16 minute read
IN HARM’S WAY
GUNNI MARÍS
On Thursday, November 25, 2021, I left a COVID testing clinic near the Kringlan shopping centre in Reykjavík. Stepping into my car, the phone rang and an unknown number appeared on the screen. I listened as the voice of an old acquaintance, meek but quietly upbeat, worked its way through the speaker. We had known each other through music, and as we exchanged pleasantries, my mind – always guessing at uncertainties – wondered whether he had some kind of a collaboration in mind. That notion was quickly dispelled.
Gunni Marís needed money.
He was getting back on his feet after rehab but because he was unvaccinated, the charity organisation Mæðrastyrksnefnd (Subvention for Mothers) was refusing him and his mother help. I assumed he was lying, and as we talked, tried to invent an excuse for being unable to help (while evangelising on the importance of vaccines). But he wasn’t asking for much: two or three-thousand króna. The modesty of the request so surprised me that I said “yes” almost immediately and was left thinking that he was clever; as opposed to asking a handful of people for generous donations – and being frequently rebuffed – he was, I conjectured, asking everyone he knew for small amounts.
I hung up and transferred the money.
A few weeks passed before Gunni Marís called again. Answering the phone and recognising his voice, I found myself wishing I had saved his number – so that I could have screened his call. Again, he asked for a meagre amount of money, to which I replied that I’d “consider it,” caveating this consideration with the sentence, “I can’t make a habit of this.” This time, I saved his number on my phone and, after some deliberation, transferred 3,500 króna into his account.
The final time that he called, sometime in spring, I did not answer. By August, he was dead.
A NEW OPIOID CRISIS
When asked if talk of a “new opioid crisis” in Iceland is an exaggeration, Dr. Valgerður Rúnarsdóttir, the Medical Director of SÁÁ (National Centre of Addiction Medicine), refers to the data: between 2010 and 2022, the percentage of patients being treated for opioid addiction at the Vogur detox centre and rehabilitation hospital rose (from 10.3% to ca. 30% of the clinic’s patients). These patients are twice as likely to relapse than others, and thirty-five of those who have sought treatment over the past five years have died.
“We know what’s happening because we see such a broad range of people. So, no – it’s not an exaggeration to say that a new opioid crisis is upon us.”
This does not necessarily mean, however, that the number of people struggling with substance-use disorder is on the rise, but rather that opioids are becoming more common among that subset.
“Often when people read a news article,” Valgerður explains, “citing statistics on drug-related deaths, for example, they think that these people are dying on the street. But that’s not the complete picture. Drug-related deaths can mean overdoses and suicides – but it can also mean that someone died in an accident and happened to be taking codeine tablets.”
According to the investigative journalism programme Kompás), 21,000 people are categorised as “long-term users of addictive drugs” in Iceland. Five-hundred people were prescribed Oxycontin in 2011. In 2021, that number had increased sevenfold, or 3,500.
As Valgerður notes, opioids relieve pain but they also produce a high, which is problematic for individuals who struggle with addiction: “Opioids are extremely useful in treating acute illnesses,” she says, “in palliative care, or surgeries, but when people are using opioids to treat chronic back pain, for example – you can say that the pendulum has swung too far in the wrong direction. In that case, almost every other form of treatment is preferable, whether exercise, physiotherapy, etc.”
Iceland is currently undergoing its second opioid crisis, sponsored, at least in part, by increased prescriptions. The first opioid crisis began at the turn of the last century; in the late 1990s, the directors of Vogur – seeing an increase in opioid use and opioid injections among patients – responded by establishing medication-assisted treatment in 1999.
While most people are familiar with Vogur’s detox and rehab facilities, which has beds for 60 patients and admits approximately 600 new patients annually, fewer will have heard of the clinic’s medication-assisted treatment (MAT for short). But it was this treatment, Valgerður maintains, alongside the adoption of a prescription database by the Directorate of Health, which helped stabilise the first crisis during the early aughts.
