Below you will find the entire text of a recent report on The Four Pillar Drug Policy in Switzerland – 20 years after. What is more interesting are the comments of our colleague Calvina Fay, of Drug Free America, which precede the Swiss report.
Many thanks to Hans Koeppel for this overview of the last 20 years of drug
policy and a current update from Switzerland. Interesting how the Swiss
government declares its heroin distribution program a “success.”
The retention in the program is good because who wouldn’t want to stay in it
and get free heroin…. The employment rate improves because the government
creates jobs for the addicts. Their overall health improves because the
government provides regular healthcare for them. Their housing situation
improves because the government provides housing for them. I suggest that
all of these things could be provided without providing the heroin but
instead providing abstinence based treatment to get them drug free and they
would be MUCH better off. The fact that addicts, aged 50-60, are being sent
off to retirement homes for the elderly, due to their declining health, is
just plain sad. Their lives are being wasted on drugs, compliments of the
government. Most people (who don’t use drugs) remain healthy and active
well into their 80s these days.
Calvina
The Four Pillar Drug Policy in Switzerland – 20 years after
Hans Koeppel, M.D.
Swiss Physicians against Drugs, June 2012
In the 1980s, Switzerland had a drug policy consisting of three pillars: Prevention, Therapy, and Law Enforcement. At that time, as the number of heroin addicts increased to tens of thousands, the authorities in several cities tolerated so-called “Needle Parks”. An open drug scene was established where thousands of addicts injected heroin in public, slept in parks, dealt in all drugs, and lived in slum-like misery, most of them in poor health. Several overdosed every day. The media published hundreds of reports on this scandalous situation and, eventually, the police were forced to close the parks and send addicts back to their own region.
In order to cope with the increasing number of heroin addicts, methadone programs were expanded. More than 17,000 heroin addicts were included in those programs which previously were very strict. Concomitant heroin or cocaine use was sanctioned by exclusion. Thenceforwards addicts received unusual high dose of daily methadone. Positive urine tests of heroin and cocaine had no consequence; nobody was excluded because of breaking the rules. Injection rooms were installed. Most of them still exist and they recently celebrated their 20th anniversary. During this time period, the concept of harm reduction was created. Drug liberalizers proposed to add it to the national drug policy as a fourth pillar. In this context, drug use was seen as a lifestyle – a human right. Harm reduction meant providing substitution programs for the majority of heroin addicts, which included the distribution of methadone as well as heroin. To introduce heroin distribution, a so-called trial was established. Although it failed to help addicts stop drug use, the maintenance of 70% of the addicts on these programs was celebrated as a success. As a result, the health authorities set up these so-called heroin-assisted treatment programs in several cities.
These events were accompanied by thousands of articles in newspapers to promote drug liberalization. Each article started with the sentence: “The drug war has failed”. “Law enforcement criminalizes sick people.” Pictures of people injecting heroin, needles and syringes or joints, were part of the message to habituate the public on drug paraphernalia. The continuous media campaign had a big impact on prevention and therapy.
Prevention
As a consequence, drug use skyrocketed. The consumption of marihuana, ecstasy, heroin, and cocaine was seen as a recreational activity. The Green Party, which started a referendum to legalize marihuana, claimed drug use as a human right.
The media praised the positive effects of the high evoked by drug use, while deriding those who warned of its dangerous effects on body and mind. These people were described as hard-liners, sectarian, or extreme right, by the media
All jobs in the field of drug prevention and counseling, among health authorities and social workers, were occupied by advocates of the drug liberalization movement. They became the experts in all drug issues and other opinions were excluded. Eventually, information about the harmful effects of drug use, was no longer distributed.
The prevailing opinion among members of the younger generation was that it was only a matter of time before marihuana and other drugs were legalized. Fortunately, the voters rejected any form of legalization of marihuana in two referendums, the last in 2008.
The drug problem is no longer publicly discussed and has vanished from the political agenda. In some sense, the establishment of heroin distribution has had a positive effect on drug prevention. Heroin is no longer attractive, but is now seen as a “loser drug”, therefore, very few young people ever start using heroin.
