Medical prescription of heroin – now available in almost all cantons of Switzerland and tested timidly in Canada, Germany, the UK and the Netherlands – is a response to the crisis of open drug scenes, writes Cedric Gouverneur for Le Monde Diplomatique and The Nation. The Swiss have moved from prohibition to regulation, which does not eliminate problems but allows them to be managed.
“Istarted taking heroin as a way of coping with my psychological problems,” said David, 50, an addict for 25 years. “It destroyed me. I lost my job as a watchmaker. I ‘borrowed’ money from my girlfriend, and my friends. I ended up on the street. To fund my habit, I became a user-dealer.”
Every day for 18 months, he’s been attending an injection center attached to the Geneva University Hospitals, where, under the experimental heroin-prescription program (PEPS), he is given a syringe of diacetylmorphine – heroin manufactured legally by a Swiss laboratory. “The program has allowed me to rebuild my life, and pay my friends back.” He looked at his watch: “I’ve got to go. It’s time for my treatment.”
The 1,500 patients at Switzerland’s 22 PEPS centers have all tried unsuccessfully to kick their habit with drug-replacement therapy.
Marco, 44, said: “Methadone didn’t work for me. The side effects were terrible, and I didn’t get any tranquilizing effect. So I was taking other drugs on top of it. I’ve been registered here for the last six months. I’ve put on weight, and cut my heroin use by 80 percent. Eventually, I want to get clean.”
Chantal, 54, an addict for 30 years, said: “The treatment gives me structure. I don’t have to chase after my dealer anymore.” Jeff, 54, had just injected his daily dose; his pupils were dilated, and he spoke in a loud voice: “My quality of life has definitely improved. It’s stabilized my day. Before I got into the program, I was a dealer. I was cunning, I found ways to get money, I did stuff.”
Yves Saget, an addiction nurse, said: “Addiction happens when taking drugs becomes the only strategy for dealing with difficult situations. We don’t say ‘fix’ here, we say ‘treatment.’” He explained: “The brain becomes dependent, and needs heroin to maintain its balance. At this center, we are treating 63 patients with diacetylmorphine. Medical heroin is pure, unlike the drug you buy in the street, which is cut with caffeine, paracetamol, and other substances. Street heroin isn’t satisfying, so addicts often take other narcotics with it, or alcohol, or psychotropic drugs such as benzodiazepine. Our dosage, which is individually tailored, allows patients to live as normal a life as possible.”
Good citizenship, psychological breathing space
He added: “We emphasize good citizenship – patients must treat our staff and the neighborhood with respect. This is their treatment center, so it’s up to them to protect it.”
“Heroin on prescription gets them out of the vicious circle of antisocial behavior,” said Pedro Fereira, a psychiatrist. “They don’t have to buy the drug for themselves, so they don’t have to resort to desperate measures, such as theft or prostitution, to get money.
“That gives them psychological breathing space to get their lives back on track, set goals for themselves, and rebuild relationships with their family and friends. And they get access to a psychiatrist, too.” Every patient is assigned a nurse, a doctor, and a psychiatrist.
Medical prescription of heroin, available in almost all cantons of Switzerland (Vaud adopted it this summer) and tested timidly in Canada, Germany, the UK, and the Netherlands, is a response to the crisis of open drug scenes. Heroin use in Switzerland rose sharply in the 1980s.
Zurich psychiatrist Ambros Uchtenhagen said: “Most users were young people who had fallen out with their families.” Switzerland attracted addicts from across Europe and the overstretched Swiss police tried to limit the public nuisance – theft, violence, the dumping of used needles—by confining them to areas that soon became known as “needle parks.”
There was even one next to the Federal Palace, the seat of the Swiss Federal Assembly, in Bern. “Members could see people injecting right outside their windows,” said Daniele Zullino, an addiction specialist.
Ruth Dreifuss, federal councillor for health at the time, said, “It was like a scene from Dante’s Inferno.” Dreifuss is a Social Democratic former president of the Swiss Confederation, and since 2016 has chaired the Global Commission on Drug Policy, which brings together former political leaders who advocate state regulation of the drug market. She recalled: “An economy of misery and squalor had grown up, involving prostitution and small-time trafficking. It was a tragedy.
Health-care professionals found themselves in a battlefield situation.” Repeated injections and dirty needles caused abscesses that required emergency treatment. “We had deaths from overdoses every week,” said Robert Hämmig, a psychiatrist. “AIDS was exploding, and tritherapy didn’t exist at the time.”
To limit the spread of HIV infection, “Contact Netz opened the world’s first injection room in Bern in 1986,” said Jakob Huber, a former director of the society. Such facilities initially had no impact on crime. Thilo Beck, chief of psychiatry at the Arud (Association for Risk Reduction in the Use of Drugs) centers in Zurich, said some patients had had adverse reactions to drug-replacement therapy. Hundreds of heroin addicts were evicted from Zurich’s Platzspitz Park, but just moved into the abandoned Letten Station; in Bern they moved from Kleine Schanze Park to Kocher Park.
“It was a stalemate,” said Huber. “Change comes when suffering is intense, and visible. That’s when we, the actors on the ground, proposed a solution”—the prescription of heroin to addicts for whom replacement therapy didn’t work. A 1995 survey found that 65 percent of Swiss people considered drugs a major problem in their country; today, only 15 percent do so.
