that patients are provided with a medicine without any psychosocial support. If this is the case, an important underlying cause is probably the recurrent demand of increasing the provision of substitution treatment. Reports also allege large-scale abuse of illicit substances among patients at least in Finland and Norway. It is therefore difficult to say whether an objective to rehabilitate actually remains in force. Norway could be seen as an example of slightly shifting the aim of rehabilitation toward harm reduction. The somewhat one-sided focus on substitution treatment in the public discourse NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

16 is likely to affect resources allocated to other kinds of treatment and diminish or hamper the possibilities of getting and developing treatment for other than heroin problems. There is a relatively wide consensus in the literature about the necessity of psychosocial support of patients in substitution treatment. Without such support, most often provided by drug-free services, the goals of substitution treatment itself are likely to be jeopardised. Astrid Skretting, researcher Norwegian Institute for Alcohol and Drug Research (SIRUS) Oslo, Norway Pia Rosenqvist, head of unit Nordic Centre for Welfare and Social Issues (NVC) Alcohol and Drug Research Helsinki, Finland REFERENCES CAN (2009): Rapport 117, Drug Trends in Sweden Stockholm Dahl, H.V. (2007): The methadone game: control strategies and responses. In: Fountain, J. & Korf, D.K. (eds.): Drugs in Society, European Perspectives. Radcliffe Publishing: Oxford Drug Situation 2008 (2008): National reports to the EMCDDA by the Finnish National Focal Point. Stakes: Helsinki Drug Situation 2009 (2009): National reports to the EMCDDA by the Finnish National Focal Point. Stakes: Helsinki Engdahl, B. & Romelsjö, A. & Sand, M. (2006): Behandling av opiatmissbrukare i Sverige med Subutex en studie av ändrad behandlingspolicy (Treatment of opiate addicts with Subutex in Sweden a study of changing treatment policy). SoRAD Forskningsrapport nr 35, Stockholm Ervik, R. (1997): Evaluering av metadonprosjektet i Oslo [Del 2]. Behandlingsforløp og status (Evaluation of the methadone project in Oslo, part 2. Treatment development and status). SIFA-rapport nr. 5: Oslo Frantzen, E. (2001): Metadonmakt (Methadone power). Universitetsforlaget, Oslo Hakkarainen, P. & Tigerstedt, C. (2005): Substitutionsbehandlingens genombrott i Finland (The breakthrough of Finnish substitution treatment). Nordisk alkohol- & narkotikatidskrift 22 (3 4): Hakkarainen, P. & Tigerstedt, C. & Tammi, T. (2007): Dual-track policy Normalization of the drug problem in Finland. Drugs: Education, Prevention and Policy 14: Helsedirektoratet (2010): Nasjonale retningslinjer for legemiddelassistert rehabilitering ved opioidavhengighet (National guidelines for rehabilition by substitution treatment at opioid dependence). Nasjonal_retningsli_ a.pdf Johnson, B. (2003): Policyspridning som översättning. Den politiska översättningen av metadonbehandling och husläkare i Sverige (Policy translation. The political treatment of methadone maintenance treatment and family doctors in Sweden). Doktorsavhandling. Lund: Statsvetenskapliga institutionen Johnson, B. (2007): After the Storm, Developments of Maintenance Treatment Policy and Practice in Sweden In: Edman, J. & Stenius, K. (eds.): NAD publication 50 On the Margins. Nordic Alcohol and Drug Treatment Helsinki National Board of Health (2007): 2007 report to the EMCDDA. Copenhagen, Denmark National Board of Health (2009): 2009 report to the EMCDDA. Copenhagen, Denmark Partanen, P. & Hakkarainen, P. & Hankilanoja, A. & Kuussaari, K. & Rönkä, S. & Salminen, 596 NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

17 M. & Seppälä, T. & Virtanen, A. (2007): Amfetamiinien ja opiaattien ongelmakäytön yleisyys Suomessa 2005 (Prevalence of amphetamine and opiate use in Finland 2005). Yhteiskuntapolitiikka 72 (5): Pedersen, M. U. (2007): Professional Expertise versus Market Mechanisms in Contempory Denmark. In: Edman, J. & Stenius, K. (eds.): NAD-publication 50 On the margins. Nordic alcohol and drug treatment Skretting, A. (1997): Evaluering av metadonprosjektet i Oslo [Del I]. Etablering, inntak av pasienter og forholdet til øvrige hjelpetiltak (Evaluation of the methadone project in Oslo, part 1. Establishing, in-take of patients and the relation to other help interventions). SIFA-rapport nr. 4: Oslo Skretting, A. (2007): Medicalisation with a focus on Injecting Drug Users. In: Edman, J. & Stenius, K. (eds.): NAD-publication 50 On the margins. Nordic alcohol and drug treatment Social- och hälsovårdsministeriet (2008): Förordning om avgiftning och substitutionsbehandling av opioidberoende personer med vissa läkemedel (Decree of the Ministry of Social Affairs and Health on the detoxification and substitution treatment of opioid addicts with certain medicinal products). Helsingfors, 17 januari, Finland Socialstyrelsen (2009): Läkemedelsassisterad behandling vid opiatberoende (Substitution treatment of opioid addicts). SOSFS 2009:27, Sweden Sosial- og helsedepartmentet (1997): Narkotikapolitikken (Drug policy). Stortingsmelding nr. 16 ( ), Oslo, Norway Sosial- og helsedepartementet (2000): Rundskriv I-35/2000 Retningslinjer for legemiddelassistert rehabilitering. Oslo, Norway Sundhedsstyrelsen (2007): Vejledning om ordination af afhengighedsskabende lægemidler og om substitutionsbehandling af personer med opioidafhengighed. Denmark Sundhedsstyrelsen (2008): Vejledning om den lægelige behandling af stofmisbrukere i substitutionsbehandling. Denmark Sundhedsstyrelsen (2009): Vejledning om ordination af injicerbar diacetylmorphin (heroin) ved opioidafhængighed. Denmark Tourunen, J. (2007): Buprenorphine in Finland. Ten years after the beginning of substitution treatment. Unpublished paper presented in Lisbon, 29 November 2007 Winsløw, J.H. (1984): Narreskibet: en rejse i stofmisbrugerens selskab fra centrum til periferi af det danske samfunn. Holte: Sospol, København Waal, H. & Clausen, T & Håseth, A. & Lillevold, P.H. (2010): Statusrapport Senter for rus- og avhengighetsforskning. Seraf rapport 1/2010. Siste år med gamle retningslinjer. Universitetet i Oslo isbruker+narkotika+i+norge%3f.d25- SMRbM4x.ips Communication (2010): Oral communication at the conference on opioid maintenance National regulations and guidelines Assets and problems. Lysebu, Norway. NORDIC STUDIES ON ALCOHOL AND DRUGS V O L

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