Switzerland

"According to what is currently known, there are only a small number of dependent drug users who exclusively consume cocaine; most of those who are dependent on drugs consume heroin first and foremost. However, cocaine is increasingly consumed in addition to heroin.

"On the basis of existing data it can be assumed that the number of heroin dependents dropped from around 30,000 in 1992 to 26,000 in 2002. At the same time, in the last 10 to 15 years the number of deaths related to drug consumption has decreased from what used to be 640 to 740 per year to a current annual figure of 250. However, for several years now the trend has stopped moving downwards."

"The consumption of cannabis, cocaine and ecstasy has increased in the past ten years. At present, around 20% of the population over 15 years of age have consumed cannabis (24% of men and 15% of women). Experience of consumption has also risen in the case of cocaine (from 1.6% to 2.8%) and ecstasy (from 1.0% to 1.8%)."

"Among young people, it is clear that more boys consume cannabis than girls (current consumers number 11.5% and 5.1% respectively). However, here consumption has stabilised and has recently begun to fall among school pupils.⁵⁶ The number of young men who have experience of hard drugs has increased, whereas the number of young women with such experience has remained stable.⁵⁷"

"Heroin has been, at least until very recently, the principal drug problem for Switzerland, as for most Western European nations. In the mid-1990s Switzerland had a heroin addiction prevalence that may have been the highest in Europe. Switzerland’s heroin problem has been declining steadily over the last decade. The estimates of the size of the group are crude but show a reduction from about 29, 000 in 1994 to 23,000 in 2002, the most recent year for which an estimate is available. The aging of the population in treatment is a reassuring indicator that initiation rates have been low since the mid-1990s; whereas in 1994 the median age of those in treatment was 26.5 years, that had risen to 30.5 by 2006. The health of the heroin dependent population has been improving."

"Heroin misuse in Switzerland was characterised by a substantial decline in heroin incidence and by heroin users entering substitution treatment after a short time, but with a low cessation rate. There are different explanations for the sharp decline in incidence of problematic heroin use. According to Ditton and Frischer, such a steep decline in incidence of heroin use is caused by the quick slow down of the number of non-using friends who are prepared to become users in friendship chains. Musto's generational theory regards the decline in incidence more as a social learning effect whereby the next generation will not use heroin because they have seen the former generation go from pleasant early experiences to devastating circumstances for addicts, families, and communities later on."

"Overall, results indicate that heroin prescription is a very promising approach in reducing any type of drug related crime across all relevant groups analyzed. It affects property crime as well as drug dealing and even use/possession of drugs other than heroin. These results suggest that heroin maintenance does not only have an impact by reducing the acquisitive pressure of treated patients, but also seems to have a broader effect on their entire life-style by stabilizing their daily routine through the commitment to attend the prescription center twice or three times a day, by giving them the opportunity for psychosocial support, and by keeping them away from open drug scenes."

"Total drug arrests increased substantially in the 1990s and rose slightly in this decade. There was a large decline in heroin arrests (from 18,000 in 1997 to 6500 in 2006), compensated for by an increase in cannabis arrests. About 80 percent of arrests are for possession rather than dealing. Switzerland makes more arrests (per capita) for simple possession of cannabis than even the United States; comparative figures for a number of countries are provided in Figure S2. However at the other end of the criminal justice system, small numbers are sentenced to incarceration; out of roughly 40,000 persons arrested each year for drug violations, fewer than 2,000 receive terms of incarceration. Moreover the total number of convictions and incarcerations for drug offenses has hardly changed over the period 1990-2006, Fewer than one quarter of those sentenced receive terms as long as eighteen months. The majority of arrests are for possession of cannabis and result in fines of 250-300 CHF; these are not even recorded as convictions."

"The harm reduction policy of Switzerland and its emphasis on the medicalisation of the heroin problem seems to have contributed to the image of heroin as unattractive for young people."

