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The Swiss Heroin Experiment

During the last few decades of the 20th century, Switzerland dealt with high rates of heroin use and illicit drug-related HIV transmission. It tried several different approaches before turning to an unlikely solution: prescribing heroin to addicts. This program eventually became part of the country’s treatment toolbox for addiction. However, only a small number of addicts use these programs, and Switzerland employs multiple other treatments, including methadone and supervised injection sites.

These efforts appear to have made a positive impact toward managing the national heroin crisis. But the country still struggles with addictions to other drugs, and other countries have been reluctant to follow Switzerland’s lead in this area.

Switzerland’s Heroin Problem

The prevalence of the heroin epidemic.Beginning in the 1970s, Switzerland saw a rise in heroin use. By the 1980s, heroin abuse had become a public health crisis. In 1986, the country had an estimated 500 HIV cases per 1 million people, which was the highest proportion in Western Europe. By 1989, half of the new HIV cases were related to illegal drug injection. And in 1990, the HIV rate was over 40% among those who had used drugs for more than 10 years. Many of these people died due to the lack of available treatment.1

Switzerland’s initial response was to revise its drug law in 1975. It emphasized abstinence and led to an uptick in arrests. Police had to register drug users and sellers, and methadone prescribing programs had to go through a difficult licensing process.1

The response was considered a failure. In Zurich, the number of people who injected drugs went from less than 4,000 when the law was revised to about 10,000 in 1985, to 20,000 in 1988, and 30,000 in 1992.1

Creating a Needle Park for Addicts

Injecting drugs to feel its effects faster.In 1987, Zurich attempted to better contain its heroin problem by creating a zone in Platzspitz park where people could use drugs. The area was coined “needle park.” 1

This move did lead to some encouraging results. The ZIPP-AIDS project, which was based in the park, treated 6,700 overdoses, vaccinated thousands of people for hepatitis B, and handed out 10 million sterile syringes.1

However, the park caused many problems for the city. By some accounts, about 3,000 addicts a day were in the park buying or using drugs, and about 300 to 400 lived there without shelters, toilets, or showers. In addition, drug trafficking, robbery, and prostitution were common.2

Meanwhile, drug-related deaths in Switzerland continued to rise and spiked twelvefold from 1975 to 1992.3

Due to these issues, the open drug-use zone was closed in 1992. But drug use continued in the city, as did the effects of it.1,3

It became clear that another solution was needed.

Prescribing Heroin for Medical Use

Prescription drugs and potential for abuse.In the early 1990s, the Swiss government adopted a new approach that focused on harm reduction, treatment, social support, and heroin-assisted treatment (HAT), in which addicts were prescribed heroin in controlled doses.1

In 1994, Switzerland opened the first HAT clinics as part of a multiyear trial. People in the program went to a clinic once or twice a day and used their prescription under medical supervision. The heroin in the programs was of a predetermined strength and purity and had no adulterants, and users injected it with clean equipment.1

In addition to the drug, the program provided educational, social, and psychological services.4 It was aimed at addicts who had not fared well in other types of rehabilitation programs.5

What were the Results?

The HAT trial found reduced heroin use, physical and mental health, and crime, as well as improved social participation, though the study was criticized for not being a randomized controlled trial. An evaluation also found a positive cost-benefit ratio of 2:1. Follow-up studies found that the program had high retention rates, but many patients went on to use other types of treatment, such as methadone maintenance, or even became abstinent.5

In 1997, the Swiss government approved an expansion of the trial. The goal was to treat 15% of the country’s estimated 30,000 heroin users—especially chronic users who had not benefited from other treatments.1  In 1999, the government officially adopted HAT as a treatment option for heroin addiction.5

In addition to HAT, methadone maintenance treatment is widely accessible through both clinics and private health care providers throughout Switzerland. The national methadone maintenance system reaches more than half of the estimated number of heroin addicts.6  In fact, most people who use opioid substitution therapy in Switzerland are on methadone. Only about 8% or 1,400 people were on HAT in 2016.3

Switzerland has also set up drug consumption rooms where users can inject heroin under safe conditions, and it also uses syringe exchange programs.

Does harm reduction work?Studies found that HAT and the other harm reduction measures have led to a 60% decrease in felony crimes by patients, an 82% decrease in patients selling heroin, and reduced HIV rates and overdose deaths among IV users. Another study found that the country saves about $38 per day in reduced costs for court and police work under HAT.4,7

Switzerland estimated that there was a yearly decline in the number of heroin users by about 1% between 1992 and 2002. While there have been demonstrable positive outcomes from harm reduction approaches, no program can single-handedly solve collective substance abuse issues. For example, street sales of heroin have not been eliminated, and dealers still sell heroin in cities with HAT clinics.4 Cocaine use also remains high in Switzerland.3

Germany, Denmark, The Netherlands, Belgium, England, Spain, and Canada have experimented with similar HAT programs.4

How the HAT Program Works

To qualify for a heroin prescription in Switzerland, a patient must:4

  • Be at least 18 years old.
  • Have been addicted to heroin for at least 2 years (a non-user cannot receive heroin from a clinic).
  • Be determined to be in poor health.
  • Have had 2 or more attempts at other treatments.
  • Obtain the heroin at a clinic and consume it on site.

Patients can acquire up to 3 heroin doses per day. About 66% inject the drug, while the rest take a pill or mix it with juice. Most people average 3 years in the plan, and they can return and restart treatment if they relapse. Most patients are satisfied or very satisfied with the program, and no one has died from overdose since the program began.4

The program is not free. Patients cover their costs through the national health insurance agency, which costs about $700 per year.4

What the Next Step Is

Given the success of HAT in Switzerland and in other countries, several experts have called for these programs to be expanded.1,4,5,7

Researchers caution, however, that the positive effects of HAT are limited to short-term data, and long-term outcomes should be studied. It could be that HAT is more useful to stabilize users and prepare them for other therapies.5

Further, since HAT is politically controversial, it is probably best used as a last resort option for people who have failed at other types of treatment. HAT should not be used as a blanket approach to heroin addiction, and any type of treatment should be tailored to the unique needs of the addict.5

Heroin addiction treatments available.While certain harm reduction measures have gained traction in the United States, a HAT program would likely be very contentious. However, Switzerland’s experience raises interesting questions about whether such innovative addiction treatments could work elsewhere.

In the meantime, a variety of treatments are available to heroin addicts in the United States, including medication-assisted treatment with methadone and buprenorphine.

If you know someone who needs help for heroin addiction, you can browse rehab centers on our site using our directory.

Sources

  1. Transform. (2017). Heroin-assisted treatment in Switzerland: successfully regulating the supply and use of a high-risk injectable drug.
  2. Treaster, J. (1990). Zurich Journal; A Marketplace for Drugs, a Bazaar of the Bizarre. The New York Times.
  3. Knoll, S. (2016). The US can learn a lot from Zurich about how to fight its heroin crisis. PRI.
  4. Citizens Opposing Prohibition. Swiss Medication-Assisted Treatment 1994-2018: Summary.
  5. Fischer, B. (2007). Heroin-assisted Treatment (HAT) a Decade Later: A Brief Update on Science and Politics. Journal of Urban Health, 84(4), 552-562.
  6. Reuter, P., and Schnoz, D. (2009). Assessing Drug Problems and Policies in Switzerland, 1998-2007. Government of Puerto Rico.
  7. Nebehay, S. (2010). Swiss drug policy should serve as model: Experts. Reuters.

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