Treating Heroin Addiction in Norway

The Pharmaceutical Other

Aleksandra Bartoszko

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000406528
• Edition: 1
• Topic: Social Sciences
• Subtopic: Anthropology
• Index: Social Sciences

Focusing on the world of Norwegian Opioid Substitution Treatment (OST) in the aftermath of significant reforms, this book casts a critical light on the intersections between medicine and law, and the ideologies infusing the notions of "individual choice" and "patient involvement" in the field of addiction globally.

With ethnographic attention to the encounters between patients, clinicians, and bureaucrats, the volume shows that OST sustains the realities it is meant to address. The chapters follow one particular patient through complex clinical and legal battles as they fight to achieve a better quality of life. The study provides ethnographic insight that captures the individual, experiential aspects of addiction treatment, and how these experiences find a register within different domains of treatment and policy, including the familial, social, legal, and clinical.

Offering a rare view of addiction treatment in a Scandinavian welfare state, this book will be of interest to scholars of medical and legal anthropology and sociology, and others with an interest in drug policy and addiction treatment.

1 Through the opioid landscape

“Heroin users”

Heroin users. Who are they really? People who use heroin are much more than the descriptive term they are assigned and by which they are defined. “Heroin users” are mothers, brothers, musicians, vegetarians, bird-watchers, friends, and caregivers. Nevertheless, this reductive concept and term (heroinbrukere/heroinmisbrukere) is assigned to people who use heroin in the society that I studied. Numbers and phenomena related to this category govern Norwegian health and social policy, the law, and the public’s understanding of opioid use, addiction, and pharmaceutical treatment. The pharmaceutical landscape within which Siv lived and in which her case unfolded consisted of many social, political, and scientific sites. I introduce them briefly here, but then develop each in greater detail in the analytical chapters that follow.

Norway has more than 5 million inhabitants with about 650,000 residing in Oslo, the capital. Between 6,700 and 14,000 Norwegian residents are estimated to use illicit opioids (predominantly injecting heroin), with approximately 3,000 living in the capital (Gjersing & Amundsen, 2019). In the past, users of illicit drugs could be divided into subcultures based on their drugs of choice; however, lately the prevalence of poly-drug use has evinced a rise. Combinations of opioids (heroin, methadone, buprenorphine, morphine, and other morphine-like substances) and benzodiazepines are most common. Amphetamine and other central nervous system stimulants are widely used in combination with opioids.

Apart from health hazards, “heroin users” are exposed to social exclusion, stigmatization, and everyday oppression by authorities of justice (e.g., Lundeberg & Mjåland, 2017; Nafstad, 2013). For many years the national drug policy’s official goal was to envision Norway as a “drug-free society.” In the latest governmental papers, however, this goal has been reformulated as more of a directional indicator than an achievable outcome (Waal, 2004, p. 11). Yet the legal system underscores a “drug-free society” with its focus on criminalization, prohibition, and punishment. It must be stressed, though, that the public debate in the last years has shifted in favor of treatment of addiction rather than punishment. Until recently, Norway remained immovable on its conservative drug law. In 2018, after I finished my fieldwork, the governmental majority agreed to make changes and proposed decriminalization of drug use. Minister of Health and Care Services Bent Høie appointed a public inquiry commission to design a less restrictive drug policy, aiming to move responsibility for sanctions for illicit drug use from the justice to the health sector. However, if passed, the legislative changes and their consequences for persons using drugs will take years. Until then, even with the official national health policy ordaining health care and support for people with addiction, possession and use of all illegal substances are legally prohibited and punishable through fines or prison sentences (Statistisk Sentralbyrå, 2019).

Many “heroin users” end up in prison circumstantially. Both Bergen and Oslo, which, until recently, belonged to the network of “European Cities Against Drugs” (ECAD), have experienced a tremendous push to designate drug-free areas as a way to limit open drug scenes. In Bergen, persons suspected of using drugs were given a map with marked areas in which they were prohibited from staying, sitting, or walking. Those who disobeyed could be fined and banned from visiting the same area/street for the next 24–48 hours. Most designated areas were places with low-threshold services, including food banks and health services. These areas serve as both hotspots for the sale and purchase of illegal substances as well as important hubs for social activities, gatherings, and food and shelter. Unable to pay fines, people end up being imprisoned for visiting the designated spots or for possessing illegal substances (Larsen, 2016; Lundeberg & Mjåland, 2017).

Because of economic hardships, the housing situation is difficult, and homelessness is common. Forty percent of the patients in specialized treatment for their addiction (Tverrfaglig spesialisert behandling av rusavhengighet, TSB) and half the users of low-threshold institutions are homeless (Dyb & Holm, 2015). The majority of people using heroin are unemployed and frequent recipients of social services.

Opioid deaths

The number of opioid-induced deaths has increased gradually in consonance with a rise in use of heroin injections since 1977, when Norway began keeping records. The increase peaked in 2001 with more than 400 deaths registered. Four out of five deaths due to overdose were caused by opioid injection, typically in combination with benzodiazepine and/or alcohol intake (Helsedirektoratet, 2014). Previously, heroin had accounted for 86% of the opioid drug-induced deaths; however, over the past few years, statistics indicate that the number and proportion of heroin-induced deaths have fallen, while the number and proportion of methadone and buprenorphine-induced deaths have increased.¹ In 2012, deaths caused by heroin and those by methadone were almost equal in number, with methadone-related deaths decreasing again in the last years (Amundsen, 2015).