"Drug-related deaths, most of which are a consequence of heroin dependence, have declined since the early 1990s, from 350-400 per annum to 150-200 per annum in this decade. HIV infections related to injecting drug use have also declined. This may reflect a modest decline in injecting, as opposed to smoking or snorting, of heroin, a decline in needle sharing among users because of Syringe Exchange Programs and the lower population of heroin dependent users."

"It has emerged that heroin-assisted treatment is a suitable option only for a small proportion (currently 4%) of the 30,000 severely dependent injecting drug users. Heroin-assisted treatment is not a replacement for other substitution or abstinence-based therapies, but an important addition for those drug users that have so far fallen through the therapeutic net. This is confirmed by the relatively modest increase in patient numbers since the bar on the legally permitted maximum number was lifted."

"Despite the availability of a wide range of treatment programs, including methadone substitution, not all drug addicts with serious health and social problems could be motivated to enter treatment. A core group remained, which was characterized by numerous social and physical deficiencies. In an attempt to reach this group, Heroin on prescription was launched in 1994 as part of a nationally-based research project. Admission criteria were a minimum age of 20 years, at least a two-year duration of daily intravenous heroin consumption, a negative outcome of at least two previous treatments, and documented social and health deficits as a consequence of their heroin dependence. The treatment consisted of between one to three injections of heroin a day, and medical, psychiatric, and social monitoring.

"After three years, the results showed, amongst numerous other findings, that:
"• The program is able, to a greater extent than other treatments, to reach its designated target group.
"• The improvements in physical health proved to be stable over the whole period.
"• Illicit heroin and cocaine use regressed rapidly and markedly, whereas benzodiazepine use decreased only slowly and alcohol and cannabis consumption hardly declined at all.
"• The participants' housing situation and fitness for work improved considerably.
"• The income from illegal and semi-illegal activities decreased dramatically (10% as opposed to 69% originally).
"• Both the number of offenders and the number of criminal offenses decreased by about 60% during the first six months of treatment."

"Based on its 1992 call for proposals, the Federal Office of Public Health authorized HAT trials in Zurich, Bern, Basel, and Geneva involving about 1,000 persons in the first instance (Bammer et al. 2003). Studies of HAT continued in Switzerland beyond the first trials. The full results of this work are beyond the scope of this paper, but what may be hundreds of peer-reviewed journal articles on the trials, as well as a book produced by FOPH (RihsMiddel et al. 2005), attest to the care taken to document a wide range of health and social outcomes from the HAT experience. In brief, some of these results are as follows (See esp. Uchtenhagen 2009, 34 and Bammer et al. 2003, 365):

"• It was possible to stabilize dosages of heroin, usually in two or three months, without a continuing increase of dosages, which some had feared.

"• There was significant and measurable improvement in health outcomes for patients, including significantly reduced consumption of illicit heroin and even illicit cocaine.

"• There was a significant reduction in criminal acts among the patients, to the point where the estimated benefits of this effect well exceeded the cost of the treatment (See also Killias et al. 2005).

"• Heroin from the trials did not find its way into illicit markets.

"• Initiation of new heroin use did not increase.

"• Utilization of treatments other than HAT, especially methadone, increased after the advent of HAT rather than declining as some had feared.

"In short, the fears of opponents of HAT were largely refuted by solid evidence, though, of course, political debate would continue."

"With respect to the group of those treated uninterruptedly during four years, a strong decrease in the incidence and prevalence rates of overall criminal implication for both intense and moderate offenders was found. As to the type of offense, similar diminutions were observed for all types of offenses related to the use or acquisition of drugs. Not surprisingly, the most pronounced drop was found for use/possession of heroin. In accordance with self-reported and clinical data (Blaettler, Dobler-Mikola, Steffen, & Uchtenhagen, 2002; Uchtenhagen et al., 1999), the analysis of police records suggests that program participants also tend strongly to reduce cocaine and cannabis use probably because program participants dramatically reduced their contacts with the drug scene when entering the program (Uchtenhagen et al., 1999) and were thus less exposed to opportunities to buy drugs. Consequently, their need for money is not only reduced with regard to heroin but also to other substances. Accordingly, the drop in acquisitive crime, such as drug selling or property crime, is also remarkable and related to all kinds of thefts like shoplifting, vehicle theft, burglary, etc. Detailed analyses indicated that the drop found is related to a true diminution in criminal activity rather than a more lenient recording practice of police officers towards program participants.

