By Taylor Knopf
North Carolina Health News
January 21, 2019
ZURICH and GENEVA, Switzerland — Today, Platzspitz Park serves as a peaceful respite for those meandering along the Limmat River and past the Swiss National Museum. But it’s best known by the nickname “Needle Park.”
Local police were tired of trying to control and disperse large groups of users, so Needle Park became one of the spots law enforcement left alone.
Rates of HIV infection soared from the sharing of needles. And the number of drug overdose deaths climbed.
People were injecting and dying outside one of the most beautiful hotels in Zurich. The same thing happened near political buildings in Bern, the nation’s capital, said Rita Annoni Manghi, director of the opioid substitution and heroin-assisted treatment programs at Hôpitaux Universitaires Genève.
It was the equivalent of people dying on the White House lawn, she said.
“So you are obliged to see the problem,” she said. “And Switzerland is not so modern, but it’s very pragmatic. And Swiss politics is very pragmatic.”
The rise in HIV infections, drug overdose deaths and the public nature of the drug problem led the Swiss to make major changes in how they approached illegal drugs and treated people who use drugs.
And in 1994, Switzerland went on to pass one of the most progressive and controversial drug policies in the world, which included the dispensing of heroin.
“Switzerland is no one’s idea of a leftist country,” Joanne Csete wrote in her paper “From the Mountaintops: What the World Can Learn from Drug Policy Change in Switzerland.”
“Its famous tradition of protecting bank secrets, its having granted women the right to vote only in the 1970s, and its referendum-based rejections of minarets on mosques and decriminalization of cannabis illustrate its quirky conservatism,” Csete wrote.
But the Swiss are pragmatic. Instead of endlessly fighting drugs, they took a new approach and began supporting drug users through new treatment options.
The majority of Swiss citizens supported the measures, despite some pushback inside and outside the country.
The nation cut its drug overdose deaths significantly. HIV and Hepatitis C infection rates dropped. And crime rates also dropped.
The Four Pillars
To address the Swiss drug problem, elected officials, community members, law enforcement and medical experts all worked together to create the “four pillars” drug policy.
Those four pillars of the Swiss law are harm reduction, treatment, prevention and repression (or law enforcement).
“The goal was not to fight drugs anymore. It’s completely ridiculous to fight drugs,” said Jean-Félix Savary, secretary general of the Romand Group of Addiction Studies in Geneva. “We came to this conclusion and decided to change.”
“It was a big revolution. We don’t try to ask people not to take drugs, but take care of problems generated by the situations around people being addicted to drugs.”
The policies became as much about public order as public health, Savary said.
There was some resistance among some Swiss civil groups. Their push ultimately forced a national referendum in 1997 challenging the four pillars policy. But 70 percent of Swiss citizens voted in favor of the law. The four pillars have withstood other challenges as well, as the majority of Swiss voters continue to support it.
The multi-pronged approach included some controversial measures — such as legalized drug consumption rooms and heroin-assisted treatment facilities — but ultimately, the statistics show it has been successful.
Over the past two decades, the number of opioid-related deaths in Switzerland has decreased by 64 percent.
The number of new HIV infections also dropped significantly. In 1986, more than 3,000 people tested positive for HIV in Switzerland. In 2017, there were fewer than 500 new positive tests in a country of 8.4 million.
Switzerland began mandatory Hepatitis C reporting in 1988. The number of reported cases peaked between 1999 and 2002, declining since then.
Harm reduction strategies aim to lessen the damage caused to a person by their use of drugs. Needles exchange programs fall under this category, as do legalized drug consumption rooms.
Offering drug users clean needles and other supplies reduces their use of dirty needles, therefore reducing the spread of HIV and Hepatitis C infections.
Drug consumption rooms go one step further by providing users with a safe place to use under medical supervision, which reduces the chance of an overdose.
(What’s a drug consumption room like? More on that later in our series.)
Swiss drug experts said the public also benefits: passersby no longer see people injecting in the streets or come in contact with many used syringes.
