SWISS SAY YES TO DOLING OUT HEROIN

Last summer Swiss voters endorsed state distribution of heroin to addicts in
the name of ‘harm reduction.’ Some Americans want the United States to
emulate the Swiss. Picture a well-lit room with metal tables.

On each is a candle and a kidney-shaped dish. Inside the dish are a syringe,
some cotton, a spoon, Band-Aids and a rubber tourniquet. Mirrors line the
walls to be used by junkies who must shoot up into their necks because their
arm veins are gone. A medical practitioner stands ready, if needed, to
provide instruction in the proper injection of heroin or to intervene in the
case of an overdose. Addicts return several times a day to such
“safe-injection rooms” to receive their high-quality fix at little or no
cost, sometimes with a cup of coffee. And all thanks to the Swiss
government.

The Swiss government has authorized the controlled distribution of
prescription heroin since 1994 and it was approved by Swiss voters in a June
1999 referendum after a furious campaign based on Swiss government reports.
Never mind that those studies were deeply flawed, say independent analysts,
including the World Health Organization, or WHO.

Now, despite the emphatic claims of independent agencies that Swiss drug
policy has been a failure, some are advocating that the United States follow
the Swiss example.

There is a libertarian-populist streak in the American political temperament
to which this sort of thing appeals.

Rep. Tom Campbell, the Republican senatorial candidate seeking to unseat
Sen. Dianne Feinstein in California, tells Insight that although he is not
endorsing any such proposal, “if a city wants to try what was tried in
Zurich, it should have the freedom” to do so.

But even some recovering addicts are dubious about this approach.

Former heroin addict Jerome Hunt of Atlanta tells Insight that
safe-injection rooms involve “exploitation of freedom” and “an incentive to
remain addicted.” He adds that heroin is “a tool of self-destruction,
whether it’s free or whether you have to steal to get it. It’s fueling an
allergy that’s going to make you break out, no matter how you get it. It’s
going to lead me to the same consequences that it has led me to over and
over and over again.

That’s just the nature of addiction.”

Nevertheless, the advocates of legal venues for heroin use have no doubts.
Ethan Nadelmann is the executive director of the Lindesmith Center, a New
York-based think tank funded by billionaire George Soros and dedicated to
liberalizing drug policy.

In an interview with Insight, Nadelmann calls the Swiss heroin-prescription
experiments “extremely successful” and proposes that, “at the very least,
[we should] try them here to see if they’d work.” Nadelmann invokes the
Swiss example as a “harm-reduction” guide for treating hard-to-reach
addicts.

The idea is that abuse of narcotics is here to stay and that policies must
be developed to deal with the reality by seeking to minimize harm to drug
users and to society itself.

The Swiss experiment was a response to the widespread marketing and use of
drugs in public spaces such as railroad stations and Zurich’s “Needle Park.”
The feasibility of prescribing and supervising self-administered heroin
injections to more than 1,000 persons in safe-injection rooms was evaluated
in 18 projects from 1994 to 1996, often known as the Swiss drug trials.
Although these projects were officially authorized on condition that they be
studied scientifically, physician analyst Ernst Aeschbach of Swiss Doctors
Against Drugs writes that the principal impetus was “political pressure to
devise a plan for easy and unlimited access to heroin” and other drugs.

The Swiss federal Office of Public Health and the experiment’s directors
were praising the results even before the end of the test period.

The public was informed that almost every possible measurement showed a
plus — that drug use stabilized, crime was down, health and social
functioning of addicts improved, the death rate plummeted and society was
saving money.

The Swiss were promised that the forthcoming report from WHO would
corroborate all of this.

At the request of the International Narcotics Control Board, or INCB, the
WHO had convened an independent evaluation by experts to study the integrity
of the Swiss projects.

When the long-awaited report was released in April 1999, the WHO experts
pronounced the studies deeply flawed.

