The Norwegian State Clinic for the Treatment of Addicts

Sections

Introduction
The extent of drug addiction in Norway
The drugs most frequently abused in Norway
The situation in Norway before the opening of the clinic
Location, surroundings and communications
Admission of patients to the clinic
Payment for a patient's stay
Staff of the clinic
Admission procedure
Treatment
Group therapy
Instruction
Freedom, money, visits and leave
Duration of the treatment
The framework of treatment
Sex distribution and experiences with a mixed hospital
Age distribution
Geographical distribution
Occupational distribution
Diagnostic distribution
Classification of discharges
Results
Research, information, after-care and further development of services

Details

Author: Armfinn TEIGEN
Pages: 13 to 22
Creation Date: 1964/01/01

The Norwegian State Clinic for the Treatment of Addicts

Dr. Armfinn TEIGEN
Director of the Norwegian State Clinic for the Treatment of Addicts

Introduction

The first special clinic in Norway for drug addiction was opened in June 1961 at Hov i Land, about 120 kilometers north of Oslo. The clinic can accommodate thirty-four patients, and in its two years of operation it has treated about 160 patients of both sexes who have accounted for 230 admissions. A good deal of experience that may possibly be of interest has been acquired in the process of setting up the clinic and starting operations.

The extent of drug addiction in Norway

No formal register of drug addicts is maintained in Norway. It is impossible to determine with certainty what proportion of the population is addicted to drugs. The number of cases involving drug addiction alone is relatively small in comparison with those in which addiction is combined with alcoholism or mental illness. It has been estimated that out of the country's total population of about 3.5 million, some 800 to 900 persons are addicted to drugs in the opium group, and about 4,000 to 5,000 to barbiturates, meprobamate and stimulants such as amphetamine, phenmetrazine and methylphenidate. The Pharmaceutics Office of the Department of Public Health, which receives reports concerning addicts, has a record of some 300 persons addicted to narcotics and amphetamine, and about 200 of these reside in the Oslo area. The number of new addicts in the Oslo area each year is roughly estimated to be at least thirty.

The drugs most frequently abused in Norway

The term "narkoman" [drug addict] is used in Norway to describe a person who habitually abuses the drugs listed in group A of the regulations made by the Director of Public Health concerning the prescribing and dispensing of medicaments.

Group A includes the following substances:

Amphetamine
Methadone (amidone)
Dexamphetamine
Methylphenidate (Ritalin)
Dextromoramide (Palfium)
Morphine
Diacetylmorphine
Normethadone (Ticarda)
Dihydrocodeine (Paracodin)
Oxycodone (Eucodal)
Phenmetrazine (Minaditt)
Opium
Hydrocodone (Dicodid, Nyodid)
PethidinePipradol (Gerodyl, Meretran)
Hydromorphone (Dilaudid)
Tetrapon (Thebaicin, Pantopon)
Ketobemidone (Cliradon)
 
Cocaine
 

The term "narkoman" is also used of persons who abuse barbiturates as well as pharmacodynamically and psychopharmacologically related preparations.

The clinic admits patients who have used many different drugs, either singly or in combination. A number of our patients have been drug addicts and alcoholics; some were alcoholics earlier, and then became addicted to drugs alone.

The records at the clinic show that the largest group of patients has been addicted to barbiturates and other hypnotic drugs. In some cases, however, these were used in combination with other drugs. Of the forty patients who were admitted to the clinic in 1961, twenty-five were addicted to drugs of the opium group, such as morphine, Ketogan, methadone, Thebaicin and phenethyl (a combination of barbiturates, morphine and papaverine).

Among the psychopharmaceuticals, meprobamate seems to lead increasingly to dependence and addiction. Eleven of the forty patients were addicted to meprobamate. This drug is very widely used in milder forms of nervousness, and physicians have only recently become aware of the danger of dependence arising from its use. Several of our meprobamate addicts have taken as much as twenty to thirty grammes of this drug daily. The withdrawal of meprobamate is frequently accompanied by symptoms of acute distress, such as anxiety, sweating, fibrillary twitching, cramps, difficulty in breathing, nausea, vomiting, a tendency to diarrhoea, hallucinations with anxiety symptoms, dehydration and the like.

Amphetamine, phenmetrazine and methylphenidate are present in varying combinations in such medicaments as reducing drugs. Patients have stated that these narcotics produce definite sexual fantasies and have aphrodisiac effects. Four of our patients have used phenmetrazinc (Minaditt) in connexion with distinct sexual neuroses involving frigidity or impotence. One patient used thirty to fifty tablets (750-1,250 mg) a day. Under the influence of the drug, the patient lived in a fantasy world far removed from reality, where external difficulties and his own problems seemed trivial and insignificant. His emotional conflicts could thus be kept completely in the background. As each of the drugs used in addiction produces its own special syndrome and withdrawal symptoms, the measures to be adopted in the treatment of a patient during the withdrawal period must, of course, be suited to his individual case.

