Enrollment in Opioid-Substitution Treatment on the Rise

Individuals receiving opioid-substitution treatment have significantly increased over the past years. According to Minister of Health Willum Þór Þórsson, 276 people were enrolled in the treatment in 2019, compared to 438 in 2021.

A formal enquiry before parliament

Following a formal enquiry by MP Diljá Mist Einarsdóttir – on whether doctors would be granted greater authority to prescribe opioids to those struggling with addiction – Minister of Health Willum Þór Þórsson gave no indication before Parliament that greater authority would be granted.

Read more: In Harm’s Way: Opioid Addiction in the Age of Harm Reduction

Willum Þór explained that opioid-substitution treatment is provided primarily by three institutions in Iceland: SÁÁ (the National Centre of Addiction Medicine), the University Hospital of Iceland (Landspítalinn), and the Akureyri Hospital in North Iceland. The main drug employed during treatment in Iceland is Buprenorphine, both in tablet and injectable form, which is a licensed drug (“costly and/or must be treated with care”) administered at no cost to patients and supervised by the University Hospital’s Medicines Advisory Board.

The use of Buprenorphine in injectable form, Willum noted, is restricted to healthcare institutions (H-label) while Buprenorphine in tablet form must be prescribed by doctors with knowledge and experience of addiction (Z-label). This means that physicians specialising in addiction treatment, who have secured a license and can demonstrate experience, outnumber psychiatrists when it comes to the prescription of Buprenorphine.

Willum also noted that Buprenorphine is primarily administered to patients at Vogur’s MAT (medication-assisted treatment) clinic in Reykjavík (in accordance with an agreement regarding opioid substitution treatment signed by Icelandic Health Insurance and SÁÁ) although a number of patients retrieve their drugs in tablet-form at pharmacies.

As noted by the National Library of Medicine, opioid-substitution therapy (OST) is an “evidence-based intervention” for opiate-dependent individuals, which replaces “illicit drug use with medically prescribed, orally administered opiates such as buprenorphine and methadone.”

OST/MAT programme responsible for reducing overdose rates

As noted in the Minister’s response before Parliament, individuals receiving opioid-substitution treatment (OST) have “increased significantly over the past years.” According to the minister, 276 people were enrolled in the treatment in 2019, compared to 438 in 2021.

SÁÁ’s medication-assisted treatment (MAT) clinic at the Vogur treatment centre has gradually expanded over the years and as of late summer treats 250 patients – most of whom have injected opioids or have suffered serious consequences as a result of their addiction. According to Dr Valgerður Rúnarsdóttir, the Medical Director of SÁÁ, MAT patients receive methadone, buprenorphine pills, or injections, which reduce withdrawal symptoms and cravings for opioids.

“There’s a low threshold for participation,” Valgerður stated. ‘We’d be seeing a much higher overdose rate if it weren’t for this programme. We also collaborate with other healthcare and social services to help people become sober. If we want to improve the lives of these people, these factors must be entwined.”

Although most of the patients in Vogur’s MAT are either sober or aspiring toward abstinence, there are also some who are not ready to quit. It is important to provide services to these individuals, and the City of Reykjavík, according to Valgerður, has greatly improved access to housing for this group of people over the past years. “Things are much better today compared to ten years ago,” she stated, adding that besides offering treatment and other services, removing stigma is also vital.

Opioid Admissions to Detox Centre on the Rise

The Vogur detox centre and rehabilitation hospital has seen a steady rise in admissions due to opioids. Vísir reports that a recent survey conducted by National Centre of Addiction Medicine (SÁÁ) found the supply of opioids in Iceland has increased in recent years and police seized large quantities of OxyContin last year, a situation that has doctors at Vogur particularly concerned.

The percentage of patients admitted to Vogur for opioid addiction has gone up from 22.5% to 27.3% in the last three years. In 2011, the percentage of admissions for opioids was just 10.3%.

Proscribed use of OxyContin has also gone up significantly, even though doctors have more awareness of the risks the drug poses for addiction. At the beginning of 2022, there were 3,500 people registered with OxyContin prescriptions in Iceland. Ten years ago, there were only 500. Ragnheiður Hulda Friðriksdóttir, quality control manager and assistant to the director of Vogur, says that steps are being taken to reduce the number of patients proscribed with the drug, as well as limit its distribution among nonprescription users.

“There are, of course, plenty of people who need these medications, but it’s also common knowledge that people sell medication they don’t need. I know the Icelandic Medicine Agency and the Directorate of Health have been enacting various measures to cut back on this,” stated Ragnheiður Hulda Friðriksdóttir, director of quality control and assistant to the director of Vogur.

Suðurnes Police have seized ever-larger quantities of black-market OxyContin in recent years, but there is strong indication that the drug is widely available to non-prescription users. SÁÁ conducts an annual survey on the price of various narcotics. There has been no noticeable increase in the price of OxyContin in five years, which indicates that the supply is stable and has even gotten bigger in recent years.

The most important thing remains access to treatment, says Ragnheiður Hulda. “That and a limit on access to [opioids] such that they are only proscribed when absolutely necessary. So it’s important that we think about how to wean people off them when they are prescribed.”

Ragnheiður Hulda concluded by saying that Vogur needs additional funds from the Icelandic Health Insurance Office to support the treatment of patients with opioid addiction. The current funding supports the treatment of 90 patients.

Debate Over Waitlists at Rehab Centre Continues

Minister of Health Svandís Svavarsdóttir is calling for a proactive response to the lengthy patient waitlist at Vogur, Iceland’s government-sponsored detoxification clinic and hospital, RÚV reports. Vogur’s chief physician says this waitlist has never been longer, meaning that individuals who are seeking help with their addiction problems have increasingly long waits for treatment.

Svandís says the rationale for the waitlist must be better explained, as must the steps that a person has to take to get on said waitlists. “I think it’s very important that it’s clear what the waitlists are and what they stand for, such that the requirements for getting on the waitlist are common knowledge. That’s not the case right now and so we also need to look at that.”

The director of the National Center of Addiction Medicine (SÁÁ), which manages Vogur, has stated that it is the Health Minister herself who is responsible for taking action (or not) on long-term budget cuts at their facility.

One notable example revolves around the treatment of minors at Vogur. In April, SÁÁ announced that they would no longer be able to admit patients under 18 because it had become clear, they said, that minors should not be sharing facilities with adults who were in rehab. The decision was made in the wake of allegations that a 60-year-old patient at Vogur sexually assaulted a 16-year-old who was also in treatment there. However, Vogur has continued to treat minors while new age-specific protocols and facilities are established for these patients.

Svandís has said that the Ministry is still working on a solution but says that the working group is expected to deliver a plan no later than December 15th.