These flaws have been corroborated by Aeschbach and Yale University’s Sally
Satel, both physicians who state flatly in the Journal of Substance Abuse
Treatment that “the Swiss heroin trials cannot be considered a valid
experiment.” Aeschbach and Satel point out that the scientific method of
these trials was faulty; the sample of participants was not representative;
the verification of outcomes was inadequate; and finally, the doctors note,
even the Swiss report itself cites negative consequences.

Nadelmann responds by attacking the critics.

He tells Insight that the INCB is “a corrupt and dishonest body [which has]
lost sight of its basic mission — which is that drug control should be about
public health.” With scant mention of the WHO findings, he and the
Lindesmith Center continue to tout the alleged successes of
heroin-maintenance projects, using experts from Switzerland now in other
countries attempting to transplant the Swiss model.

Nadelmann cites the work of Ambros Uchtenhagen, the head of the Swiss
program, whose summary of the drug trials was published by Lindesmith in
1997. The summary does not mention that the scientific protocols set up to
use double-blind and randomized studies to compare the effectiveness of
heroin with other narcotics such as morphine and methadone were discarded
after 42 days. This raises grave suspicion since, in a double-blind study,
neither researchers nor participants know which substance is received by the
subject. The WHO report reveals that both parties in the Swiss trials were
aware of which substances were injected.

According to Aeschbach, participants thus may be “choosing” their own drugs,
eliminating the possibility of being randomly assigned to a group.

Even Nadelmann’s publication confirms that “the trial quickly determined
that virtually all participants preferred heroin, and doctors subsequently
prescribed it for them.” In the end, the ratio of heroin users to those of
morphine and/or methadone became 8-to-1, respectively.

Initially the target group or sample was to include only the “severely
addicted” who were more than 20 years of age — addicts of at least two years
duration who had failed in at least two other treatment programs.

As the study progressed, these criteria were not met. For instance, 49
percent of participants had not had any inpatient therapy for their
addiction, while another 26 percent had only had one therapeutic experience.
Their state of health at the time of recruitment was classified as “good” or
“very good” in 79 percent, with 80 percent deemed to be in a good
nutritional state.

Only 2 percent were in “very bad” psychological condition.

According to Aeschbach, the volunteers’ overall good health casts doubt on
the categorization of these persons as “severely addicted.” Moreover, 18
percent of the sample did not qualify as heroin addicts according to a
prescribed criteria of usage, and some 61 percent of participants should not
have been included since they were in active treatment programs which had
not yet proved unsuccessful.

The alleged positive outcomes attributed to the Swiss drug trials become
less conclusive the more they are scrutinized. Many of the reports of
reduced crime were in fact “self-reports” from the addicts themselves. Such
measurement, without verification, is not scientifically valid.

Also HIV/AIDS testing was not done consistently; thus, the rate of infection
could not be determined accurately. And urine testing to check for drug
usage was performed only at expected times, making it an unreliable modality
for assessment.

While addicts reported improvements in their health and social functioning,
there was no control group that received social services but did not take
narcotics. As Aeschbach and Satel record, the heroin trials spent almost
five times more per patient for social services than is spent on those
receiving standard methadone treatment.

And the WHO report concludes that it was not possible to determine whether
any positive effects were the result of the heroin maintenance itself or of
the psycho-social care.

A summary booklet of the WHO findings graphs drug-related deaths from 1986
through 1998 and explains that these data “very clearly show that the
reduction in the number of drug-related deaths is chronologically correlated
with the closing of the drug scenes and not with the distribution of heroin
to addicts.”

Generally speaking, the studies failed to provide “convincing evidence that,
even for persistent methadone failures, the medical prescription of heroin
generally leads to better outcomes than further methadone-based treatment.”
In the Geneva project, two-thirds of those assigned to a waiting list for
the heroin-prescription trials chose not to enroll six months later since
they had been stabilized on methadone.