The situation in Norway before the opening of the clinic

In Norway, the problems of drug addiction and the illicit drug traffic are not nearly so great as in many other countries. These problems do, however, arise in Norway too, and have in particular become gradually more serious in the towns. The character of the population is influenced to some extent by the fact that Norway is a seafaring nation and has abundant contact with other countries. It is therefore reasonable to suppose that increasing urbanization and frequent contacts with foreign countries might also contribute to an increase in addiction. Among medical personnel such as physicians, nurses, pharmacists, dentists, veterinary surgeons and others who have access to drugs, there has always been a certain percentage of addicts.

Drug addicts have sometimes undergone regular treatment in our hospitals, but all the hospitals that have had such patients have felt inadequate to the task and have been pessimistic about the possibility of achieving any permanent cure. This pessimism has been reinforced by the many cases of readdiction that have occurred. In 1957, the Director of Public Health, acting by virtue of a royal decree of that same year, made new regulations concerning the prescribing and dispensing of medicaments. These regulations are subject to amendment whenever addiction to new drugs becomes known. Moreover, the laws of Norway have long included explicit provisions concerning the sale and prescription of narcotics. In his regulations of 1958 the Director of Public Health pointed out that the number of drug addicts has tended to increase in recent years. He emphasized the responsibilities and obligations of physicians in combating this tendency. The prevention of addiction, even in prolonged and painful illnesses, is a task which can be accomplished if the necessary care is exercised. The treatment of addiction once it has become established is much more difficult, and with the means available today even the most experienced person must, in many cases, admit defeat. The treatment of addicts in the medical and psychiatric wards of ordinary hospitals has proved to be a very thankless and difficult task; the addicted patient has been and has felt himself to be out of place among the other patients. For that reason, the Director of Public Health had planned to establish a special clinic for drug addicts long before it was decided to acquire a county general hospital that was about to be closed. This hospital, together with a nurses' home, a medical director's residence, outbuildings, a tennis court and a park of about 20,000 square metres, was taken over by the State in the autumn of 1960.

The renovation and re-equipping of the hospital were carried out during the winter of 1960/61, and the hospital was officially opened on 22 June 1961.

Location, surroundings and communications

The clinic is situated on the Randsfjord, the second largest lake in Norway, and is not far from the Hov railway station, a two-and-a-half-hour ride from Oslo. It lies in a beautiful rural area in which there are many large farms.

In addition to the farms, the clinic is surrounded by wooded mountains which provide abundant opportunities for outdoor activity and good ski slopes in the winter. During the summer season there are fishing excursions, boat trips and so on.

The climate is usually stable, with little precipitation, dry, warm summers and severe winters. It is thirty kilometers from the nearest pharmacy, which is at Gjovik, a small town of 7,000 inhabitants.

The people in the area around the clinic had previously maintained close relations with the hospital and had been disappointed at its closing; little by little, however, they accepted the hospital's new status as a special clinic for drug addicts. As everything in the area is in the open, and as everyone knows everyone else, anybody from the outside who might, for example, attempt to sell or smuggle in drugs would most likely be easily discovered. Thus, the clinic is favourably situated in many respects; the relatively long distance from Oslo, however, also involves some inconvenience in the rehabilitation of patients when they return to their homes and their work, and require after-care and supervision.

Admission of patients to the clinic

An Act setting up temperance boards was passed in Norway in 1932. These are popularly elected committees whose purposes are to promote sobriety in the country, assist in the hospitalization of alcoholics and carry on educational work to combat alcoholism.

An Act of 1957 provided that the temperance boards should perform the same functions in cases of drug addiction. This new assignment was difficult to carry out as there was no specialized institution for taking care of such patients. Pending the establishment of such an institution, a sanatorium for alcoholics was used for the purpose. Since the opening of the Clinic for Drug Addiction in 1961, the sanatorium reverted to the treatment of alcoholics only.

Patients may be admitted to the State Clinic for Drug Addiction at the initiative of the temperance boards and their physicians, or directly at the request of the patient's physician alone; in some cases a request is made for the patient's transfer from a prison or a detention institution. Admission through the temperance boards may be on a voluntary basis or may be compulsory for a period of not more than two years. Every patient admitted through a temperance board must sign a so-called patient's declaration in which he or she undertakes to remain at the clinic for a period of as long as twelve months, if the physicians consider this necessary, and to obey clinic regulations. The text of the declaration is as follows:

PATIENT'S DECLARATION

I have been offered, through ..... , an opportunity to stay at the State Clinic for Drug Addiction for a period of as long as twelve months, and I have accepted this offer.