Unfortunately, the young generation is not so worried about recreational use of cocaine, ecstasy, and marihuana. At weekend parties, all these drugs are excessively used. During these parties, drug counselors limit their intervention on organizing laboratories testing the purity of illegal substances.
Drug prevention, which means informing people to avoid drug use because of the harmful effects, no longer exists. The health authorities prefer to emphasize the dangers of eating disorders, smoking, gambling, and other addictions. Despite this situation, the perception of marihuana has changed, and more people now realize the negative consequences of drug use.
Drug use in Switzerland is an interesting and evolving situation. Unfortunately, no continuous monitoring exists, therefore casual studies, such as the following, provide insight into what is happening.
Cannabis Monitoring in 2008
The study shows the changes in Marihuana use, comparing 2004 and 2007. The diagram relates to young people between 13 and 29 years of age. The lifetime prevalence went down from 46.1% in 2004 to 43.5% in 2007 (total of former and present users of Marihuana). In 2007, 11.2% used Marihuana in the six months before questioning. In 2004, the figure was 13.3%.
Women
Men
Total
2004
%
2007
%
2004
%
2007
%
2004
%
2007
%
no use
60.3
61.9
47.7
51.3
53.9
56.5
former use
31.1
31.2
34.5
33.5
32.8
32.3
present use
8.6
6.9
17.8
15.3
13.3
11.2
Source: Arbeitsgruppe Cannabismonitoring (Annaheim B. et al.)(2008) Veränderungen im Cannabiskonsum 2004 bis 2007. Edited by Bundesamt für Gesundheit (BAG)
The rate of marihuana use remains at a high level and does not appear to be going down significantly. However, it seems to have lost a little of its attraction.
Therapy
Drug addiction must be seen as a severe chronic disease, which eventually results in premature death. The most effective solution for addicts, to avoid this outcome, is to terminate the use of the toxic substance. This way out of drug use is very difficult to achieve. Very often addicts will experience several cycles of withdrawal, rehabilitation, and relapse, before they are finally physically and mentally weaned off the drug.
This idea of abstinence-oriented treatment has been clouded by the conception of harm reduction. Drug addiction is seen as similar to diabetes; people with diabetes need insulin, and addicts need heroin. So the logical solution is to distribute heroin to those who need it. In this climate, facilities which offer abstinence-oriented treatment are rare. They have difficulties being acknowledged and financed by health authorities. Many of them have had to close because of lack of money, and their clients are being redirected to substitution treatment. Most of the rehabilitation programs offer “partial withdrawal” (cocaine or heroin withdrawal, but not methadone) and substitution of methadone.
Harm reduction
Together with injection rooms, needle and syringe exchange, the drug policy is primarily based on methadone, buprenorphine (Suboxon) and heroin distribution. The following, from the summary of the annual report “Heroin assisted treatment 2007” (HAT), edited in 2008 by the Federal Health Authorities, gives a good picture of the present situation.
Heroin assisted treatment 2007
(in alphabetical order)
Age: The mean age of the patients was 40 years, and the median was 39. The ages ranged from 19 to 70.
Centres: Heroin-assisted treatment is currently being offered in 23 institutions (including two centres in prisons) which have an interdisciplinary structure and hold special authorization from the Federal Office of Public Health.
Concomitant substance use: Especially with regard to alcohol, cocaine, cannabinoids and tobacco, it can be seen that patients who had been in treatment for a year or more consumed the relevant substance on fewer days and hence had less concomitant substance use than the newly enrolled patients.
Costs: One patient-day in a HAT centre cost on average 57 francs in 2007 with an overall benefit to the economy of 104 francs. Treating a heroin-dependent in a HAT centre therefore saves society 47 francs per day, mainly in the form of costs for criminal proceedings.
Delinquency: A study published in 2002/3 revealed that, according to statements by patients themselves, there is a dramatic short-term and long-term decrease in the delinquency rate (particularly serious theft and drug dealing – by more than -80%) and patients’ victim experience. Similar figures emerge from analyses of criminal offences recorded by the police (downward trend of -65% after one year’s treatment or longer and more than -80% after four years’ therapy) and Criminal Records entries (downward trend of more than -80% after four years’ treatment).
