Norway

The Norwegian policy pertaining to substance use problems rests on two pillars – health policy and crime policy – which often approach the issue from opposite directions (Skretting, 2014). Among the Nordic countries, Norway is seen as having one of the most restrictive control policies on substance use (Hakkarainen et al., 1996; Pedersen, 2022a). Accordingly, the primary aim of substance use treatment has historically been total abstinence. However, there has recently been a slight shift towards a policy approach of harm reduction, at least in the health domain (Olsen, 2019; Pedersen, 2022a; Skretting, 2014). 

User involvement has meant that the Norwegian government has not explicitly defined a single specific goal of substance use treatment. However, common denominators may be aims such as a worthy life and better quality of life as specified by the individuals themselves. According to the government, the overarching goal of treatment is to reduce the negative impacts of drug use for the individual, third parties, and the society (Meld. St. 23, 2022-2023). Thus, the Norwegian substance use treatment system aims to help individuals with substance use problems to improve their quality of life, which may include helping them to live fulfilling and meaningful lives without the harms associated with substance use. This can involve helping individuals to overcome substance use problems, addressing co-occurring mental health issues, providing support for employment and education, and promoting social inclusion and community engagement.

In Norwegian public discourse, there is a consensus that the workplace is a useful arena for preventing the negative consequences of alcohol and substance use, both because the workplace socialises and influences employees and because employers have a responsibility for the health, environment, and safety of their employees. Furthermore, work is considered the key to active citizenship in society (Juberg & Skjefstad, 2019).

Over the past decades, Norway, in line with most other European welfare states have strengthened their efforts at moving the unemployed into work. A key element of these efforts are activation policies defined as ‘…those programmes and services that are aimed at strengthening the employability, labour-market, or social participation of unemployed benefit recipients of working age, usually by combining enforcing/obligatory/disciplining and enabling/supportive measures in varying extents.’ (Caswell et al., 2017, p. 3). Currently, activation policies are directed at ever wider target groups, such as persons with poor mental health and substance use problems.

One of the hallmarks of the Norwegian activation policies is the reform of the national labour and welfare administration NAV. Bridging several policy domains, the NAV reform constitutes one of the greatest revisions in the history of the Norwegian welfare state and was a response to service fragmentation. By merging the municipal social assistance services and national social security and employment services into one organisation, NAV was envisioned to represent an integrated service model. The aims of the reform were, among others, to offer a more unified frontline and more labour market-oriented services (St.prp. nr. 46., 2004–2005).

Currently, NAV is in charge of a significant portion of the state budget. It is responsible for a wide range of welfare services, including unemployment benefits, disability benefits, child and family benefits, and services related to employment and job training.

Evaluations of the reform have yielded mixed results. Some researchers argue that the reform has brought about stricter work conditionality for vulnerable groups without fulfilling the promise of holistic service provision (Minas, 2014). Other researchers have shown that transition to work for vulnerable groups of people has become more time consuming (Fevang et al., 2014). However, these negative effects were only visible in the early years of the reform, suggesting that the unfavourable development was related to the adjustment process during the first phases of the reform, and was not necessarily the result of the new model itself (Fevang et al., 2014). Still others maintain that the reform has delivered desired impacts, in particular for recipients of social assistance. The reform has enabled these beneficiaries to receive individualised support aimed at activating them and getting them into work (Erlien, 2017).

Overall, evaluations of the NAV reform suggest that while progress has been made, there is still room for improvement. Ongoing monitoring and evaluation of the reform are important to ensure that it continues to meet the needs of citizens and remains an effective and efficient system of welfare delivery.

The Norwegian welfare state is regarded as one of the most generous globally, given its liberal welfare benefits, particularly those related to health (Greve et al., 2021; Kuitto, 2016). Persons with substance use problems often receive monetary benefits due to insufficient financial self-reliance. These benefits are regulated by the National Insurance Act and the Social Services Act. One of the most frequently offered benefit schemes granted to the target group is work assessment allowance (WAA), which is a national insurance-based temporary disability benefit applying to the long-term sick. Eligibility for WAA requires documentation of a medical diagnosis. In line with the country’s overarching activation policies, the ongoing receipt of the WAA is conditioned upon participation in active measures, such as medical treatment and/or various work training schemes. The aim of the scheme (benefit and participation in measures) is to increase the (re)integration of people with long-term health issues into the labour market and avoid permanent disability. 