During my stay at the clinic I will abstain from alcohol and other intoxicating, narcotic or hypnotic substances. I shall perform to the best of my ability all work assigned to me during my stay and shall in other respects obey the regulations and requirements of the clinic.

I realize how important it is that the treatment should not be interrupted unless the chief physician so decides, and that, under the law, I may be held at the clinic or brought back to it - by the police if necessary - during the period mentioned.

If I am discharged earlier on probation, I am prepared to sign a pledge of abstention and to remain under such surveillance as may be decided upon for two years after the date of discharge. I realize that if I violate the conditions of probationary discharge, I may be recommitted by order of the chief physician for such period not exceeding one year as he may deem necessary.

Signed at ........ on ........ (Patient's signature)

A request for admission must be accompanied by medical information sufficiently detailed to enable the chief physician of the clinic to determine the patient's suitability for active treatment. The chief physician alone decides which patients shall be admitted. He is thus able to select the combination of patients that will help to create the most favourable environment for treatment. In some cases a physician seeking the direct admission of a patient to the clinic is advised to have his request sent through a temperance board. This is done, for example, when a patient's economic and social circumstances are somewhat unfavourable; the temperance board is then able to provide the patient and his family with economic and other assistance during and after his stay - e.g., means for purchasing clothes, prosthetics, spectacles and the like, payment of rent and so on.

Payment for a patient's stay

The patient himself pays nothing for his stay at the clinic. Everyone in Norway belongs to some insurance fund, and these funds currently pay 45 kroner per patient per day. The actual cost in 1962 was 67.32 kroner a day. The difference between the actual cost and the amount reimbursed by the insurance fund is covered by the National Treasury. The insurance fund benefits are financed by the members' contributions plus a subsidy from the State. Some patients who before being admitted were gainfully employed and were paying their insurance contributions are entitled to a cash sickness benefit of 5 to 10 kroner a day from the insurance fund. Patients whose insurance status does not entitle them to a daily cash benefit receive up to 50 kroner of pocket-money a month from the temperance board through which they were admitted.

Staff of the clinic

Physicians

In addition to the chief physician, the clinic is authorized to employ a ward physician and a reserve physician, making three physicians in all. Because of the shortage of physicians in Norway, the clinic currently employs two physicians, both of whom work full time and live in family quarters on the hospital grounds. Both are specialists in psychiatry and have been trained in psychotherapy.

Psychologist

The clinic is authorized to employ a clinical psychologist, but this post is currently vacant. From September 1961 to February 1963 the post was filled by a clinically trained psychologist, who, in addition to conducting intelligence tests, personality tests such as Rorschach TAT and the like, also carried on a long-term psychotherapy programme for a number of patients, under the chief physician's supervision.

Social Worker

This post has been filled ever since the clinic opened. The social worker's main function is to assist the patients with their economic, home and work problems. During a patient's day at the clinic the social worker acts as a link between the clinic and the patient's home, family and employer, other institutions, etc. Another function of the social worker is to arrange gatherings, evening parties, outings, entertainments and games for the patients.

Nurses

The nursing staff of the clinic consists of one head nurse, two ward nurses and twelve to fourteen ordinary nurses. Some of them worked there when it was run as a general hospital. Most of the nurses have passed a state examination, and some have also special training in psychiatric nursing. Since the opening of the clinic, the nursing staff has acquired considerable experience in the treatment and observation of drug addicts, and it is regarded as an advantage to have fully trained nurses who will gradually become capable of assuming responsibility for more and more of the treatment, making it more effective.

Superintendent and Treasurer

These are combined into a single post, the duties of which are to supervise the collection of insurance fund payments, make disbursements and purchases, supervise the maintenance and service staff, and be responsible for the maintenance of buildings, equipment and grounds. The superintendent has two assistants, who also perform clerical duties for the physicians.

Work Supervisors

Three work supervisors are responsible for the organization and supervision of the patients' work, Two of them supervise work in the park, the management of the domestic animals, work in the vegetable, fruit and berry garden, some carpentry and so on. One of the work supervisors, a woman, is specially trained in occupational therapy, and supervises this type of treatment in co-operation with the physicians. During the colder months, many types of activity are carried on in the work-room.

Kitchen Staff

One chef, one cook and two kitchen maids are employed. A patient generally works several hours a day in the kitchen. The patients take all their meals in the dining area, which is divided into three dining-rooms.