Discontinuations: 169 patients discontinued HAT in 2007 (not counting 7 discontinuations arising from a transfer to another HAT centre.) Discontinuation questionnaires recorded six deaths in 2007. 71% of the patients who left the programme changed to either abstinence-oriented treatment (16%) or to methadone substitution (55%).
64% of those who enrolled between January 1994 and March 1995 were available to answer questions as part of a six-year follow-up study: 111 had completed either methadone treatment or abstinence-oriented therapy since discontinuing HAT, and 16% said they had not consumed any illegal drugs in the last six months before the survey.
Dosage forms: About 2/3 of treatments were given in an injectable form, and 1/3 in an oral form.
Employment situation: With regard to the employment situation, 19.0% of the patients were active in the employment market and 20% were seeking employment when they enrolled in the treatment. By contrast, a year or more after the start of treatment, 33% of all the patients had a full-time or part-time job, 9% were seeking employment, 5 people were in training and 2 had been offered a job.
Enrolments: 130 patients newly enrolled in the HAT programme in 2007. The mean age of the enrolling patients was 38 years. 69.8% of the patients stated that they started HAT on their own initiative.
Gender: 76% of the persons treated were male, 24% female.
Heroin dependency in Switzerland: In 2002 the FOPH put the number of heroin-dependent people in Switzerland at between 18,500 and 25,500. The total number is estimated to be falling by 4% per year.
International: Studies from the Netherlands, Germany, Spain and the UK confirm the positive results from Switzerland. Other studies are ongoing in Canada and Belgium. Treatment with diacetylmorphine is thus one of the best evaluated treatments in the field of addiction, and both the scientific and clinical evidence can be regarded as proven.
Housing situation: Patients who had been in treatment for at least a year were more likely to lie in a stable housing situation (96%) and be living alone (58%) than newly enrolled patients (73% and 46% respectively).
Patient numbers: The number of patients was 1283 at the end of December and the maximum number of HAT places available 1444, which gives capacity utilization of 89%.
Physical stress: Among the people tested at enrolment, 75.5% had positive hepatitis C virus (HCV) test results, 39.7% positive hepatitis B (HBV) and 56.2% positive hepatitis A (HAV), the lowest prevalence being for HIV at 7%. Vaccination was planned for the majority of the HAV and HBV-susceptible patients.
Psychological stress: Compared with a representative survey of the general population using SCL-27, the HAT patients in Switzerland have higher average scores on all scales, which indicate a higher level of psychological stress in the HAT patients. The scores on the enrolment questionnaires in 2005-2007 are higher than those in the questionnaires to monitor progress in 2006-2007: a sign of diminishing psychological stress during the course of treatment. At enrolment another confirmed psychiatric disorders is diagnosed (apart from the addiction diagnosis) in 49% of the patients (suspected diagnoses not included because they cannot be confirmed until a later stage).
Retention rate: More than 70% of all the enrolled patients were still in HAT after one year and 60% after two years or longer. The period spent in heroin-assisted treatment which 50% of all the treated patients at least achieved (median retention rate) was three years.
Satisfaction: 91.1% of patients are generally very or largely satisfied with the treatment they have received in the HAT centres.
Staff: At the end of 2007 a total of 370 people with an average workload of 60% were employed in the 23 HAT centers operating 365 days a year.
Substitution treatments: In 2006 HAT accounted for 8% of the total of 16,388 substitution treatments carried out in Switzerland, while 87% of the substitution patients were maintained with methadone. The remaining treatments included buprenorphine, morphine and codeine.
HAT Annual Report 2007
More than 50% of addicts leave heroin distribution programs because they no longer want to attend a treatment center daily, as is required. However, if they are on a substitution program such as methadone, they are given the dosage for a whole week, rather than daily. Because the effect of heroin vanishes after 3-5 hours, most of these heroin patients receive an additional, high dosage of methadone for the night and next morning, in order to avoid withdrawal.