In the words of the WHO panel, “[T]his indicates the need for extreme
caution in the prescription of heroin” and suggests that the need for such
prescriptions may be lessened if more efforts are made to engage patients in
methadone-type programs.

One of the consequences of the Swiss heroin projects has been the marked
reduction in the number of people enrolling in residential treatment
facilities. In some instances, the caseload decreased by 50 percent.
Abstinence-oriented clinics also reported a drop in registration, which
forced some to close.

Given the finding that heroin maintenance could not be found to produce
better outcomes than more conventional abstinence-oriented treatments, the
closing of such treatment facilities is viewed by many as a negative
by-product of the experiments.

In response to the Swiss trial data, Dan Schecter, a spokesman for the White
House Office of National Drug Control Policy, tells Insight, “Sure. [Take]
people who are hard-core addicts and put them in a medicalized environment
where they’re getting more-frequent access to medical care [and], of course,
you’re going to see some positive outcomes from that. But compare anything
they’ve achieved through these heroin-stabilization programs with what drug
treatment achieves, and there’s no comparison whatsoever! There are ways to
go that achieve much better outcomes by many orders of magnitude compared
with simply enabling an addict to be a heroin user.”

For instance, Schecter points to a 1997 study by the National Institute on
Drug Abuse in which methadone treatment reduced heroin use by 70 percent
during one year, while illegal activity decreased 57 percent among
outpatient participants. In addition, a 1998 long-term study of treatment
effectiveness by the Substance Abuse and Mental Health Services
Administration evaluated outcomes for a national sample of 1.1 million
individuals. Five years after discharge from treatment, it found 21 percent
fewer users of any illicit drugs.

Longer stays in treatment predicted greater decreases in alcohol abuse, drug
use and criminality.

Even if the science of heroin maintenance should someday yield valid
findings, the practice of harm reduction which underpins heroin by
prescription would remain problematic to many. Satel, for example, has
written of “the raw truth about harm reduction [as] the public-policy
manifestation of the addict’s dearest wish: to use free drugs without
consequence.” And, according to Schecter, “The source of harm is the nature
of heroin and what it does to the human brain.

It’s not due to a moral failing on the part of someone, or necessarily to
weakness.”

Indeed. A heroin addict of 30 years, now with almost 10 years in recovery,
shares his experience with Insight. “I loved being on drugs, I loved it,” he
says. “My [dream] was that I was going to be in a rocking chair and have me
a home-care nurse who gave me my injections twice a day. But I was ‘dead,’
dead. I didn’t [have an] interest in anything, only heroin.

All I wanted to do was use it.” Now drug-free and working, this former
addict claims to have everything he really needs. “I have those things
because I stopped using and got back with you guys in this real world.

I used to stand on the street corner saying, ‘Look at that sucker having to
go to work in the morning.’ No! We were the suckers, the ones that was
using.”

According to Patrick Holzmann, a Swiss surgeon and activist against
liberalizing his country’s drug policy, rehabilitating the addict requires
abstinence. To him, it stands to reason that a tolerant atmosphere toward
drug use, emblemized by the safe-injection room, only will increase the
number of persons who try drugs.

In turn, the more people who experiment with drugs, the more who will become
addicted.

Holzmann, who also volunteers his time to help prevent the spread of AIDS,
denies the claims that new AIDS cases went down with the drug trials and
cites the WHO report that, at any rate, inadequate testing made this
impossible to prove.

In the end, Holzmann characterizes shooting rooms as “paint over rusty
iron.”

The Swiss organization Courage to Take a Moral Stance, known in Europe by
the acronym VPM, was at the forefront of the attempt to dissuade the Swiss
public from adopting the so-called harm-reduction program.

Its president, Florian Ricklin, is a psychiatrist who is discouraged by the
failure of efforts to persuade the Swiss to vote against the program in last
year’s referendum. Ricklin tells Insight: “The whole world thinks the Swiss
model works, but it doesn’t really.

It’s crazy what we are doing here in Switzerland.”