Persons with substance use problems who do not qualify for the medical criteria of WAA usually receive social assistance. This is meant to be the final safety net for those who cannot provide for themselves through paid work, social security benefits, or otherwise. Although the social assistance scheme does not specify a maximum period of receipt, it is meant to be a temporary solution (Meld. St. 06., 2002-2003). The Social Services Act also specifies regulations requiring active participation in labour market activities in order for a person to receive social assistance. This mostly applies to those under the age of 30 (Sadeghi & Terum, 2020).

In addition to income maintenance during unemployment, individuals with substance use problems, like other unemployed individuals, have the right to receive labour market services, that is, activity measures aimed at strengthening their employability. These measures are regulated by the Act on Labour Market Services (Lov om arbeidsmarkedstjenester, 2004) and typically include work assessment (an assessment of the individual’s work capacity, usually by observation of task performance), work training (placement in a company without wage), formal mentoring programme (NAV funds a mentor at the workplace), follow-up, training (such as courses), wage subsidies (partial funding by NAV of ordinary employment in a company), and permanent customised work (usually applied to those on permanent disability benefits). 

The Norwegian Labour and Welfare Administration (NAV) is responsible for implementing the Norwegian activation policy, aiming to move people from passive income support to active integration of unemployed citizens (Sadeghi & Terum, 2022). NAV is a unified service that contributes to social and economic security and promotes the transition to work and activity. In line with the country’s activation policy, the ultimate goal is to increase self-sufficiency and employment (Lødemel & Moreira, 2014). This specific activation policy also applies to people with substance use problems (Meld. St. 30., 2011–2012). In the Norwegian public opinion, there is a strong consensus that participation in working life creates integrity and meaning for the individual, but also acceptance as a full member of society (Fugletveit, 2018).

NAV is the main public provider of employment services. It is a one-stop shop and a partnership between local (municipality) and national governments (Sadeghi & Fekjær, 2019). Each municipality has a designated NAV office which the inhabitants of the municipality belong to. In addition to employment services, NAV is responsible for provision of income maintenance for people not able to provide for themselves, and social services such as housing and financial advice.

In addition to NAV, non-profit voluntary organisations play an active role in the provision of employment services to individuals with substance use problems. These service providers are highly dependent of public funds and are claimed to represent a central supplement to public services (Hansen et al., 2019; Hyldmo & Marken, 2015). The Salvation Army, The Church City Mission (Kirkens Bymisjon), and Erlik Oslo are a few examples of such private service providers. Typically, a purchaser–provider split model is followed, in which NAV procures employment services from these organisations.

According to the Act on Labour and Welfare Administration (Lov om arbeids- og velferdsforvaltningen, 2006), anyone who wishes or needs assistance to get into work has the right to receive an assessment of their need for assistance. This assessment results in a decision with one of four possible outcomes, and as such it constitutes NAV’s categorisation of clients into groups of standard effort, situationally contingent effort, specially customised effort, and permanent customised effort. Those who are placed in the standard effort group are expected to be integrated into the labour market within a short time and primarily by their own efforts. Clients who are offered situationally contingent effort can presumably reach their occupational goals through a combination of own efforts and NAV services. Clients placed within the specially customised effort group are considered to have reduced work capacity and are at the same time expected to be able to access the labour market by their own efforts or services from NAV or other agencies. Those placed within the permanent customised effort are similarly considered to have reduced work capacity, but without the expectation of work inclusion. Individuals in this latter group are usually granted permanent disability benefit and receive few or no labour market services. Clients with substance use problems are most frequently categorised within the two latter effort groups.

The Norwegian Directorate of Health has published a national guideline for examination, treatment, and follow-up of people with concurrent substance use problems and mental problems. The guideline stresses the importance of integration of employment and social services from NAV with mental health services in order to succeed with the task of integrating people with substance use problems into the labour market. However, research has demonstrated that collaboration between health and employment services is challenging due to professional contradictions: there are differential professional understandings and objectives (Fyhn et al., 2021) and lack of knowledge about each other’s services, practices, and competencies (Håvold et al., 2018; Pedersen, 2022a).

