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Substance use disorders in Norway
- Alcohol use disorder is the most common type of substance use disorder in Norway.
- The 12-month prevalence of harmful use of, or dependency on, alcohol is approximately 8 per cent for men and 3 per cent for women.
- Patients with substance use disorders often also suffer from other mental disorders and somatic conditions.
- Globally, it is estimated that the prevalence of substance use disorders is increasing.
- In Norway, 335 alcohol-related deaths and 286 drug-related deaths were recorded in 2018.
About substance use disorders and drug addiction
“Substance use disorders” is an umbrella term for the harmful use of, and dependency on, drugs and alcohol.
Harmful use of drugs involves the use of drugs that have caused physical or psychological harm to a person’s health over a defined period of time.
The WHO uses the term harmful use in its classification system for diseases and related health problems (ICD). Harmful use corresponds to alcohol use disorder in the US diagnostic system DSM-IV. We have opted to use the term harmful use.
Drug addiction is characterised by the user having a strong desire to consume the drug and finding it difficult to control his or her use. The user continues to use the drug despite the harmful consequences of doing so, and prioritises drug consumption over other activities and commitments.
Drug addiction also entails a need to take increasing doses (tolerance development) and sometimes withdrawal symptoms (abstinence). These symptoms vary with the type of drug and the extent of use.
This chapter covers the harmful use and dependency on:
- addictive prescription drugs
- heroin and other opioids
- cannabis (hashish and marijuana)
Tables 1 and 2 show the prevalence of various substance use disorders. These tables are mainly based on interview surveys conducted using diagnostic instruments on a sample of the general population in other countries. No such studies have been conducted on representative samples of the Norwegian population, although two surveys were carried out on random samples in Oslo and Sogn og Fjordane during the period 1994-1999, along with a survey of young adult twins in 1999-2004.
Data have also been used from the Norwegian Patient Registry (NPR), the Norway Control and Payment of Health Reimbursement (KUHR) Database, the Norwegian Prescription Database (NorPD) and the Norwegian Cause of Death Registry (DÅR). The results shown below have also been taken from the report entitled ‘Psykisk helse i Norge’ (Mental Health in Norway). In addition, various research reports have been used; these are listed under References.
Harmful use and alcohol dependency
International studies show wide variations between countries for the number of people who suffer from an alcohol use disorder, from 1 to over 12 per cent.
- In Norway, about 8 per cent of men and 3 per cent of women have an alcohol use disorder, over a 12-month period; see Table 1 (Kringlen, 2001, 2006; NIPH, 2011). The calculations are based on the previous studies from Oslo and Sogn og Fjordane in the 1990s.
Alcohol use disorders are most common among young adults between the ages of 18 and 35 (SAMSHA, 2017). The disorders begin during the early teens at the earliest, and prevalence increases steadily during adolescence and young adulthood.
In all age groups, men are at considerably greater risk than women of developing alcohol use disorders. In the Oslo and Sogn og Fjordane surveys in the 1990s and the twin study around 2000, alcohol use disorders were two to three times more common among males than among females (Kringlen, 2001, 2006; Ystrom, 2014). There is also a higher prevalence among males than among females in international studies, both for alcohol use disorder and drug use disorders in general (SAMSHA, 2017; Hasin, 2015).
Globally, it is estimated that the prevalence of drug use disorders is increasing (Whiteford, 2013), but we lack recent or repeated measurements in Norway over time.
There is evidence that an increase in the total consumption of alcohol in the population is associated with an increase in consumption at all levels (Whiteford, 2013; Forest, 1985; Rossow, 2014). This means that there is a close correlation between total consumption in the population and the proportion with very high alcohol consumption.
In Norway, sales of alcohol have risen from 3.6 litres of pure alcohol per capita per year in 1970 to almost 7 litres in 2017. We therefore assume that the prevalence of alcohol use disorders has increased during this period.
Harmful use and illicit drug addiction
The prevalence of other substance use disorders is substantially lower than that of alcohol use disorders. The 12-month prevalence was 0.9 per cent in the Oslo survey and unmeasurable (0.0 per cent) in Sogn og Fjordane; see Table 1 (Kringlen, 2001, 2006; NIPH, 2011). Lifetime prevalence was 3.4 per cent in Oslo, 0.4 per cent in Sogn og Fjordane and 1.4 per cent in the twin sample; see Table 2. For alcohol, there is considerable variation in international figures for prevalence.