"On average, males had higher overall rates than females in the pretreatment period. However, no marked gender differences were found with regard to intreatment rates. Taken as a whole, this suggests that the treatment had a somewhat more beneficial effect on men than women. This result is corroborated by selfreport data (Killias et al., 2002). With respect to age and cocaine use, no relevant in-treatment differences were observed. As to program dropout, after one year, about a quarter of the patients had left the program, and after four years, about 50% had left. Considering the high-risk profile of the treated addicts, this retention rate is, at least, promising."

"Overall, results indicate that heroin prescription is a very promising approach in reducing any type of drug related crime across all relevant groups analyzed. It affects property crime as well as drug dealing and even use/possession of drugs other than heroin. These results suggest that heroin maintenance does not only have an impact by reducing the acquisitive pressure of treated patients, but also seems to have a broader effect on their entire life-style by stabilizing their daily routine through the commitment to attend the prescription center twice or three times a day, by giving them the opportunity for psychosocial support, and by keeping them away from open drug scenes."

"The incidence of regular heroin use in the canton of Zurich started with about 80 new users in 1975, increased to 850 in 1990, and declined to 150 in 2002, and was thus reduced by 82%. Incidence peaked in 1990 at a similar high level to that ever reported in New South Wales, Australia, or in Italy. But only in Zurich has a decline by a factor of four in the number of new users of heroin been observed within a decade. This decline in incidence probably pertains to the whole of Switzerland because the number of patients in substitution treatment is stable, the age of the substituted population is rising, the mortality caused by drugs is declining, and confiscation of heroin is falling. Furthermore, incidence trends did not differ between urban and rural regions of Zurich. This finding is suggestive of a more similar spatial dynamic of heroin use for Switzerland than for other countries."

"Switzerland’s progressive implementation of the Four Pillars policy resulted in a significant decrease in problems related to drug consumption. The rise in heroin consumption, by far the greatest problem in the late 1980s, was halted and has steadily declined since the early 1990s. According to The Lancet, the The introduction of the Four Pillars strategy also brought about a significant reduction of deaths directly attributable to drug use, such as overdose (OD), and of deaths indirectly related, such as HIV and Hepatitis. Between 1991 and 2004, the drug related death toll fell by more than 50% (See figure 3). Additionally, levels of drug-related HIV infection were divided by eight within ten years."

"Generally speaking, it is reasonable to conclude, on the basis of the available knowledge, that to a large extent DCFs [Drug Consumption Facilities] achieve the objectives set for them, and that the criticisms made of them are rarely justified. In fact, DCFs help to:

"• reduce risk behaviour likely to lead to the transmission of infectious diseases, particularly HIV/AIDS, among the population of the worst affected drug users;

"• reduce the incidence of fatal overdoses and, therefore, the mortality rate in this population;

"• establish and maintain contact between this population and the social-service and health-care network, within which low-threshold facilities (LTFs) are often the First point of access because of the care and social assistance they offer;

"• reduce public order problems, particularly by doing away with open drug scenes, reducing drug use in public places, recovering used syringes, and reducing the impact of drug problems on residential areas (apartment buildings).

"At the same time, the available data do not indicate any specific detrimental effect on:

"• the number of drug users and the frequency with which they use drugs; the figures are falling in both cases;

"• entry and retention in treatment, because the majority of DCF users are undergoing treatment, the proportion of those in treatment is growing, this subject is tackled within the facilities, and the users themselves state that DCFs do not have any major influence on their treatment.