Since 2002, the number of deaths has stabilized at around 260 annually, or five deaths per week.² This figure places Norway among the European countries with the highest recorded drug mortality rates, according to yearly reports of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA, 2017, 2020). Such cross-national comparisons are riddled with problems, however. For instance, methodological variations among member countries could partially explain Norway’s high number of (registered) overdose deaths (Waal & Gossop, 2014). A significant number of deaths related to drug intoxication are often included as overdose deaths, even without illegal drugs being detected in the deceased (Clausen, Havnes, & Waal, 2009). Thus, changes in registration procedures may largely explain the increase in overdose deaths in Norway in 2007. Nonetheless, more than 3,000 individuals who injected illicit drugs lost their lives during the last decade in Norway. Notwithstanding the country’s comprehensive expansion of its national Opioid Substitution Treatment program since the late 1990s, its substantial commitment to low-threshold health care programs since the early 2000s, and its high number of treatment centers, Norway has failed to reduce significantly the mortality rates among persons injecting drugs (Bryhni, 2006; Gjersing & Amundsen, 2019; Skretting & Rosenqvist, 2010). Against this backdrop, I examine the ways in which Norwegian health authorities approach the problematic use of opioids.

Opioid Substitution Treatment

Opioid Substitution Treatment (OST), in which patients receive in controlled conditions a long-lasting substitute for illegal heroin, is an increasing yet controversial treatment. Because of their long half-life, substitution medications such as methadone or buprenorphine are said to eliminate withdrawal symptoms for 24 to 36 hours. Administered in higher doses they are assumed to reduce the craving for heroin while blocking the effect of injected heroin (Gutwinski et al., 2014).

Methadone treatment first became available in the 1960s in the United States after physician Vincent P. Dole and psychiatrist Marie Nyswander developed the medication for addiction treatment and defined opioid addiction as “a metabolic disease” (Dole & Nyswander, 1965, 1967). Gradually, substitution treatment with methadone and later buprenorphine emerged to dominate the approach to heroin addiction worldwide. A significant factor in this development has been overdose mortality and morbidity, especially due to HIV infection, which is related to the injecting practice.

Treatment of opioid addiction with substitution therapy has shown an increased survival rate in addition to diminution in health damage, criminal behavior, and somatic diseases compared with psychosocial treatment alone (Hedrich et al., 2012; Riksheim et al., 2014; Skeie et al., 2011). In 2005, methadone and buprenorphine were incorporated into the World Health Organization’s list of essential medicines. Global and national initiatives to expand pharmaceutical treatment also are the result of calls to end the vision of drug-free societies in favor of drug policies that promote harm reduction, human dignity, and agency.

In Norway, throughout the 1970s and ’80s, the use of medication in the treatment of substance addiction was largely viewed with skepticism. The most prevalent arguments against this type of treatment were related to a strong belief that addiction could be ended with alternative, drug-free treatments. Methadone was considered symptomatic of a degrading attitude towards one’s fellow human beings, a loss of faith in people with addiction and their ability to change—as if methadone condemned people to lifelong “addiction” (Frantzsen, 2001; Skretting & Rosenqvist, 2010, p. 591; Sosial- og helsedepartementet, 1997). Opposition to pharmaceutical treatment also may reflect the relatively minor role that the medical profession had traditionally played in the treatment of addiction, an area that had been dominated for many years by social workers and, to a lesser degree, psychologists (Skretting & Rosenquist, 2010).

However, fearing an HIV epidemic in 1997, the Parliament accepted a harm reductionist approach and allowed access to pharmaceutical treatment. Hence, methadone treatment became available through a nationwide program in 1998. Initially, the program was designed as a relatively high-threshold treatment for “heroin users” who had not benefited from other types of treatment. The initial inclusion criteria were a minimum age of 25, 10 or more years of opioid dependence, and previous experience with medication-free and abstinence-oriented treatments. Individuals with severe mental or physical disorders or positive HIV status were prioritized (Waal, 2007). Later, these admission criteria were relaxed, and new medications were introduced, buprenorphine in 2002, a buprenorphine-naloxone combination in 2007, and slow-release buprenorphine-injections in 2019.

From the beginning, the broad political and professional consensus has been that the objective of Norway’s substitution treatment should be rehabilitation. This goal is reflected in the terms Methadone Assisted Rehabilitation (Metadonassistert rehabilitering, MAR) and today’s Medicine Assisted Rehabilitation (Legemiddelassistert rehabilitering, LAR). I have translated the Norwegian program as Opioid Substitution Treatment (OST), which is an established, recognizable term in global literature related to the subject. However, I wish to indica...

Table of contents

• Cover
• Half-Title
• Series
• Title
• Copyright
• Dedication
• Contents
• Foreword: This happened while
• Acknowledgments
• Introduction
• 1 Through the opioid landscape
• 2 Pharmaceutical polyphony
• 3 Pharmaceutical atmospheres
• 4 Waiting for evidence
• 5 Living longer than life
• 6 From hope to §3-1
• Conclusions
• Glossary
• Bibliography
• Index