Cannabis is the most commonly used illicit drug. Figures from Statistics Norway and the Norwegian Institute of Public Health show the following figures for 2016:
- About 4 per cent of the population aged 16-64 reported having used cannabis during the past 12 months (NIPH, 2016A).
- Just over 20 per cent stated that they had used cannabis once or more during their lifetime.
We do not have sufficient background data to describe trends in the prevalence of harmful use/addiction to illicit drugs.
For addictive drugs, there is a correlation between overall consumption and the number of people with overconsumption (Rossow, 2015).
- After the Norwegian Prescription Database was established in 2004 until 2015, sales of prescribed sleep medication and sedatives (which account for a significant proportion of the addictive drugs) have remained fairly constant; approximately 20 defined daily doses (DDD) per capita.
This may indicate that the prevalence of drug use disorders related to addictive drugs remained relatively stable during the period 2004-2015.
Tables 1 and 2: 12-month and lifetime prevalence of substance use disorders based on Norwegian and international studies. Click to enlarge.
Drug-related deaths include deaths where the consumption of alcohol or narcotics is considered to be the underlying cause of death (Amundsen, 2016, 2017). The definition does not include violent deaths, such as accidents or assault where drug use was involved, but it does include suicide where drugs were the underlying cause of death (Darke, 2006).
There were 286 drug-related deaths and 336 alcohol-related deaths registered in 2018 (Cause of Death Registry Statistics bank, 4.12.2019) (Gjersing, 2019).
82 per cent of deaths in 2018 were linked to the use of opioids, according to the Narkotika i Norge report (in Norwegian only).
In eight out of ten cases, alcohol-related deaths recorded in the Cause of Death Registry include diseases linked to prolonged and high alcohol consumption, such as addiction, chronic liver disease and alcohol poisoning (Amundsen, 2017).
Drugs can also contribute to death in connection with many other causes of death (Amundsen, 2017). For example, alcohol use is linked to an increase in the risk of some types of cancers. The number of recorded alcohol-related deaths therefore only constitutes a small proportion of the total mortality associated with alcohol use.
Trends in deaths
Alcohol-related deaths: From 1996 to 2018, the number of alcohol-related deaths fell by 25 per cent (Cause of Death Registry 4.12.2019, see figure below).
Measured against population growth, there has been a marked decline in alcohol-related mortality, particularly among men (Amundsen, 2017).
Drug-related deaths (overdose deaths): From 1996 to 2001, the number of drug-related deaths rose sharply. This was followed by a decrease through to 2003 and a period of stability, see figure 1 (Cause of Death Registry 4.12.2019).
Measured against population growth, there has been no decrease in drug-related mortality over the past couple of years, according to the Narkotika i Norge report (in Norwegian only).
Socio-economic and geographic differences
Most studies show that people with a high level of education and income drink more frequently than others (NIPH, 2009). Nevertheless, fewer become alcohol dependent in these groups, compared with groups with a low education and income (Directorate of Health, 2016).
The repeated use of strong painkillers and sedatives/sleep medication prescribed by a doctor is more common among groups with low socioeconomic status (Hartz, 2011; Log, 2013; Svendsen, 2014).
Problems linked to alcohol use appear to be greater in major cities than elsewhere in the country (NIPH, 2009). The study by Kringlen et al. (2001, 2006) showed major differences between Oslo and Sogn og Fjordane in the prevalence of all types of drug use disorders (Kringlen, 2001, 2006). Oslo had much higher lifetime and 12-month prevalences than Sogn og Fjordane. No recent studies are available, but the possibility that regional variations still exist cannot be excluded.
Substance use disorders and other mental disorders co-exist
Substance use disorders often occur in conjunction with other mental disorders (Rossow, 2015; Andreas, 2015; Conway, 2006; Kendler, 2006; Landheim, 2002; Lauritzen, 2012; Long, 2017; Torvik, 2017). It has for example been found that a high proportion of patients undergoing drug therapy also have a mental disorder. Results from Norwegian studies show that:
- Nine out of ten patients suffered from one or more mental disorders (Bakken, 2003).
- Approximately 70 per cent of patients met the criteria for one or more personality disorders (Landheim, 2002; Lauritzen, 2012; Ground, 2003).
It is not clear whether the mental disorders develop as a result of drug use or vice versa, or whether common risk factors lead to both mental disorders and drug abuse. There is probably a reciprocal influence between drug use disorders and mental disorders (Cerdá, 2008; Chassin, 2013; Schulenberg, 2002).