"All of these observations relate to the overall level of public health and do not mean that DCFs may not have negative effects in some individual cases. However, on the basis of existing knowledge, it would appear that the overall effect of DCFs on drug-related problems is positive."

"The vision towards which the federal government is directing its efforts is a reduction in drug-related problems in Switzerland. This vision is to be implemented by achieving three goals:
"– reducing the consumption of drugs
"– reducing the negative consequences for drug users
"– reducing the negative consequences for society as a whole.
"In implementing its drugs policy the federal government will continue to base its global strategy on the four pillar model:
"– Prevention helps to reduce drug consumption by making it harder to start using drugs and by preventing the development of addiction.
"– Therapy helps to reduce drug consumption by enabling users to break free of their dependency and to stay free of it, or at least by keeping this option open to them. In addition it promotes the social integration of those under treatment and helps to improve their health.
"– Harm reduction helps to reduce the negative consequences of drug use on the consumer and indirectly on society as well, by providing individually tailored and socially less problematic ways of consuming drugs.
"– Law enforcement uses appropriate regulatory measures to implement the prohibition of illegal drugs, thus helping to reduce the negative consequences of drug taking for society as a whole."

"The activities of the FOPH [Federal Office of Public Health] in the area of harm reduction up until now have proved to be effective and will be continued. Nevertheless, because of changes in the nature of the substances consumed, of the patterns of consumption and of the target groups, it is necessary to adapt the concept of harm reduction in order to take it on to a further stage. Existing gaps in the services available – with regards both to particular areas of Switzerland as well as specific contexts and issues – are to be closed.
"Measures
"– Financing Infodrog, the Swiss Office for the Coordination of Addiction Facilities, to support the range of services offered in the area of harm reduction and interlinking these with services aimed at therapy and prevention
"– Enhancing quality by certifying institutions according to a flexible, modular quality standard
"– Formulating the basic principles for need and demand-oriented harm reduction including encouraging pilot projects
"– Keeping further training abreast of the latest knowledge and developments as well as the promotion of career development opportunities for harm reduction specialists
"– Strengthening measures aimed at preventing hepatitis infection and HIV/Aids
"– Clarifying the requirements for harm reduction and therapeutic services in prisons
"– Expanding the interface between harm reduction and prevention"

"In 1995 the last open drug scene, the Letten in Zurich, was closed. After that the importance attached to the drug problem in opinion polls decreased. Today only a handful of people still regard the drug issue as one of our country’s most pressing problems. At the same time, the number of motions in Parliament connected with drugs policy has also fallen. Pressure on the part of the public and from politicians is thus currently very slight, while at the same time a number of drugs policy measures are being queried due to increasing pressure for public spending cuts.
"A planned amendment to the Narcotics Act which also provided for the decriminalisation of cannabis use sparked renewed controversy for a time in 2002. Opinion polls showed that on the issue of cannabis there was no clear majority among the public for any one policy. The amendment of the law, which would also have included the incorporation of the four pillar policy into legislation, failed to get through Parliament in 2004.
"Despite the demonstrable successes in drugs policy, it has not yet proved possible to incorporate the four pillar policy into legislation. A National Council committee is currently working on a draft for a partial revision of the Narcotics Act, which would lead to the policy being made part of legislation. The cannabis issue is to be excluded and dealt with instead through the popular initiative 'For a rational hemp policy with effective protection of young people'."

"For the last 15 years, the federal government has therefore been supporting a variety of measures (e.g. needle-exchange programs, injection rooms, housing and employment programs) in order to improve the health and the lifestyle of drug addicts and to prevent the spread of HIV and other infectious diseases. Compared with the late 1980s, the incidence of new HIV infections among drug addicts has decreased significantly."

"Increasingly desperate to find a way to control crime and social and health harms associated with injection drug use, in 1987 the Zürich authorities allowed people who used illicit drugs to gather in a defined space near the main train station—the Platzspitz park, which sat on a small spit of land surrounded by the water of two converging rivers (Grob 1995). This space came to be known as the 'needle park.' Up to 1,000 drug users per day would come to the park at its peak (Grob 2010). Surveys conducted in the Platzspitz showed that by 1990 these included not only young people but significant numbers of older working and professional adults among whom heroin use had spread (Grob 1995)."

