The Norwegian government's new "Guidelines for medically-assisted rehabilitation of drug misusers" don't seem so bad at first glance. They mouth the right phrases about harm reduction and how "the client's wishes should be of significant importance," and they provide for state-directed opiate maintenance programs to serve the Nordic nation's officially estimated 9,000 to 13,000 injection drug users.
But the new guidelines are also tightening the bureaucratic controls under which treatment providers and clients must work. Currently, doctors may prescribe and pharmacies may dispense maintenance opioids such as methadone, buprenorphine, and North European maintenance favorites such as Temgesic. Injection drug users on opiate maintenance could work directly with doctors or participate in the MAR, the government's methadone maintenance program. Under the new guidelines, all opiate maintenance treatment providers must come under the MAR umbrella.
Users, doctors, and their advocates are not happy. The new guidelines will disrupt and constrict working maintenance regimes already in place, according to Per Arvid Eikeland of the Norwegian Drug User Union. "The doctors have often treated people just fine, but now they now longer have the right to prescribe Temgesic or buprenorphine or methadone to addicts without MAR supervising," he wrote. (The Norwegian Drug User Union is an affiliate of the older, more established Danish Drug User Union, Danish union leader Joergen Kjaer told DRCNet. The web site of the parent group can be found at http://www.brugerforeningen.dk online.)
Joycelyn Woods of the National Alliance of Methadone Advocates (http://www.methadone.org) said the Norwegian government is overreaching, but that it will respond to international public opinion. The new guidelines are "a change in the wrong direction," she told DRCNet.
"The state program, the MAR, treated a small number of people, but many municipalities also had doctors prescribing independently," Woods explained. "The problem is not so much in the new regulations, but they can't handle what they're doing right now. The guidelines say doctors must join the state system. What will happen is that people will be thrown out of treatment because their doctors aren't able to get the proper certification."
"Norway does not want to admit that it has an opiate addiction problem -- that's the problem," said Woods. "They don't want to look like the United States. It's very hard for them to even admit that there are that many users. The problem is they don't realize what they're dealing with. European reformers tell me they had never seen drug users in as bad a shape as Norway, but then they haven't seen New York," Wood laughed ruefully.
The Norwegian Department of Health Affairs and Social Matters, which runs the MAR program, says approximately 1,100 people are participating and another 1,100 on waiting lists, but Eikeland argues that the real number of users seeking and receiving opiate maintenance therapy is much higher, in part because of doctor-patient contacts outside of MAR and in part because users fail to apply for programs they know are full.
"In the last year, people got the clear message that there was no more capacity," wrote Eikeland, "so they have no reason to apply to the MAR. Thus, the MAR waiting list numbers are not reliable. The majority of people don't get past the social office at the municipal level, and the municipalities keep no statistics on this."
Eikeland also noted that the MAR program with its emphasis on rehabilitating hard-core addicts is inappropriate for many stable opiate maintenance patients. Accusing the program of "terrorizing" users, he wrote that up to half of MAR participants are dismissed from the program for "side abuse," or using other drugs while in the program.
And, Eikeland pointed out, many patients do not need or desire programs aimed at the most far-gone junkies. "Some of us need control, but for most of us care, empathy, trust, and obligations are much more important. We are mostly people who are resourceful and doing well in society, with education, work and a healthier lifestyle," he wrote, describing some 300 Temgesic maintenance patients in his home county of Vestfold.
"Now they will have to apply for rehabilitation that they have no need for," he concluded. "Here in the provinces, we see that our members have better network and social skills than the MAR program is designed for, and it thus often does more harm than good."
NAMA's Woods told DRCNet that the Norwegian government responded to a letter it sent last year addressing efforts to restrict opiate maintenance therapy and that the government, sensitive about its image, might back down on this issue in order to keep a low profile. She urged readers to write to the Norwegian government to express their concerns (and to send a copy to NAMA). The correct government officials to write to are:
Affairs Guri Ingrebrigtsen, Minister of Social Affair & Tore Tonne, Minister of Health, Norway Department of Health and Social Affairs, P.O. Box 8011 dep., 0300 Oslo, Norway