A PRAGMATIC PRESCRIPTION

Dealing With Drugs The Swiss Way

Drugs project officer at the United Nations Office for Project Services
(Unops); formerly drugs policy coordinator for the city of Berne (1997-2000).

In the early 1990s Berne, along with other Swiss cities, achieved
international notoriety when drug addicts began appearing in municipal
parks injecting themselves in full view of the passing public. The American
media coined the term "needle parks" to describe this much talked about
phenomenon.

How had such a situation come about? The police and drugs welfare people
had very different views of the addicts' presence in the cities but they
agreed on one thing: having the addicts grouped together in the defined
limits of a public park and left more or less to their own devices meant
that they were not seen in other parts of town.

As a way of containing the drug problem, the city authorities decided this
had something to recommend it. Drugs usage was no longer so visible to the
public at large, and addicts could be given on-the-spot services and
assistance. However, Swiss cities are relatively small communities and the
problem could not be so easily contained.

Moreover, the possibility of open drugs usage was attracting drug users not
only from smaller surrounding towns and villages, but also from abroad. The
growing numbers meant that they soon exceeded their allotted space and
became visible on the streets again, and people were up in arms. The
tourist industry in particular was concerned that this would threaten
Switzerland's image as a "clean and orderly" society.

Just as alarming, as the number of addicts grew, their health began to
deteriorate. At that point, Switzerland began looking for long-term
solutions. Several cities set up committees of experts where, for the first
time, organisations from outside the public sector sat together with people
from the municipal authorities. Realising that the idea of achieving a
drugs-free society was illusory, they opted for pragmatism and sought to
develop a model to take into account the needs of all concerned. Abandoning
preconceived ideas and seeking to improve communications between the
various partners, they adopted the now-famous "four pillars" approach : -
reduce the numbers of new consumers (prevention); - increase the rate of
successful drug rehabilitation (treatment); - lessen the damage to health
and work to reduce the exclusion of drug users (survival aid/risk
reduction); - protect society from the consequences of drugs usage, and
combat organised crime (repression) (1).

On prevention, the four pillars approach does not distinguish between legal
and illegal drugs and assumes that the reasons for their consumption are
identical (2). The aim of prevention is to strengthen the self-confidence
of both adults and adolescents, to get them off drugs and to encourage them
into a way of life that is not health-threatening. In addition, it aims to
make contact with occasional users in the hopes of preventing them from
becoming regular users.

On repression, the approach focuses on drug dealing and the laundering of
drugs money, and in 1998 new laws were introduced to deal with this. This
means that police efforts are no longer centred on drug users as such. "The
consumers ... are no longer at the centre of police interest" (3). The
police's main interest is in preventing a return to the scenes of open
drugs usage.

The aim of treatment is to provide health care for addicts, to encourage
them to give up drugs and to help reintegrate them into society. There are
no generally applicable treatments for drug addiction, and this means that
a broad range of options has to be offered. Experience shows that it takes
on average 10 years and several attempts before a user succeeds in giving
up. The main factor is a person's desire to kick the habit.

So the social worker's job is basically to encourage the drug user to
accept treatment. The possibility of acceptance is increased by the fact
that treatment also reduces the associated risks. To this end, Switzerland
has decided to offer a whole range of treatment options, from
rehabilitation clinics and medical treatment to methadone on prescription,
as well as provision of shelter, work and training. Heroin is also made
available on prescription, on the basis that this is a valid aspect of
treatment, as well as an aid to survival. In any event, it is only one of
the several treatments on offer.

Medical and social monitoring

Heroin on prescription was launched in 1994 as part of a nationally-based
research project and is today recognised as a vital part of official policy
(4). It was driven by the recognition that numbers of addicts were living
in situations of increasing wretchedness; Aids, hepatitis and other
sexually transmittable diseases were rampant within this group; and
existing treatments were not reaching large numbers of the most vulnerable
addicts. So a new form of treatment had to be found for Switzerland's addicts.

The criteria for acceptance for treatment are extremely rigorous:
applicants have to be adults, drug-addicted for at least two years, and
must have started and dropped out of at least two other courses of
treatment. They must have social and health problems, and are required to
sign a written form of consent. Obviously the people accepted into the
programme are a very difficult group, and the eventual results will have to
be viewed in this light. Completing a course of treatment and maintaining a
status quo in terms of health and social situation are enough in themselves
to constitute success (5).

