Danish methadone policy under change?

by Jørgen Jepsen

In the Scandinavian context, Denmark stands out as a relatively "drug liberal" nation, compared in particular with Sweden and Norway. In relation to methadone, Denmark started experimenting long before its sister countries. This article will describe the rise and fall of methadone treatment in Denmark. A concern with present developments is expressed.

After its introduction in the 1960’s, a long period ensued with methadone being used only discreetly - but increasingly - through private medical practitioners. Later, clinics run by General Practitioners ("GP’s") sprang up and from the early 1980’s a development began which resulted in a near explosion in the use of methadone maintenance. After a "scandal" in the late 1970’s, in which the Health Department stepped in and debarred a Copenhagen GP from prescribing methadone, the clients were transferred to other GP’s, and in 1983-84 an evaluative study by Ege & Winslow (1984, 1984) concluded that the results of the liberal use of methadone by private physicians has had little success. One major reason for this was the failure of the Welfare Services of the City of Copenhagen to provide the social support which - on the Dole-Nyswander model - was supposed to be an important part of the methadone treatment modality. To some extent Denmark lived up to the image which its Scandinavian partners had of it: A "laissez-faire", (rather than a truly liberal) country. Methadone became a substitution, both for heavier opiates and social support. It had a clear sedative effect upon both users and politicians.

The rise and fall of methadone treatment in Denmark

In their report in 1995 on the use of methadone in European countries Farrell et al placed Denmark - along with Holland - as the European country which used the highest amount of methadone per inhabitant. Practically all of this was, and is, used for treatment of opiate addicts.

But, in 1995, after a period of increasing scepticism over the indiscriminate dispensation of methadone, the health authorities (the Ministry and the Department of Health), in connection with a general reconsideration of Danish drug policy, gave tighter guidelines for the prescription of methadone. At the same time the Ministry of Social Affairs - in connection with a programme of economic support to the municipalities - revised the Social Welfare Act.

Too liberal?

The main motivation for the reform was the feeling that methadone was being prescribed much too liberally. It was said that the receivers sold a good deal of their prescribed methadone on the black market, and there was little or no control of their consumption, including their "side abuse" - which was assumed to be extensive. As a consequence, the right to prescribe methadone was taken away from the GP’s and placed (in principle) with the counties (including Copenhagen and Frederiksberg). These were then supposed to create separate clinics or outlets for controlled distribution, where urine testing would be used frequently and where the actual intake of the methadone liquid would be scrupulously controlled. At the same time, economic responsibility for granting treatment to addicts was transferred from municipalities to the counties, which can claim a 50% refund of expenses from the municipality where the addict resides. Thus, on the administrative side, methadone dispensing and responsibility for treatment were placed on the same political level. Ideally, people should not receive methadone without also being offered social support and treatment. The changes outlined above went into force on January 1st, 1996 and at the same time a 3-year programme of economic support to counties and municipalities was commended. In actual practice, it seems that - at least up until the present (Summer 1996) - the main results of changes have been a tightening of control over methadone clients, little care in securing offers of social support, and waiting lists for the addict group as a whole for treatment and even the establishment of individual treatment plans. In many counties, the methadone clinics have not been established yet and in other places the dispensation of methadone is separated from the social service offers in different physical locations. In the treatment sector, there is - and always has been - heavy resistance to methadone maintenance and an ideological commitment to drug-free treatment. The preliminary results indicate a considerable drop in methadone prescriptions, but as of yet no significant rise in treatment being granted. In some locations the new system of dispensing methadone has made life very difficult for the clients. The tendency to return to black market drugs is as yet uncertain, but there are indications that this is happening more and more. The number of addiction-related deaths has risen considerably in the first half of 1996, but the role played in this by methadone restriction is uncertain as yet.

The development described here goes hand in hand with neo-moralistic and discriminatory attitudes towards addicts and drug users which have been stimulated by several years of diabolization of the drug user, established through years of repression-dominated discourse. With its policies Denmark seems to be moving away from the declared goal of harm reduction and towards an uneasy state of anomie.

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