Since then, Vogur’s MAT has gradually expanded and currently treats 250 patients (most of whom have injected opioids or have suffered serious consequences as a result of their addiction). These patients receive methadone, buprenorphine pills, or injections, reducing their withdrawal symptoms and cravings for opioids.
“It’s an evidence-based approach, and there’s a low threshold for participation. We’d be seeing a much higher overdose rate if it weren’t for this programme. We also collaborate with other healthcare and social services to help people become sober. If we want to improve the lives of these people, these factors must be entwined.”
Although most of the patients in Vogur’s MAT are either sober or aspiring toward abstinence, there are also some who are not ready to quit. It is important to provide services to these individuals, and the City of Reykjavík, according to Valgerður, has greatly improved access to housing for this group of people over the past years. “Things are much better today compared to ten years ago,” she states, adding that besides offering treatment and other services, removing stigma is also vital.
“We’ve certainly seen a change in attitudes over the past 20 or 30 years – and especially in Iceland. If you’re employing someone who has a substance-use disorder, you tell that person to go to rehab. This isn’t necessarily the case in other countries.”
When asked if the rumour was true: that the only two offices in Iceland that have not had a representative at Vogur are the office of the President of Iceland and the Bishop of Iceland, Valgerður seems to insinuate that even those venerable offices have not been unaffected by addiction:
“I don’t want to generalise,” Valgerður says, and lets out a hearty laugh.
MADAME RAGNHEIÐUR
There are 1,000 intravenous drug users in Iceland, 600 of whom are clients of Frú Ragnheiður: a specially-equipped medical reception vehicle that cruises the capital area six evenings a week and operates according to the philosophy of “harm
“IT’S AS IF
HE DOESN’T
UNDERSTAND
THAT
TAKING DRUGS
AWAY FROM
THIS
VULNERABLE
GROUP
OF PEOPLE IS
A FORM OF
PUNISHMENT.
THE EFFECTS
OF
WITHDRAWAL
ARE
EXCRUCIATING.”
reduction;” focusing on the consequences and risks of drug abuse over abstinence. Frú Ragnheiður provides clean injection equipment, condoms, and advice on safe injection methods to prevent bloodborne diseases such as HIV and Hepatitis C – offering succour to Iceland’s most vulnerable habitual users.
“We’re seeing an increase,” Kristín Davíðsdóttir, Director of Frú Ragnheiður, observes, “both in terms of the number of individuals and the number of annual visits. I can’t say whether there’s an increase in actual users, but overdose deaths are definitely on the rise.”
Last year, drug-related deaths reached an all time high in Iceland (46), and to Kristín, our inability to prevent these deaths has something to do with the fact that we’ve adopted a one-size-fits-all approach to addiction treatment. “We need to improve access and offer a greater variety of options,” Kristín explains. “This is not a uniform group of people.”
As Kristín notes, Vogur is the only institution that offers withdrawal treatment in Iceland – and the waiting period for admission is overly long. According to data from the clinic, for those attending their first treatment, or if a long time has elapsed since their last treatment, the average waiting time is 2-4 weeks. For everyone else, it’s 2-4 months.
“And when you’re injecting yourself with opioids, every single day matters,” Kristín explains.
Besides offering a greater variety of treatment, another key to reversing the trend in overdose deaths is, as Valgerður Rúnarsdóttir noted, removing the stigma placed on drug users – who are often reluctant to call the police for fear of the consequences. In this regard, the legislator can be of use.
This summer, a bill to decriminalise drug possession for personal use was shelved (ostensibly owing to lack of popular support, which was also the case in 2015), but as a compromise, the Minister of Health announced that a new bill would be submitted this winter. The new bill would repeal punishment for the “most vulnerable” people – but only in special instances and for a specific quantity. While the words sound reassuring, they appear to belie the minister’s lack of awareness regarding the realities of addiction, with the bill having raised several questions about implementation. Kristín, an advisor on the Minister’s work group, is critical of the entire process.