This programme has achieved an improvement in the psychological and
physical health of its patients, and a rapid and verifiable decrease in
their illegal consumption of heroin and cocaine (6). The researchers'
report concludes: "Since the percentage of addicts pursuing the programme
is above average, we are getting significant results in terms of health and
life-style, which sometimes continue beyond the period of the treatment. A
noticeable reduction in anti-social behaviours has also been noted."

Even a highly critical report by the World Health Organisation concluded
that a heroin-based treatment as practised in Switzerland is feasible. It
points to the improvement in the state of the patients' health and social
reintegration, as well as a decline in levels of criminality and illegal
consumption of heroin.

The treatment consists of between one to three injections of heroin a day,
and medical, psychiatric and social monitoring. The patients no longer have
to go looking for their drugs on the black market, and, in a further
positive effect, they are accepting a long-term therapy that will provide
future follow-up.

In the area of risk-reduction, the aim is to prevent further deterioration
in the addicts' state of health and to stabilise their social integration.
This has benefits for the rest of society: this "pillar" reduces the
transmission of infectious diseases, and makes for savings in future social
and health spending. Also, when their state of health and social
integration are not declining - and are in fact improving - thanks to this
helping hand, drug users are more likely to set themselves the objective of
returning to a drugs-free life.

The key elements of this policy of risk-reduction are the night shelters,
contact centres, and the possibility of getting new syringes at any time of
day or night. Most towns in German-speaking Switzerland now have contact
centres. These provide an injection room, a dining room, a bathroom and a
counter where used needles can be exchanged. In the injection room, which
is monitored by qualified personnel, the addicts are able to inject the
drugs that they have brought, and do so in hygienic conditions. These
contact centres were initially a source of violent controversy, but they
are now viewed as indispensable, and this infrastructure has led to a
considerable improvement in the state of the addicts' health.

From the police point of view, the existence of these facilities makes a
return to scenes of open drugs use less likely; injecting in public places
has decreased significantly and the population feels safer. The effect of
the 10 years of this experiment has been a levelling-off in the number of
addicts. Also, the rise in the average age of addicts suggests that the
number of new addicts is decreasing. City parks can be given back to the
public; the numbers of drugs-related deaths have dropped significantly; the
rate of Aids infection among drug users has fallen, and their general state
of health has improved.

Results such as these have encouraged other countries to follow the Swiss
model. Contact centres for drug addicts have been set up in Germany, and a
pilot experiment in heroin-prescribing is under way in Holland.

However some problems remain unresolved. Illegal trafficking in drugs is
flourishing and remains well organised. And while young people may be
consuming less heroin, they are also turning to legal drugs (alcohol and
nicotine), cannabis, and synthetic drugs (ecstasy and amphetamines). So far
no prevention measures have been adopted to deal with these.

Some of the programme's infrastructures, particularly in the area of risk
reduction, are threatened by budget cuts and the new drugs-management
approach is ahead of legislation. So a revision of federal laws on
narcotics is eagerly awaited.

(1) "Die schweizerische Drogenpolitik", Office federal de la sant publique,
Berne, March 1999.

(2) France only accepted this idea in 1999, after the report of the Mission
de lutte contre la drogue et la toxicomanie (Mission for combating drugs
and addiction).

(3) "Gesundheitliche Aspekte der Polizeiarbeit im Drogenbereich", Institut
universitaire de medecine sociale et preventive", Raison de sante,
Lausanne, 1999.

(4) In 1998 a bill to this effect was adopted by parliament. But the
introduction of this form of therapy will require a revision, currently
being prepared, of the federal law on narcotics.

(5) The latest results have been published in the report of the Federal
Bureau of Public Health, "Le traitement par l'heroine en 1999", Berne, 13
September 2000. The evaluation results of the project are published in
"Essais de prescription medicale des stupefiants", the final report of the
ISF and ISPMZ, Zurich, June 1997. Observations in this section are taken
from that report.

(6) However their consumption of alcohol and cannabis has not diminished.