Laundry

The clinic has its own laundry, where two women and a patient operate the washing machines and also iron and mangle all the bedclothes and the patients' clothing.

Other Staff

In addition, the clinic has a number of ward attendants, a janitor and a chauffeur. Thus, the total staff equals the number of patients (about thirty-five). The relatively large staff is necessary partly for purposes of security and partly to meet the need for round-the-clock care and supervision without exceeding the legally prescribed working hours.

Admission procedure

Arrangements for the admission of patients must always be made beforehand between the clinic and the physician or temperance board concerned. To prevent the smuggling of drugs into the clinic or any other undesirable incidents, a patient must usually be accompanied by one or two reliable persons. On admission, the patient surrenders all his belongings, money, valuables and clothes to the ward staff, who later examine, mark and record all his effects and give him a receipt. The patient is then taken to the bath-room and given an enema and a bath. After that, he is dressed in the night-clothes used in the clinic and put to bed. All new patients are put to bed on the first story of the clinic, which is locked, and contains a ward for nine women and a ward for eleven men. This section also includes three specially constructed isolation rooms, which are seldom used for the isolation of patients, but mostly as individual rooms. Immediately after admission the patient undergoes a physical examination; an attempt is made to determine the amount of drug used just before admission and the duration of the addiction. Some patients are transferred from other hospitals, usually psychiatric wards, where they have undergone preliminary withdrawal treatment. Patients who have not passed through such a withdrawal period before admission are put on a withdrawal regimen adapted to their individual needs and determined, in particular, by the type and amount of drug the patient has used and his physical condition.

Treatment

The treatment consists mainly of two phases: "physiological" withdrawal and "psychological" withdrawal.

The type of phy siological withdrawal to be used with each individual patient depends on the patient's attitude, his general physical and mental condition, the type and amount of drug and the duration of the addiction. In some cases the patient himself prefers rapid withdrawal, whereas in other cases gradual withdrawal is considered more suitable and advisable. To a large extent the drug used by the patient earlier can be gradually and temporarily replaced by increasing doses of tranquillizers and other sedatives. An abundant supply of vitamins, high-protein food and anti-epileptic agents are used as a matter of routine in all withdrawal regimens. As soon as the patient has passed through the first withdrawal pangs, he is put to some kind of work, first as part of an occupational therapy programme in which the hobby aspects predominate and, later, work of a more general kind. As the interviews with the physician, occupational therapy and contacts with the other patients continue, the physicians and staff observe the patient in order to gain as thorough a knowledge as possible of his character, nature and personality. The results of this observation provide the basis for the subsequent plan of treatment. Throughout the patient's stay, considerable emphasis is placed on extended and keenly perceptive observation in order to record the effect of the treatment and, of course, to guard against any possible irregularities in drug use. On occasion, these observations also lead to a change in treatment for the remainder of the patient's stay at the clinic. Our experience has shown that most addicts require observation and treatment of the same kind as patients in a psychiatric clinic. In some cases psychotherapy of an analytic type will be required, and in others a type of treatment based on the principle of de conditioning and training. Whatever the basic psychiatric condition of an addict may be, it is complicated by his physical and mental dependence on the drug. The treatment must, therefore, always be applied with that complication in mind.

It is important during withdrawal that the patient himself should understand and agree to the principle of treatment, which, basically, consists in strengthening his will-power and his tolerance for pain and disappointment, so that he may be capable of enduring greater stress.

The aim of establishing a "drug-free atmosphere" in the clinic may be difficult to achieve, since at any particular time there will be some patients in the withdrawal stage who must have their drugs. In individual and group therapy the patients are guided away from the "tablet mentality" and toward an atmosphere which is both "internally" and "externally" drug-free. At various intervals the patients are asked to contribute to this effect by avoiding any talk or thought of drugs. During periods of a generally positive attitude to the treatment, patients have responded to such appeals.

In many cases it is hard to produce a genuine motivation for more intensive psychotherapy, and a number of patients find various excuses for stopping the treatment. The resulting difficulties may be so severe as to compel the clinic to discharge the patient.

The pronounced tendency toward repression and the personality defences against the unpleasant insights of psychotherapy lead to a greater degree of dissimulation and lying than is found in other psychiatric patients. Some of the patients treated at the clinic have undergone 200 hours of psychotherapy (analysis).

Since the summer of 1962 Delysid (LSD) has also been used as an aid in psychotherapy. This treatment has been administered to a number of patients and has, in our opinion, helped to make some of them more aware of of the need for an intensive study of deviations and distortions in personality and a correction of these in order to counteract the emotional and dynamic forces which drive the patient to addiction. This understanding and insight have been increasingly successful in introducing a more positive motivation for treatment into the atmosphere of the clinic.

