Opioids in Norway
Country snapshot - Stig Erik Sørheim
What is your view on the quality of EMCDDA data? Does it reflect the actual situation?
Stig Erik Sørheim: Yes, the overdose deaths figures are quite accurate. The leading researchers say that there are few missed cases, and there is a high autopsy rate. The number of high risk users is an estimate based on a combination of different methodologies but is probably a good indication. The number of people in opioid substitution treatment is accurate.
Has opioid related harm increased or decreased in your country in recent years?
Opioids are involved in a large majority of overdose deaths (>80 %). Many overdose deaths involve a combination of opioids and one or more other substances (alcohol, benzodiazepines etc). Opioid related harm has been relatively stable over the past decade, but the average age of opioid related deaths has increased, suggesting that recruitment to high risk opioid use has slowed down. However, in 2020, there was a significant jump in overdose deaths, from around 260 to 324 deaths, mainly driven by an increase in heroin and other opioids like morphine, codeine and ocycodone.
If possible can you describe the procedures for data collection (autopsies, forensic investigations)?
In most cases (90%) autopsies are carried out, but some cases are determined by medical examination or forensic investigation. Source: https://oslo-universitetssykehus.no/seksjon/avdeling-for-rettsmedisinske-fag/Documents/Opioidrelaterte%20d%C3%B8dsfall%202000-2017.pdf
What are the main measures taken in your country regarding opioid-related harm?
Norway has a national overdose strategy. The main measures are - expanding access to substitution treatment, access to naloxone, encouraging users to switch from injecting to smoking, provide access to sterile user equipment, preventing overdoses in vulnerable periods (e.g. after pauses in use, after release from prison etc), follow up structure for people who have experienced non-fatal overdose, consider establishing early warning system for strong or particularly harmful drugs in the market, consider drug testing.
Have there been recent changes in these policies? What are the main reasons for these changes?
The first overdose strategy was launched in 2014, the second in 2019. The second strategy is based on the first, with some additions. There is a continuous debate over what drugs to include in substitution treatment, and recently Heroin was included as a substitution drug. The main driver for these policies is the concern for the high overdose rates in Norway.
What has been valuable or effective intervention in your country?
The combined overdose strategy seems to have been somewhat effective, although the data from 2020 shows a sharp increase in overdoses after several years of stable deaths. It remains to be seen if the 2020 figures were a result of access to services due to the corona epidemic or part of a long term trend.
What additional policies/laws (not directly targeting drug use) do you think would be needed to improve the opioid-related situation?
One of the challenges is the "rehabilitation" aspect of "medically assisted rehabilitation", i.e. providing housing, meaningful activities and social integration for patients in recovery from opioid use.
How would you rate the current political commitment to deal with these problems?
There is a strong political will to address the issue, though perhaps a lack of good solutions.
What are the main measures/decisions/interventions that you see missing at the moment in your country?
The main areas are probably strengthening rehabilitation and social integration, as well as better coordination between various services and governmental levels (state/health region/municipalities).
What are the primary obstacles to these expected developments in your country?
Probably institutional barriers to cooperation in a field where multisectoral action is required.
Stig Erik Sørheim is head of the International Department of Actis.
Actis - Norwegian Policy Network on Alcohol and Drugs is a Norwegian umbrella organization for NGOs in the alcohol and drug field.
National definitions usually refer to acute deaths directly related to drug consumption ("overdoses", "poisonings" or "drug-induced"). Note that, in a few countries, the figures might include also a limited number of cases of deaths indirectly related to drug use (e.g. accidents with positive toxicology). Note in addition that in some countries, statistics published at national level may differ from those presented here, owing to differences of case definition used at national level.
These are absolute numbers, and not all drug deaths are caused by opioids, though a majority are. In 2018 the number of overdose deaths with opiates was 238 (overall overdose deaths - 286).
High-risk drug use in Norway is linked mainly to injecting amphetamines and opioids, primarily heroin. The estimated number of people who inject drugs (PWID) has stabilised since 2012, following a decline during 2008-12. It was estimated that the population of PWID was around 8 900 people in 2015 (2.6 per 1 000 inhabitants aged 15-64 years). Injecting is very common among marginalised
Data from specialised treatment centres in Norway indicate that polydrug users are the main group entering drug treatment; the other main groups are users of cannabis and opioids. The long-term analysis indicates that there has been a decrease in the number of clients seeking treatment as a result of heroin (and opioid) use over recent years. In addition, a substantial proportion of clients entering treatment report more than one problem drug, and opioids are frequently reported in a polydrug context. The proportion of females in treatment varies by primary drug and type of programme.