People with drug use disorders often suffer from somatic conditions as well. This may be due to the harmful effects of drug abuse (van Amsterdam, 2013). Falling levels of personal care can also leave a person vulnerable to infectious and chronic diseases through inadequate nutrition, physical inactivity and social isolation. The ability to seek help for illness is often impaired in people with substance use disorders (NIPH, 2016a; van Amsterdam, 2013; Mørland, 2015).
A high level of alcohol consumption over time can lead to the development of liver disease, gastrointestinal cancer, cerebral organic changes and neurological disorders.
Needle use also results in a high risk of blood-borne infections, such as liver inflammation with hepatitis C virus. These conditions are widespread among those who inject drugs and can cause serious illness if untreated.
The use of alcohol during pregnancy can cause foetal injuries. Insufficient knowledge is available about the use of LAR drugs during pregnancy, and how these drugs affect the foetus and the subsequent development of the child (Berg, 2008; Bakstad, 2011).
Disease burden due to substance use disorders
The use of alcohol and illicit drugs is one of the most important risk factors for death before the age of 70 in Norway (NIPH, 2017).
Results from the Global Burden of Disease project show that drug use disorders make a substantial contribution to years lived with disability (morbidity) and years of life lost both globally and in the Norwegian population (NIPH, 2016b).
For alcohol use disorders, men account for approximately 80 per cent of both years of life lost and years lived with disability.
Addiction to illicit drugs is one of the main causes of years of life lost and among the main causes of years lived with disability. There are also major differences between men and women in this regard, particularly for years of life lost. There is a higher proportion of men than women who are addicted to illicit drugs, but among addicts themselves, women have a higher mortality rate than men (FHI, 2017, 2016b). For more figures from GBD Compares, visit www.healthdata.org.
Risk factors associated with development of substance use disorders
Access to drugs is a prerequisite for developing a substance use disorder, and financial access plays a major role in the extent of drug use in the general population (Babor, 2010; Rehm, 2010). There is also a clear correlation between total consumption and the proportion who suffer from drug use disorders and injuries among the population.
However, individual risk factors will influence who develops a substance abuse disorder. Both genetic vulnerability and environmental factors increase the risk of developing serious drug problems (Mørland, 2015; Galea, 2004):
- Approximately half of the overall risk factors for developing substance use disorders are linked to genetic factors (Ystrom, 2014; Kendler, 2006; Kendler, 2003; Verhulst, 2015).
- Emotional abuse, bullying and physical and sexual abuse during childhood are key risk factors. This is supported by two Norwegian treatment studies. In both studies, half of the participants reported that at least one parent had a significant substance use problem (Lauritzen, 2012; Lauritzen, 1997). Other risk factors found included problems at school, low level of education, and low level of occupational activity.
Consequences and challenges
The development from use via harmful use to addiction can be a gradual process, and the problem is often not recognised until the process is well-advanced.
Heroin, morphine and other opioids are highly addictive if consumed repeatedly (Mørland, 2015; Dixon, 2016). Heroin injection is particularly associated with an increase in the risk of life-threatening overdoses. The risk of overdose increases for people who take a number of drugs at the same time, particularly if heroin is combined with sedatives or alcohol.
Cannabis is less addictive than opioids but addiction can develop if the drug is taken repeatedly. Dependency can be experienced as strong (Mørland, 2015; Dixon, 2016). Prolonged use may increase the risk of symptoms of anxiety and depression and in some cases can even trigger psychosis. Cannabis use can also make it more difficult to treat existing mental disorders.
Amphetamines can trigger prolonged mental illness, even after prolonged abstinence (Mørland, 2015; Dixon, 2016). Overdosing or extensive use can increase the risk of somatic conditions and psychosis.
Addictive drugs are used to treat both somatic and mental disorders (Mørland, 2015; Dixon, 2016). Short-term treatment with these medications is normally recommended. A significant proportion of patients develop prolonged and addictive use, often in combination with alcohol and/or illicit drugs. The addiction can be severe.
Difficulties and consequences for relatives
Growing up in a home where one or both parents experience drug problems can have serious consequences for children.
- It is estimated that 8 per cent of Norwegian children have at least one parent who meets the diagnostic criteria for an alcohol use disorder, while approximately 3 per cent of Norwegian children have a parent with severe harmful use (NIPH, 2011).