Familiarity with this treatment has also provided the staff with a better insight into the reactions and behaviour patterns of patients, and thus made them better able to approach and understand the emotional conflicts which underlie a patient's sickness and the difficulties he must face before and after his stay at the clinic.

This has also caused occupational training and occupational therapy to be given greater recognition as an integral part of treatment. The same is true of other activities, such as games, study, entertainment and other forms of social life, which therefore become more valuable as purposeful forms of therapy. Considerable importance is attached by us to fostering this trend so that the entire day's programme may be understood by and be meaningful to both patients and staff as an element of the treatment that the atmosphere of the clinic can itself provide.

Group therapy

Every patient is assigned to one or more groups. The number of members in a group varies between seven and ten. The groups have been conducted by the physicians, the psychologist and, to some extent, the social worker. Individual members of the nursing staff have also occasionally assisted in conducting the groups. Each group meets once or twice a week. Although the shortage of physicians has prevented more frequent meetings, it is hoped that this type of therapeutic activity can be expanded by training some of the nurses as group leaders.

A joint meeting of the nursing staff and the patients is held every week. These meetings have some of the characteristics of the so-called " community groups ". The problems discussed at these meetings have been chiefly practical and administrative - e.g., changes in regulations, reminders of common duties, criticism and suggestions - but they have also been concerned with the clarification and solution of conflicts between patients and staff, and the planning of courses, outings and entertainments. Occasional attempts have been made to establish clubs with special programmes or assignments - study groups, poetry groups, music groups, cultural evenings and the like. These groups have been difficult to keep up, owing possibly to a lack of encouragement by the medical staff and possibly also to a general lack of interest on the part of patients. This lack of interest has also been interpreted as a general characteristic of drug addicts. Perhaps this very fact would justify the effort to stimulate intellectual activity in such groups.

Instruction

In line with this concern to keep the patients mentally active, group instruction has from the outset been given in such subjects as Norwegian, mathematics and foreign languages, particularly English. There is no teacher attached to the hospital, but one of the nurses conducted the classes for a time, while at other times there have been patients who have taken on the task. Individual patients have also attended classes outside the hospital. This has played a part in the work of rehabilitation, and it also serves as a test of the patient's capacity to cope with a freer environment. Instruction in practical subjects is given only to the extent that it can be fitted into the occupational therapy programme.

Freedom, money, visits and leav e

After the initial period of observation, enough is usually known about the patient to decide how much responsibility he can be given in the form of freedom, spending money, visits and leave.

Before the clinic opened, no one would have thought it possible to give the patients as much freedom to venture outside the grounds as has in fact been the case. It is usually not long before a patient asks to be allowed out. During the withdrawal period, he must be accompanied by a member of the staff when he leaves the grounds, but later he is allowed to go out in the company of fellow patients. An effort is thus made to give gradually greater freedom with less supervision. As far as we can tell, this system has worked considerably better then might have been expected, and we believe that it has helped the patients to make better progress. There have been a few irregularities in the form of absconding and of undesirable contacts outside, but these have been relatively insignificant.

Any money which a patient has with him or which is sent to him is credited to his account and deposited with the superintendent. Subject to the submission of receipts, he can withdraw money for purchases in neighbouring shops and for travel and similar purposes. This system has, in addition, been a source of information concerning the patient's attitude towards money, for his judgement in this regard tends to be marked by a lack of realism and a proneness to excess.

All visits to patients must be requested and authorized in advance. Permission to visit is given in the light of the patient's condition and degree of responsibility. Visitors always report to the physicians or staff first and receive instructions regarding the visiting rules, especially as far as money and drugs are concerned.

Leave to visit families and others is subject to similar precautions. Leave must always be fully justified from the point of view both of the patient and of the physician, and it must fit in with the treatment. In some cases the purpose may be to encourage the patient to continue treatment, or to test his condition and strength. If the leave is to be satisfactory and useful, it must be properly prepared and the relatives must receive instructions and be made aware of the dangers and risk involved.

Duration of the treatment

Upon admission to the clinic, as already noted, the patient must sign a declaration committing himself to stay for twelve months. In the second half of 1961, the average stay was about ninety days; in 1962 this increased to 120 days. There appear to be various reasons for this increase.