“We haven’t finished our work nor reached any conclusion. It’s hardly a fully formed piece of legislation. Nonetheless, the Minister of Health has appeared in the media stating that it’s not about ‘decriminalisation’ but about ‘removing punishment.’ But it’s as if he doesn’t understand that taking drugs away from this vulnerable group of people is a form of punishment. The effects of withdrawal are excruciating.”
Kristín believes that we’re pushing these people further to the extremes, which is the opposite of what we should be doing. Whenever the police are dispatched to intervene with people struggling with an opioid addiction, they often seize their drugs, taking it for granted that they’ve been obtained illegally.
“It would be like the cops barging into our homes and taking our prescription medicine,” Kristín explains. “No one judges these people as harshly as these people themselves. When they seek help from our institutions, they often become defensive. They’re afraid and insecure. Most have a history of trauma.”
Kristín maintains that we need to integrate various institutions within the system, the healthcare and the social system, for example, to make sure that we’re adopting a more holistic approach:
“To quote our clients: ‘you can’t sleep on the street without using drugs,’ so how are you supposed to stay sober when you don’t have a place of refuge?”
MENTAL HEALTH AND ADDICTION
Erna Hinriksdóttir is a psychiatric resident employed at the outpatient clinic at the National University Hospital of Iceland who also works shifts at the hospital’s psychiatric emergency department. Having initially planned on studying paediatrics, Erna was led into the field of psychiatric medicine by dint of chance and curiosity.
“I began working at the psychiatric ward as a medical student – and sort of got sucked in; it was fascinating, interacting with people dealing with these serious conditions, whether schizophrenia or bipolar disorder.”
As a former volunteer who used to ride along with Frú Ragnheiður (she still works on call), Erna was introduced to the practical benefits of “harm reduction” and has been a proponent of the approach since. Although still very much on the fringes, harm reduction is gradually making inroads into healthcare institutions in Iceland (the Laufey project within the
National University Hospital, for example.)
“The approach differs from that of rehab clinics and addiction wards where the message has usually been ‘Stay sober or get out,’ whereas harm reduction measures success along a different metric: helping an individual to stop using opioids intravenously, for example, or substituting opioids for something else,” Erna explains.
Given that there is a high rate of comorbidity between addiction and other mental illnesses, many of the individuals who seek help at the psychiatric emergency department are also struggling with substance abuse.
“The two often go hand in hand,” Erna observes. “Substance abuse is often conducive to mental illness. Likewise, those who are diagnosed with mental illnesses tend to seek relief by self medicating. When people are far gone, it affects their income, social network, housing, etc.”
For the system to better assist individuals struggling with opioid addiction, Erna believes that there needs to be acceptance of the fact that not everyone is prepared to quit.
“We need to help people unwilling to seek help at the hospital or other treatment centres or who are not yet ready to become sober. Ensuring that those who are using these drugs are not deprived of important resources – such as housing, interviews with social workers, etc. – because experience has taught us that if these resources are provided, these people are more likely to recover. I think we’re lacking this middle stage of treatment for people who aren’t ready to quit but would like to curb their consumption.”
As far as more practical matters are concerned, Erna agrees that there needs to be a greater investment on behalf of the government. As has been widely reported, the mental health facilities in Iceland are greatly lacking, and there’s a shortage of psychiatrists and nurses. “Which is not something that you just pull out of your sleeve,” Erna admits.
Listening to Erna and other health professionals who are “on the ground,” so to speak, I get the feeling that the traditional view of addiction, that people who struggle with addiction are morally reprehensible agents responsible for their own travails, has been supplanted with the notion that they are a product of their circumstances (whether personal circumstances: genetics, physiology, trauma, etc. or societal ones), and that we, as a society, share some responsibility for those circumstances; no one willingly chooses to become addicted.
As far as recent developments are concerned, Erna, like most of her colleagues, is reluctant to generalise on the rise of opioid abuse in Iceland. She agrees, however, that we’re probably seeing similar trends to the mental health crisis among adolescents in the US.