In 2015, the Cause of Death Register reported an increase in the number of drug-induced deaths compared with 2014 and 2013. Oslo and Bergen reported the highest numbers of deaths; however, drug-induced deaths were detected in all counties. The majority of victims were male. In recent years, there has been an increase in the age of those dying as a result of overdoses in Norway, and in 2015 the victims were on average almost 47 years old. According to toxicological reports, opioids, mainly heroin, but also morphine/codeine, methadone and other synthetic opioids, were found to be the drug most commonly involved in drug-induced deaths. The annual opioid substitution treatment (OST) survey from 2016 showed a mortality rate (all causes) of 1.2 % (corrected rate) per year for patients in OST (similar to the level in 2015), and that these deaths were dominated by somatic causes. Overall, the situation in Norway is stable in terms of the characteristics and contexts of those who died.
In 2016, a total of 17 925 clients were treated in Norway, the majority of whom were treated in outpatient settings.
The largest group had opioid dependence or problem use as their primary diagnosis, followed by those who received treatment because of cannabis dependence or problem use and those who received treatment because of polydrug use.
The proportion of clients treated with methadone has been declining in recent years, as methadone is no longer recommended as the first-choice option. In 2016, 7 554 clients received OST. Approximately 6 out of 10 clients were treated with buprenorphine-based
medications, while the remaining clients were treated with methadone, and slow-release morphine was prescribed to a small proportion of clients. The long-term analysis indicates some reduction in new OST admissions since 2011. Overall, very few people are now waiting to initiate OST, and it is assumed that the system is approaching saturation in terms of numbers of current opioid users seeking treatment
In Norway, a shift has been observed in the relative importance of different opioids, with heroin now identified as the main intoxicant involved in a fifth (20 %) of the overdose deaths in 2017, compared with around half of the deaths (49 %) in 2006 (Figure 5).
Methadone (22 %) and the category ‘synthetic opioids including fentanyl and buprenorphine’ (17 %) are commonly identified as a main intoxicant in post-mortem examinations. These changes are concurrent with significant shifts in the dispensing of prescribed opioids in Norway over the last decade (Muller et al., 2019). There has been a scaling-up of buprenorphine prescription for the management of opioid dependence, and an increasing trend in the prescription of other opioids (namely tramadol and oxycodone) in the general population over the last 10 years. For example, oxycodone was prescribed to 5 200 males in 2006, compared with 19 700 in 2016 (a 279 % increase), and tramadol was prescribed to 29 600 males in 2006, compared with 94 200 in 2016 (a 218 % increase).
Update from the EMCDDA expert network
Effects of opioid maintenance treatment versus no drug therapies for opioid dependence
Norwegian Institute of Public Health, May 2020
Opioid maintenance treatment (OMT) with buprenorphine or methadone is a comprehensive treatment option for opioid dependence. The current evidence base shows that OMT patients stay in treatment longer and use less heroin than patients who receive no drug therapies.
In 2018, 7,762 persons received OMT in Norway. Patients were on average 46 years-of‑age, and 71 per cent were male.
According to Norwegian legislation, OMT should generally not be the first choice of treatment for opioid dependence. In contrast to Norway, health authorities in countries like Canada, Sweden, the United Kingdom and the United States of America do recommend OMT as first-line treatment.
Study findings: The overall effect estimates indicated that patients in OMT (72 %) remained longer in treatment than patients who received no drug therapy (57 %). OMT patients had lower overdose mortality (3 % vs 15 %). There was no difference between the treatment groups in non-prescribed opioid use (42 % vs 35 %). Patients in both groups reported having used non-prescribed opioids in 7 out of the last 28 days. The only adverse event reported was suicide attempts, for which the researchers found no difference between the groups (approximately 1 % of patients in each group had attempted suicide during the last month of treatment). However, we have very low confidence in these results. It is unclear if there is any difference in effect between OMT and no drug therapy, and in what direction any differences would point.
Norwegian product: Nasal sprays are a known remedy for preventing opioid overdose deaths
News Medical, September 2020
Between 250 and 270 people die each year from heroin or opioid overdoses in Norway. In the EU, thousands die. European users now have a better option available for helping each other.
Time is of the essence when a person has overdosed on heroin or other opioids. Mortality is high. But a friend can give an antidote quickly if it's readily available.
Users and their relatives have been part of the team as Norwegian researchers and industry developed a practical solution for twelve European countries: a nasal spray that not only is easy to store and use, but that has a low risk of withdrawal symptoms afterwards.
Active opioid users were involved in the planning of the study. The advice they gave made it possible to get the study approved by the Regional Committee for Medical and Research Ethics, says Dale.
The hope is that the final product - two sprays containing naloxone and a case - will increase the probability that the spray will become, and continue to be, something that users take with them.