Harm reduction staff workers make a point not to judge people who come through their doors. And many build relationships with frequent visitors. Resources are available to drug users at these facilities as well to connect them to anything they might need, from a place to sleep, eat, do laundry, or find addiction treatment.
The Swiss are also very deliberate when it comes to placing their drug consumption rooms.
For example, in Geneva, a lot of people gathered and injected near the main train station. So now, around the corner, a drug consumption room is housed in a modern green building that stands out among the backdrop of the traditional Swiss architecture.
Lowering barriers to treatment
“The goal in this field is to get as many users as possible into treatment,” said Thilo Beck, addiction psychiatrist and medical director of the heroin-assisted treatment program in Zurich.
He said that 75 percent of active users in Switzerland are in treatment on a given day, and about 95 percent have been in treatment at some point.
This is medication-assisted treatment, using methadone or buprenorphine. It also includes slow-release morphine or heroin, which aren’t used to treat people with substance use disorder in the United States.
“Treatment is available and accessible,” Beck said. “I think that’s how it should be in every country.”
There are circumstances in Switzerland that make treatment so accessible. First, the country has universal health care, so everyone has health insurance.
The four pillars law also expanded opioid substitution therapy (or medication-assisted treatment) and lowered the threshold for entry. Someone can walk into a clinic for the first time and start treatment 20 minutes later, Beck said.
Before the 1990s, this type of treatment was viewed as the first step toward abstinence. Beck said that people were supposed to stay on the treatment for six months to stabilize them, then taper off and stop.
“But this was not happening. Some people might do that, but the majority will not,” he said. “What we learned is you have to be pragmatic and take the problems as they are and think of the most feasible solution.
“It doesn’t help to think of goals that are not achievable.”
People in drug treatment programs no longer need to visit a treatment center every day to receive methadone, buprenorphine or morphine. Stable patients receive take-home doses. Physicians can also write prescriptions for these same treatments. And there’s no expectation of abstinence from street drugs and no mandatory drug-screening tests.
“By offering opioid substitution therapy almost unconditionally to virtually anyone willing to change their consumption from heroin to another product, the health care system became a viable competitor among those supplying people addicted to opioids in Switzerland,” wrote Christian Schneider, a drug analyst who works at the Swiss Federal Office of Police.
The treatments are safer than street drugs because the consumer knows exactly what’s in it. Switzerland doesn’t have the same fentanyl problem as the United States, but there are other unwanted substances in their street drugs. Drug check sites help with this problem. These are places a user can take their drug to be checked, and it’s given back to them with a list of what is inside it.
And because a person in treatment is spending less time and money finding and buying drugs, they can focus on other things in their life, such as housing, work or family.
“Prescribed in a way tailored to fit the needs of consumers, opioid substitution therapy not only offered a much safer and much cheaper substitute but also ensured availability and access to products in a way that street dealers could never match,” Schneider concluded.
The role of law enforcement changed under the four pillars approach. As more and more users went into treatment, the demand for opioids on the black market fell, as did the purity of the products.
The police are focusing less on the users and more on big time dealers.
“You have to help the consumer and fight the criminal,” Manghi said. “And the consumer may deal a little, but they are not organized enough to do high-level crime.”
Savary, a Swiss drug and harm reduction expert, explained that getting law enforcement support was essential to gaining public support for the four pillars law. From what Savary has seen, one supportive police officer has more influence than 100 medical experts.
The Swiss are prosecuting fewer opioid-related crimes. In 1993, the country had about 20,000 cases a year. Today, the Swiss average about 5,000 opioid-related cases annually.
Prior to the four pillars law, house break-ins were common in Switzerland, Savary said. After the law was adopted, there was a huge drop in burglaries.
“We reduced theft by 98 percent. We never had a security figure like this,” he said, referring to crime statistics. “With health measures, you can have a very big security impact… You can do both. It’s cheap and effective. It sounds like a miracle, but you can do it.”