The NAV offices offer several services to include people with substance use problems in the work force. Facilitation guarantee is a scheme that ensures employee and employer security that people with reduced functional capacity receive the necessary facilitation and follow-up. Other services are facilitation allowance (tilretteleggings­tilskudd in Norwegian), support and follow-up measures (oppfølgingstiltak), and wage subsidies (lønnstilskudd). The qualification programme (QP) (Kvalifiserings­programmet) is available to people with, for instance, substance use problems who want to get into work or activity, who have received social assistance for a long time, or are at risk of getting into such a situation. The programme must be individually adapted and contain work-oriented measures and other activities that improve the participant’s chances of getting a job (Helsedirektoratet, 2014). Previous evaluations of the programme indicate limited effects in terms of facilitating individuals’ entry into employment (Lima & Furuberg, 2018; Schafft & Spjelkavik, 2011). 

Labour market measures used to be organised as sheltered work and training, before the participants applied for regular work. However, this train-then-place paradigm has been replaced with the idea of place-then-train, which is central in supported employment (SE) and the SE variant of individual placement and support (IPS) (see Fact box 1). This implies that the participants will be supported to enter paid work at an ordinary workplace full- or part-time with close follow-up as quickly as possible (Nøkleby et al., 2017).  At present, IPS is also regarded as a promising method to improve vocational outcomes for people with substance use problems. NAV offers IPS to this group in cooperation with specialist health services. In 2021, 38% of the Norwegian municipalities were offering SE or IPS to people with substance use problems, which is double the rate in 2017 (Osborg & Kaspersen, 2021).

Even though IPS is believed to be a promising method for helping people with mental illness into the labour market, there are currently few international or national studies measuring its effects for people with substance use problems. Several Norwegian projects following the IPS logic are small and not sufficiently evaluated. However, in an American pilot study of 45 patients in methadone treatment, 50% of those in the IPS group were in employment after six months, compared to 5% in a waiting list control group (Lones et al., 2017).

In the ongoing research project ‘Hooked on work’ (Hekta på jobb), led by Oslo Univer­sity Hospital, patients with substance use problems are offered IPS in addition to ordinary treatment. The aim of the project is to investigate how effective individual placement and support is in helping patients in substance use treatment to get into work, as well as how applicable the method is for this patient group (Rognli et al., 2023).

While IPS is a follow-up model where people are integrated in ordinary working life, organisations such as the Salvation Army, the Church City Mission, and Blue Cross Norway all offer low-threshold work or work training as well as a community for people with substance use problems. While the activities in general provide a better quality of life, they could also be a means to a new beginning without drugs or alcohol in an ordinary job situation.  

‘The work’ (Jobben), organised by the Salvation Army, offers different kinds of work as well as a meal and a community. In 2022 this low-threshold work was offered in six different cities/places in Norway with a total of 282 unique participants. The Church City Mission’s equivalent scheme ‘In work’ (I jobb) had 133 participants, 40% of whom were working at least one day a week. During an ordinary week, 40 workers would be active every day. ^‘Step by step’ (Steg for steg/SFS), organised by Blue Cross Norway, is a support programme for people with former or ongoing substance use problems who want to start a new life. The aim is to contribute to meaningful activity, strengthening of social networking, work, and social inclusion. SFS is one of the few interventions evaluated by an external research institute. Their report notes that the programme has so far focused on social inclusion rather than work (Bråthen & Brunovskis, 2021).

In addition to interventions offered by established organisations, people with substance use problems are also themselves engaged in social and professional inclusion. In 2005, the magazine =Oslo was launched as a Norwegian alternative to an international phenomenon including The Big Issue in the UK. People living rough or with substance use problems are offered to make a way of living by selling the magazine. Currently =Oslo has 1,200 registered salespersons. The magazine also functions as a voice for marginalised groups. The model has spread to other parts of the country, and eight other magazines have been established (Wikipedia, 2023).

Some people with a history of substance use problems find that their experiences become an asset in a new career in peer support (Høiseth et al., 2016). As experts by experience (erfaringskonsulenter), they support and guide others with substance use problems to start a new life. In 2018, a seven-month training course was established in Oslo to provide education and training in a so-called experience school (Erfaringsskolen). Approximately 75% of their former participants, some 15 participants annually, are currently working in local municipalities or voluntary organisations (Fonneland, 2022). However, according to Recke (2021), there is a scarcity of relevant research supporting the current use of peer support in Norway and internationally. The use of peer support is also believed to be problematic from a professional aspect. While trained social workers and other professional groups must work according to set standards, peer supporters are in a much freer position, which can have negative outcomes.

Taken together, there has been a shift in Norway in the direction of place-then-train measures such as IPS to include people with substance use problems into the labour market. There are interventions, but not enough research on the impact of these activities. Many people with substance use problems still experience inactivity and exclusion.