When the clinic first opened, many of its patients were persons who had been unsuccessfully treated in other institutions. Many of these patients were so abnormal in behaviour, mentally debilitated and socially disorientated that they had to be considered unsuitable for treatment in the clinic. As the clinic gradually came to be better known among the people and the country's physicians, more applications were received for patients with a better chance of responding to active treatment and thus of taking full advantage of the clinic. There have also been patients who, during their first stay, became discontented after a few months and had to be discharged, but who later suffered a relapse and sought readmission on their own initiative. During the second stay the patient seemed to have achieved a more positive motivation for treatment, and this in its turn meant that he was more amenable and easier to treat. In such cases it must be assumed that the early discharge and relapse had a favourable effect and thus represented an experience that enabled the patient to derive greater benefit from the treatment.

We have seen that for as long as six months a new patient would take a negative attitude towards treatment and thus put a serious strain on the patience and forbearance of the physicians and staff. Gradually, however, he would acquire the motivation for thoroughgoing psychiatric treatment. In such cases the legal right of retention has been of great help in eliciting a desire for psychiatric treatment in the form of psychotherapy.

The increase in the average stay at the clinic is also attributable to the inexperience of the physicians and staff when the clinic first opened. As time passed, the physicians and staff overcame certain initial difficulties and thus became better able to select the patients judiciously and to establish the necessary relationship with new patients. The patients have, as a result, come to understand more clearly the need for a thoroughgoing change in habits, behaviour and outlook. They realize that this is necessary if they are to be freed from the tendencies in their character which make for moral weakness, exaggerated emotional and other reactions, and excessive use of drugs.

The length of stay in the clinic varies greatly from one patient to another. Some have been discharged after a few days or weeks for various reasons, but a small group have remained in the clinic for as long as sixteen to eighteen months, during which time they have undergone extremely intensive and active treatment. Our general experience has been that short stays of two or three months very often give poor long-term results unless outpatient treatment can be provided after the patient's discharge. In such cases, moreover, the outpatient treatment must be given with particular care and be subject to proper controls if it is to be successful. Even patients who undergo longer periods of treatment in the clinic must continue to receive attention and help after their discharge.

Relapses seem to bear a close relationship to deficiencies in assistance, supervision and outpatient treatment during the after-care phase. After-care services for addicts are likewise inadequately developed in this country, though they are to be expanded.

It is difficult to state definitely how long a patient should stay in the clinic in order to be able to tend for himself after his discharge, for many different factors are involved.

The duration of the stay in the clinic depends upon its " quality " - i.e., on what is done with the patient.

If the clinic had an adequate number of experienced occupational therapists with enough time to provide intensive treatment for all patients, we believe that the period of treatment could be generally shortened, though not beyond certain limits. Withdrawal and rehabilitation will in any case take a certain time, which will vary from one patient to another. Both the duration and the manner of treatment must be individual. We believe that to give our thirty-four patients the treatment they require, we should have a total of five physicians and psychologists.

The framework of treatment

The daily routine and the programme for each day and each week form the framework of treatment. Individual interviews, psychotherapy, social intercourse and group and occupational therapy are the central elements in the treatment milieu. The activities in these various spheres of treatment contribute to the general atmosphere of the clinic. Only a few patients can be given thorough individual therapy. Group therapy can in some cases serve to replace the missing individual therapy, and in this way a degree of rationalization can be introduced. Such rationalization is not, however, always desirable. It is felt that, as the very minimum, each patient should have the opportunity to meet privately with his physician in the latter's office for at least half an hour each week in order to discuss his personal problems and to receive some of the psychotherapy which he requires. To satisfy this minimum requirement and thus make the patient feel that something is being done for him and with him, we prepare a weekly plan which is issued to the patient each Saturday. The plan is made out in three copies: one goes to the patient, one to the work supervisor and one to the ward nurse. The patient is thus informed of the programme of work for the week - when he is to attend group therapy, individual interviews, gymnastics and tennis, and when he is permitted to go about inside or outside the clinic grounds. The work supervisors and ward nurses having charge of the patient are also able to know where he is at any given time, and are responsible for ensuring that he is where he should be. If the patient follows his weekly plan properly, he retains his rights and his freedom. Irregularities may be "symptoms" and lead to adjustments and changes in the treatment; they may give an opportunity for observation and allow more accurate charting of the patient's personality difficulties and abnormalities.

The physicians, staff and patients all find this weekly plan very useful, and it is our impression that it contributes to a peaceful, ordered and disciplined environment and provides a secure framework of treatment.

Sex distribution and experiences with a mixed hospital

Out of the eighty patients admitted and treated in 1962, twenty-five, or a little less than a third, were women. When the clinic was being planned, many people had misgivings about male and female addicts being put in the same hospital. The clinic's layout is such that communication between the sexes is relatively free.