The average age of addicts in substitution programs goes up yearly. Some of these addicts are in heroin distribution programs for more than fifteen years. Heroin addiction has changed to an illness of old men. Most of the addicts are in a poor state of health and get support for their daily needs. In 2010, in the city of Berne, the number of addicts who moved to a home for the elderly peaked at 5%. They were no longer able to live alone and take care of themselves, though most of them were only between 50-60 years of age. The staff in these institutions administers the daily dose of heroin.
Heroin programs were conceived to support addicts until they were ready to stop consumption and live drug free. The reality is that these substitution programs are not working, as addicts are not ready or strong enough to go to drug free therapy even after years of substitution. Drug consumption has become a life style, until death. To be drug free is a long-term objective, never achieved by the majority of heroin addicts. They never get the chance to live drug free. They continue to be monitored by the health administration for life.
Drug death rate in Switzerland over the last 25 years
The decreasing number of deaths indicates that the Swiss drug policy is successful, in some sense. During the time of the Needle Parks, “Platzspitz” and “Letten”, the death rate was at a record high, but has fallen since. After the turn of the century, the number of overdose deaths, per year, has remained at approximately 200. Addicts dying of other harmful consequences of long-term drug use are not included in these statistics.
To have an idea what this high number means, it can be compared to the number of deaths that occur in road traffic accidents. In Switzerland that figure is approximately 450 per annum.
Drug death rate from 1985 – 2005:
Drogentodesfälle in der Schweiz 1985-2005, Fedpol (Federal Police statistics), BAG)
Between 2005 and 2010 the figure remained high. Astonishingly health authorities did not take measures to bring numbers down, as did the traffic control authorities.
Law enforcement
Twice, activist of the Green Party and drug liberalizing promoters collected signatures to start a referendum. In 1998 their proposal called for legalizing all drugs. The voters rejected it. Then in 2008 there was another proposal to legalize Marihuana only. Again it was rejected. Unfortunately, the voters agreed in 2009 to make heroin distribution legal. The perception was that it is an act of humanity to give addicts the “needed” medicine.
Every year the police confiscated high amounts of all different drugs. Dozens of hemp shops were closed by the police. These shops had sold hemp plants, seeds and products like pipes, hemp beer, hemp shampoo, soaps, T-shirts with hemp plants on it, cushions of dried hemp plants. Farmers are prohibited to feed their cows with hemp, because THC could pollute the milk. There is a strong hemp lobby in Switzerland planting hemp. Very often the police confiscated them.
Still the police must be very strict to stop the establishment of new drug scenes. Parents of under aged people are informed, when the police catch those smoking marihuana. Actual, there is a change of law in discussion. Instead of punishing marihuana user by a judge, they should be fined by the police. Police departments are against this, but most political parties do not oppose to it. Last week, the new law was discussed in the Swiss Parliament. The majority said yes to a fine of 100.- sfr. (at about 94 dollars).
In conclusion, after revision of all pillars of Swiss drug policy, the result is that drug use is at a high level for marihuana, ecstasy, and cocaine. Nobody is warning of the harmful effects of these substances. Public perception is that these drugs are as good as legalized, and that law enforcement, as it relates to drugs, is useless and old fashioned.
On the other side, the majority of the population is strictly against easing the rules in direction of drug liberalization. The promoters of legalization had once the intention to make Switzerland an outstanding model for legalization. They were successful to introduce so called heroin assisted treatment. Fortunately they failed in any further liberalization.
Heroin is no longer used by the young, as it is seen a loser drug, leading to sickness and death. This opinion may be the only prevention message of heroin distribution. The continued high death rate related to heroin addiction leads to the conclusion that harm reduction is not working. It is clear that a new, more effective drug policy has to be established.
Sources:
Heroin assisted treatment 2007, published 2008, BAG
Source: Arbeitsgruppe Cannabismonitoring (Annaheim B. et al.)(2008) Veränderungen im Cannabiskonsum 2004 bis 2007. Edited by Bundesamt für Gesundheit (BAG)
Drogentodesfälle in der Schweiz 1985-2005, Fedpol (Federal Police statistics), BAG)