"Heroin misuse in Switzerland was characterised by a substantial decline in heroin incidence and by heroin users entering substitution treatment after a short time, but with a low cessation rate. There are different explanations for the sharp decline in incidence of problematic heroin use. According to Ditton and Frischer, such a steep decline in incidence of heroin use is caused by the quick slow down of the number of non-using friends who are prepared to become users in friendship chains. Musto's generational theory regards the decline in incidence more as a social learning effect whereby the next generation will not use heroin because they have seen the former generation go from pleasant early experiences to devastating circumstances for addicts, families, and communities later on."

"With respect to the group of those treated uninterruptedly during four years, a strong decrease in the incidence and prevalence rates of overall criminal implication for both intense and moderate offenders was found. As to the type of offense, similar diminutions were observed for all types of offenses related to the use or acquisition of drugs. Not surprisingly, the most pronounced drop was found for use/possession of heroin. In accordance with self-reported and clinical data (Blaettler, Dobler-Mikola, Steffen, & Uchtenhagen, 2002; Uchtenhagen et al., 1999), the analysis of police records suggests that program participants also tend strongly to reduce cocaine and cannabis use probably because program participants dramatically reduced their contacts with the drug scene when entering the program (Uchtenhagen et al., 1999) and were thus less exposed to opportunities to buy drugs. Consequently, their need for money is not only reduced with regard to heroin but also to other substances. Accordingly, the drop in acquisitive crime, such as drug selling or property crime, is also remarkable and related to all kinds of thefts like shoplifting, vehicle theft, burglary, etc. Detailed analyses indicated that the drop found is related to a true diminution in criminal activity rather than a more lenient recording practice of police officers towards program participants.

"On average, males had higher overall rates than females in the pretreatment period. However, no marked gender differences were found with regard to in-treatment rates. Taken as a whole, this suggests that the treatment had a somewhat more beneficial effect on men than women. This result is corroborated by self-report data (Killias et al., 2002). With respect to age and cocaine use, no relevant in-treatment differences were observed. As to program dropout, after one year, about a quarter of the patients had left the program, and after four years, about 50% had left. Considering the high-risk profile of the treated addicts, this retention rate is, at least, promising."

"Finally, the analysis of the reasons for interrupting treatment revealed that, even in the group of those treated for less than one year, the majority did not actually drop out of the program but rather changed the type of treatment, mostly either methadone maintenance or abstinence treatment. Knowing that methadone maintenance treatment – and a fortiori abstinence treatment – is able to substantially reduce acquisitive crime, the redirection of heroin maintenance patients toward alternative treatments is probably the main cause for the ongoing reduction or at least stabilization of criminal involvement of most patients after treatment interruption. Thus the principal post-treatment benefit of heroin maintenance seems to be its ability to redirect even briefly treated high-risk patients towards alternative treatments rather than back 'on the street'."

"As one of the responses to dramatically increasing drug scenes, heroin maintenance trials were implemented in Switzerland from 1994 onwards. The target population for this new treatment consists of heroin users who did not comply with other forms of treatment and who presented serious health and/or social problems."

"Finally, the analysis of the reasons for interrupting treatment revealed that, even in the group of those treated for less than one year, the majority did not actually drop out of the program but rather changed the type of treatment, mostly either methadone maintenance or abstinence treatment. Knowing that methadone maintenance treatment – and a fortiori abstinence treatment – is able to substantially reduce acquisitive crime, the redirection of heroin maintenance patients toward alternative treatments is probably the main cause for the ongoing reduction or at least stabilization of criminal involvement of most patients after treatment interruption. Thus the principal post-treatment benefit of heroin maintenance seems to be its ability to redirect even briefly treated high-risk patients towards alternative treatments rather than back 'on the street'."