It cannot be denied that this has sometimes given rise to a few problems. From the point of view of treatment, however, so many advantages are offered by having patients of both sexes in the same clinic that it is worth putting up with the inconveniences.

One of the advantages is that the male patients are definitely more orderly and correct in their dress and personal hygiene and in their manners and behaviour. Social relations between male and female patients prove mutually stimulating in a positive sense. A very large number of our patients prove to have sexual or marriage problems. In treatment groups comprising both men and women, problems of sex and marriage can be taken up in a way which, in our view, offers possibilities which would not be present in a single-sex milieu. Fellowship in work, in treatment and in social intercourse within the framework of the clinic provides abundant opportunities for observing a patient's behaviour towards the opposite sex and possibilities of dealing with problems in this regard. Discussions in mixed groups have often dealt with these matters and with the responsibility of the patients for the freedom that the clinic has been bold enough to give them. Attention has also been drawn to their responsibility for the clinic's reputation in the surrounding area and for the attitude of the general public towards the treatment of drug addicts. There has been considerable success in gaining the patient's sympathy for this point of view.

At the same time, we have had cases where psychotherapy was thwarted because patients became too emotionally involved in relation to fellow-patients of the opposite sex. It likewise cannot be denied that such situations have led to matrimonial disagreements and complications.

In most situations of this sort, the patient has previously had marital problems which he has been unable to master. We do not think that the undesirable aspects of a mixed hospital are more serious than, for example, in our tuberculosis sanatoria - on the contrary less so. However, in a psychiatric establishment such as our clinic, these problems are probably more serious than in a hospital caring exclusively for physical illness.

To reserve the clinic for males or females exclusively would probably mean the loss of many of the opportunities and situations which in the course of treatment can very often provide a better insight into sexual and marital matters. It is, however, of great importance that both patients and staff should be trained to show greater frankness in this regard so that the positive advantages of a mixed group might be utilized for purposes of treatment.

Age distribution

The majority of addicts are between thirty and fifty nine years of age. No patients under twenty years have yet been admitted to the clinic, but in the course of 1962 seven patients over sixty years of age were admitted. The age distribution of the 120 admissions in 1962 was as follows:

Age (in years)

Patients

20-29
8
30-39
35
40-49
49
50-59
21
60 and over
7

Geographical distribution

Of the 120 patients admitted in 1962, sixty-four were from the city of Oslo, and of the remainder, most came from the other cities of Norway. The geographical distribution of our patients would seem to confirm that the problem of addiction is predominantly an urban phenomenon. Very few patients come from rural districts.

Occupational distribution

The greater part of the patients belong to the artisan group. A great many of the addicts admitted to the clinic in this initial period of its operations are persons who have lost all social standing and given up their regular occupations and are thus listed as casual labourers of various categories. Self-employed persons and professional workers have so far been a very small minority. Some of the patients have had to be classified as mentally sick, either as a result of their addiction or in connexion with a mental disorder. Of the latter, some are classified as "assisted ", meaning that in view of their sickness they have had to be given public assistance.

The occupational distribution of the 120 patients admitted during 1962 was as follows:

Occupation

Patients

Housewives
21
Self-employed persons
9
Artisans
34
Professional workers
4
Miscellaneous casual labourers
28
"Assisted" persons
4

Diagnostic distribution

A diagnosis of the underlying or contributing cause of drug addiction will vary from hospital to hospital. Our experience has been that drug addiction complicates many of the conditions that would normally be found represented among the patients in any psychiatric clinic. With regard to our diagnostic procedure, we sometimes concentrate on the drug addiction while giving secondary consideration to a psychiatric diagnosis. In other cases the psychiatric symptoms seem to be so prominent and apparent that the main attention is quite naturally focused on a psychiatric diagnosis, the drug addiction being regarded as secondary. The decision in any given case depends upon how much opportunity there is for analysing and observing the patient. Lack of time and the shortage of physicians make us reluctant at the present time to embark on any precise evaluation of the diagnostic distribution of our patients. Our evidence seems, however, to confirm that, in the case of most of the patients, marked personality disturbances constitute the underlying or contributing cause of the addiction.

Although personality disturbances vary greatly from patient to patient, they do have many common features. Very few patients - perhaps only two or three - have shown symptoms of psychosis. The remainder of the cases may be classified as neurosis or psychopathy. A considerable number of patients may be described as character neurotics. Others would classify the same patients as psychopaths and maintain that the latter make up the largest group. Whether they are psychopaths or neurotics, there can be no doubt that intensive psychotherapy and training are required and that this treatment should be as fully developed and differentiated as possible.