“We created a forum that brought together the federal state, the cantons, and the affected cities,” said Dreifuss, “to allow the different actors to get to know each other’s viewpoints. Open drug scenes couldn’t be allowed to continue, but shutting them down would mean finding other solutions. Everything we’d tried had failed. The doctors prescribing methadone suggested allowing them to prescribe heroin. Methadone has been prescribed in Switzerland since the 1960s, so we were mentally prepared.”
Government is largely by consensus
The cantons are responsible for health care, but epidemics and narcotics are the preserve of the Federal Council. On May 13, 1992, it approved a five-year trial. Dreifuss told me: “We adopted temporary, emergency legislation that can’t be voted down. It’s an example of Swiss pragmatism, trying out a policy even before the law is changed. We’re a small country, and government here is largely by consensus.” Jean-Félix Savary, general secretary of the Romande Addiction Research Group, said: “There are also differences in medical and philosophical culture between Switzerland and France. Switzerland is influenced by Calvinist culture; Catholic countries clearly find it more difficult to tackle issues such as drugs or the end of life.”
This led to the four-pillars policy: prevention, therapy, risk reduction, and repression. In 1994, the first injection centers for prescription heroin opened, most in German-speaking Switzerland. Today, the centers—including one in a prison—are managed by public hospitals and private clinics supported by the state. Despite opposition from the far-right Democratic Union of the Centre and some members of the conservative Liberals and the Christian Democratic People’s Party, the Swiss have approved this policy with votes in 1997 (rejecting a proposed repressive policy by 70 percent), 1999 (approving the federal order formally establishing the PEPS program by 54 percent), and 2008 (approving the four-pillars policy by 68 percent).
The positive impact is clear. The open scenes have not reappeared, and drug-related crime has seen an “exceptional reduction,” according to a study by the University of Lausanne’s Institute of Forensic Science and Criminology. Though they were once “a sector of society deeply immersed in crime,” the number of drug addicts having dealings with the police has fallen by two-thirds. “Crime linked to heroin has almost disappeared, because the drug is now available for free,” explained Regula Müller, social-affairs councillor for the city of Bern. Huber said: “The police supported us when they saw that crime and public-nuisance offenses were falling.”
Reto Schumacher, chief of the Bern narcotics brigade, showed me a clipping from the Berner Zeitung dated May 20 2014, which noted: “Nowadays, when three needles are found on someone’s porch, it gets an article in the newspaper. In the days of open drugs scenes, they were collecting hundreds, even thousands, a week.” He also had photographs of Kocher Park in 1991 on his computer. “Repression alone isn’t the solution. I’m on good terms with the social workers: We have different viewpoints, but we share the same goal: to relieve society of the burden of addiction and improve addicts’ lives.”
‘Prohibition doesn’t solve problems’
The feared rise in heroin use never happened. The drug doesn’t attract young people: The average age of patients on the PEPS program is 45. “Medical prescription has destroyed heroin’s image,” said Uchtenhagen. “It has made it a drug for losers. Users are seen as people with a chronic disease. There’s no longer anything ‘heroic’ about taking it.”
Frank Zobel, deputy director of the organization Addiction Suisse in Lausanne, said, “The PEPS program has deprived the dealers of some of their best customers. Their client base is aging, and it isn’t growing. Prices are low, and the market is no longer attractive.” Addict life expectancy has risen: “The HIV positivity rate is now less than 10 percent,” said Zullino. “It was 50 percent in the 1990s. Our patients have access to uncut heroin. They no longer die from using heroin, but often from smoking.” The number of drug-related deaths under the age of 35 fell from 305 in 1995 to 25 in 2015.
Their arguments bolstered by these statistics, the authors of the four-pillars policy argue in favor of ending prohibition and replacing it with regulation. Whether a drug is legal depends on the cultural and political context: In the 1920s, “alcohol prohibition in the US was intended to increase worker productivity,” explained Uchtenhagen. “The government decided to end prohibition because it was losing out on tax revenue and Al Capone was benefiting.” Savary added that Ronald Reagan’s war on drugs “provided a convenient explanation for the collapse of the social fabric in black neighborhoods: They were no longer victims of neoliberal economic policies and social budget cuts, just of drugs.” He pointed out that it’s the same for working-class neighborhoods in the UK destroyed by Thatcherism.
“Prohibition doesn’t solve problems, it causes them,” said Beck. “At the Arud centers, we are treating the consequences of prohibition”—disease, overdoses, prostitution, crime, exclusion. “It’s the illegality of heroin that destroys addicts, more than the drug itself,” he explained. “Our societies ban a narcotic, then stigmatize the victims of the ban. Obviously, heroin addicts shouldn’t have started taking it in the first place. But we need to help them, not criminalize them. Dealers are now cutting cocaine with levamisole, which is a veterinary medicine for horses. So regulating the market would be a lesser evil.”
Huber thinks that “there is no market more liberal, more aggressive, or more harmful to health than the illegal-drugs market. The best way to prevent the use of any drug is to regulate the market, the same way as for alcohol and tobacco.” Zullino added: “Regulation doesn’t eliminate problems, but it allows you to manage them.”Switzerland’s Experiment with Addiction Treatment