| About Us | Addiction Treatment | Special Patient Groups |
Information by Country |
In the News | Resources and Events |
Frequently Asked Questions |
by Olof Blix, MD, The Bergen Clinics Foundation
Prior to 1976 methadone and morphine substitution was allowed in Norway for the treatment of opioid addiction. Treatment was office-based with no mandatory ancillary services or requirements for follow-up. Poor results, including some deaths and diversion, lead to the prohibition of this rather uncontrolled and haphazard prescription-writing practice. Subsequently, until 1997, methadone could only be prescribed to addicts who were in-patients, except in the two pilot projects described below.
Both pilot projects were limited to patients living in the greater Oslo area. The first was initiated by Dr. Gabrielle Welle Strand in 1991, and included only HIV-positive addicts with serious immunodeficiency (defined as T4 cell counts below 200). The second project included 50 hard-core heroin addicts regardless of HIV status, with the specific goal of determining the feasibility of providing such treatment despite the strong drug-free orientation that prevailed in Norway. Inclusion criteria for subjects participating in the latter project were: a minimum of 30 years of age and 10 years of addiction, predominantly to opiates; several drug-free treatment attempts followed by relapse; no pending criminal charges. This project was suggested by a scientific board at the recommendation of Professor Helge Waal, and the author (O. Blix) was recruited from Sweden to be the director. Supervision was provided by a committee appointed by the Department of Health and Welfare.
In 1997 the Government established a national system for program based Methadone Assisted Rehabilitation (MAR). The eligibility criteria were relaxed slightly (e.g., the minimum age was dropped to 25). In addition, authorization was given to waive one or more of the criteria for addicts with chronic, life threatening diseases, such as AIDS, endocarditis, active hepatitis in need of antiviral treatment, complicated epilepsy, diabetes, etc. The regulations were changed again in 1999 to allow comprehensive, individualized evaluation of each applicant; despite the added flexibility, however, it was still recommended that the earlier criteria be adhered to in most cases.
Recent revisions have made possible the utilization of other pharmacological drugs in addition to methadone, and leave the choice of drug(s) to the MAR Centres, now called Centres for Pharmacologically Assisted Rehabilitation (PAR). So far, Buprenorphine has been used in 3 projects (Oslo, Kristiansand and Bergen). Naltrexone was just registered for use in July, 2001.
In December 2000, a governmental decree required individual physicians to refer to the PAR centres patients receiving prescribed addictive drugs in a manner not consistent with the regulations. The PAR facilities evaluated such patients and decided whether prescribing should be continued, modified to meet minimum standards for safe treatment, or discontinued. Patients who were not referred to the centres for assessment by April 1, 2001, had to be tapered off the medication within 3 months.
The initial Oslo-based projects treated approximately 50 patients each at the end of 1997. By April, 2001, the number of patients treated with either Methadone or Subutex (high dose Buprenorphine) was over 1250, and another 800 were on waiting lists. Because of this persistent unmet demand, and the waiting period before admission (especially in the larger cities), the government decided once again to permit office-based treatment É which, as noted, had been prohibited for a quarter-century. Henceforth, the regional centres will no longer serve as treatment providers, but will play a quality assurance role; they will henceforth approve applications and treatment plans and order "involuntary discharge" of patients in case of violation of rules for participation. The government has agreed to provide financial incentives to encourage GPs to participate as prescribers.
Medical treatment of drug addiction is now a "right" for patients meeting the established criteria, and has been brought into line with general health services in Norway, where each citizen is assigned to one "family" doctor. The national government covers the costs of the treatment, including medication, while local communities have to pay for additional treatment and social support that may be required. Given the many changes that have occurred in the past 25 years, one must hope that the current situation will prevail, and that the office based system will be more successful than in the 1970's.