“And it’s not just adolescents. The breakneck speed of our society, and new technology, which sets us up for constant comparison, appears to adversely affect our moods, leading to increased anxiety and depression.
SOMETIME IN SPRING, I DID NOT ANSWER.
BY AUGUST, HE WAS DEAD.
THE EULOGY
Gunnar Marís was, as his friend Jóhann Dagur Þorleifsson (Jói Dagur to his friends) observes, an outsized character and a “great friend to Icelandic hip hop.”
The two met in 2007, through rapper Gísli Pálmi, and quickly became close collaborators. “Gunnar Marís had this effortless talent for rapping, with many of the lyrics he recorded over my beats being improvised on the spot,” Jói Dagur recalls.
During those 15 years between their first meeting and Gunnar Marís’ untimely death, the latter was “in and out of the psych ward” and waged a long battle against addiction. Along with making music, he enrolled in the Icelandic Film School in 2013, subsequently landing minor roles in TV shows and independent films, while spiralling ever deeper into substanceabuse.
The two friends entered rehab separately in 2018, which was when Gunnar Marís finally managed a spell of sobriety. During that time, he seemed to have regained a sense of purpose and peace, which was why his relapse 18 months later – came “like a bolt out of the blue.”
“He returned to Vogur but walked out,” Jói Dagur explains. “He went to the psych ward. He tried detoxing a few times. All of it, to no avail … it’s difficult to help someone who doesn’t want help.”
On Friday, August 12, Jói Dagur bade his friend a final farewell. The funeral also marked the first time in 12 years that all nine members of their rap collective, 3. Hæðin, were convened beneath the same roof. The church was filled with friends and collaborators, among them rapper Erpur Eyvindarson (a.k.a. BlazRoca).
In his eulogy, Erpur recalled that he had met Gunnar Marís just over fifteen years ago, that he had been passionate about music, full of dedication and industry. Many would have written him off as “a dreamer,” but at the time, Gunni Marís had already won the Rímnaflæði rap competition, released a handful of well-regarded songs, and collaborated with big names from the Icelandic rap scene, including Helgi Sæmundur (Úlfur Úlfur), Forgotten Lores, Dóri DNA, and slew of other talented rappers who were gathered in the church on that day. Erpur noted that, time allowing, he probably would have belonged to that list of collaborators but that those plans faded in the past two or three years – like most all of the good things in Gunnar Marís’ life.
After recalling the deceased’s memorable brush with the law, Erpur shed light on the character of his late friend and the poison that had claimed his life.
“Gunnar Marís worried about more than his own skin. He wanted to reach people – even as a preacher. He found Jesus everyone now and then. But his Jesus was the one who overturned the tables of the money changers in the temples; the tables of those who believed that the sole purpose of living things is to sate the greed of those who own everything; of those who start wars to sell weapons; and of those who manufacture addiction to sell us a vaporous key to a cage in which they’ve locked us …. who marketed much stronger opioids than had been previously seen here in this country – but that now are delivered in legal and more impressive packaging. You don’t have to be Jesus to want to overturn the tables of these money changers.”
Suggesting the high mortality rate of substance abuse among rappers, Erpur concluded his eulogy with a nod to those fighting to stay sober:
“To you, who remain, despite everything, alive. Jói Dagur and the rest of you, who manage to stay sober – we stand with you. You, who loved him dearest, and carry his memory – and keep his name alive – you have to live! Like they say in the Westfjords, ‘don’t you dare to die on me. If you die, I’ll kill you!’ You, who’ve plumbed the deepest valleys, now possess the greatest insight into an existence that other people don’t understand – unless they’ve dived off the cliff themselves. If pastor Þór hadn’t hidden the communion wine, I would raise a glass and toast to Gunni Marís, to some crazy stories, fine memories, and for all that he’s left behind: in lyrics, music, and expression. Cheers to the spirit, a different spirit than that which drowned you.
Rest in peace, friend.”