A family situation with substance use problems in adults increases the risk of insecurity, social isolation, various forms of conflict, abuse and neglect (NIPH, 2011; Haugland, 2012; Killén, 2003). Children may assume roles where they take over tasks and functions related to parental responsibility because they receive insufficient care from their parents or guardians.
Substance use can also have a negative impact on relationships between partners (Torvik, 2013). The risk of violence in couples and family relations is greater in families with substance use disorders (Moore, 2011).
Substance use disorders have major implications for society. Somatic treatment, mental health care and specialist drug therapy are expensive. In addition, those who need treatment for drug use are often unemployed (Whiteford, 2013; Degenhardt, 2013), and large sums of money are spent on various social security schemes and welfare benefits.
A compilation of data from the Norwegian Patient Registry (specialist health service) and data concerning work affiliation (SSB,2010) show that (Lauritzen, 2012):
- 44 per cent of patients receiving treatment for addiction to or harmful use of alcohol had been in employment during the past year
- 25 per cent of patients receiving treatment for harmful, non-alcohol related substance use disorders had been in employment during the past year.
- 19 per cent of drug users undergoing therapy received income from employment last month, according to a survey of drug users undergoing therapy (Lauritzen, 2012).
- 70 per cent of the societal costs of alcohol use are related to working life (Gjelsvik, 2004).
- Alcohol use disorders contributed little to long-term sickness absence among young workers when controlled for other concurrent mental disorders, according to a study that used diagnostic criteria (Torvik, 2016).
Little research has been conducted into the consequences of using drugs other than alcohol at the workplace (Edvardsen, 2015; Moan, 2014).
The effective prevention of substance use disorders requires co-ordinated action at international, national and regional levels.
Availability is a prerequisite for developing alcohol and drug problems, so structural measures which reduce access are an important preventive measure. Preventive initiatives should cover the entire life-cycle, but especially adolescence, and be implemented in collaboration with the community, school and workplace.
There is a close correlation between total alcohol consumption and the proportion of the population with harmful, high consumption levels (Skog, 1985; Rossow, 2014). Measures which effectively reduce overall consumption will therefore also reduce the number of high consumers, and probably also the prevalence of drug use disorders (Norström, 2005).
Political measures which reduce the financial and physical availability of alcohol in general will reduce total consumption levels (Babor, 2010; Anderson, 2009; Giesbrecht, 2016; Martineau, 2013). These include the introduction of price control (such as high excise duties) (Elder, 2010; Wagenaar, 2009; Wagenaar, 2010) and limiting the number of sales outlets, serving places, sales times and licensing hours (Babor, 2010; Bryden, 2012; Hahn, 2010; Holmes, 2014).
Selective prevention targets risk groups and risk situations.
- Growing up in a home where one or both parents have drug problems increases the risk of the child themselves developing such problems (Galea, 2004; Chassin, 1999; Sher, 1991). In Norway, efforts targeted at affected children have been intensified in recent years. Legislative changes have been implemented so that healthcare professionals now have greater responsibility for assessing childrens' need for help when parents seek treatment for drug use or other mental disorders.
- Children and adolescents with severe learning and behavioural difficulties at primary school are over-represented amongst patients with harmful substance use or addiction (Lauritzen, 2012; Lauritzen, 1997). Schools are therefore important arenas to detect problems at an early stage and to strengthen professional services and psychosocial initiatives. Training, access to resources and the possibility of close collaboration between school and home, child welfare services and mental healthcare services for children and adolescents will be key.
One particular challenge for welfare and healthcare services is to reach young people with drug problems at an early stage. Timely and co-ordinated intervention in a complex problem can eliminate the need for prolonged and expensive treatment.
A new escalation plan for substance abuse has been adopted for the period 2016-2020 (HOD, 2015). Pivotal to this plan is the need to strengthen the process of prevention and treatment and to co-ordinate services. Municipal services are identified as key focus areas.
A national overdose strategy was adopted for the period 2014-2017 entitled Javisst kan du bli rusfri-men først må du overleve (English: Of course you can become drug free - but first you must survive). This strategy aims to prevent deaths caused by overdosing (Directorate of Health, 2014). A key goal in the strategy is to steer users away from injecting drugs in favour of less harmful methods. The aim is to assist in the development of municipal plans to combat overdoses through a learning network in the hardest-hit municipalities, to make life-saving antidotes available to users and others in a research project in Oslo and Bergen, and to strengthen the focus on overdose prevention in existing initiatives.