Upon examining the records of our patients with a view to finding a relationship between drug addiction and somatic conditions, we discovered that 51 out of 145 patients seemed to have become addicted to narcotics in connexion with " outward " somatic diseases and injuries. While, of course, personality and character peculiarities or difficulties play an important part in the development of addiction among these patients too, the findings may be of some interest.

The main groups of " outward " somatic causes were as follows:

 

Patients

Tuberculosis, thoracoplasty, respiratory ailments
13
Gastric ulcer, duodenal ulcer, stomach resections
10
Head injuries, headaches
8
Kidney complaints, urolithiasis
5
Back injuries, back operations
3
Gall-bladder complaints
3
Miscellaneous somatic complaints
9

Classification of discharges

The total number of patients discharged in 1962 was 122. Eighty-five of these had never been admitted before, and twenty-eight had been admitted on two, six on three, and two on four previous occasions.

As previously noted, the average length of stay for the patients discharged in 1962 was 120 days. Three patients were transferred to other hospitals, thirty-three were discharged on the advice of the physician, and fifty-nine were discharged after a full course of treatment at the clinic. During the same year, eight of the 122 patients ran away. By comparison with the frequency of unlawful departures from sanatoria for alcoholics, this number is relatively small. The frequency with which patients leave without authorization seems to depend on the restrictions in the clinic, the forms of treatment and the kind of patients who are in the clinic at any given time. The clinic is not surrounded by a barbed wire fence or by walls. The patients have considerable freedom, and for the most part they seem to have found the environment congenial.

Results

As the clinic has been in operation for only two years, it would be inappropriate at this stage to say anything definite about the results of the treatment. Many of the discharged patients have been fully employed for as long as eighteen months and have been living a socially normal life. Our knowledge of how the discharged patients are faring is deficient and varies widely, owing to the absence of any after-care or follow-up arrangements. Some information is received from temperance boards, families and employers, but not enough to provide any statistical data on the final results of the treatment. The difficulty of keeping a check on drug addicts is well known, and in Norway it is aggravated by the fact that blood tests and the clinical testing of patients are not practicable.

To evaluate the long-term results of the treatment, as much time probably is needed as, for example, in the case of cancer patients. Many authorities consider that five years of observation is necessary before it can be said with certainty that the treatment of a patient for cancer has been successful, and we believe that a person treated for drug addiction should be observed for the same length of time in order to determine whether the treatment has really been a success.

Research, information, after-care and further development of services

One of the characteristics of drug addiction is a pronounced tendency towards relapse after treatment. Many other pathological conditions once showed the same tendency, but education, research, improved hygiene and better facilities for treatment have helped in combating them, so that today a number of the major diseases have been brought under control.

With regard to information among the general public concerning drug addiction, society's attitude and behaviour towards addicts and the chances for the treatment to be effective, it might perhaps be said that we are no further ahead today than we were in the case of mental illness fifty or a hundred years ago.

The clinic described here is only one of many endeavours which must be undertaken if we are to fight drug addiction in this country.

The clinic's possibilities for research are limited by the shortage of qualified staff, especially of physicians and psychotherapists. Apart from studies within the framework of the treatment provided at the clinic and extremely modest attempts at a follow-up of discharged patients, it has not been possible to carry out any research.

A rather extensive information campaign has been conducted through the press and through talks and lectures. The medical' students at Oslo University all visit the clinic once during their psychiatry course. While there, they attend lectures, in connexion with which the patients serve as demonstration material, and they are given an opportunity to become acquainted with the problems of treatment. Lectures are also given as part of advanced education courses. There have likewise been lectures for nurses during their training in psychiatric nursing. A number of associations situated in the neighbourhood of the clinic have been invited to hear talks and be shown around.

After-care, as has been mentioned, is inadequate, but a departmental committee has drawn up guidelines for preliminary and after-care measures with respect to drug addicts in Oslo. It is proposed in the committee's report that after-care facilities should be set up in close co-operation with the temperance boards.

It is already clear after two years' work at the clinic that something more than an active treatment clinic for drug addicts is needed. In 1962, eighteen patients were discharged who were clearly hopeless cases. When these patients return to society upon their discharge, they immediately relapse, and thus become a "source of infection" and a burden to those around them. In order to combat this situation and at the same time help these patients, a special work and nursing home for chronic addicts is being planned.

Many of the patients who are discharged should remain under supervision by being given special employment and living in an after-care or rehabilitation home. Such a home would remedy a serious deficiency in our treatment apparatus.

We also believe that a less liberal type of institution for clearly psychopathic addicts and those with criminal tendencies would be a very valuable addition to the treatment of drug addiction and would open a wider range of treatment possibilities.