By Taylor Knopf
North Carolina Health News
January 28, 2019
GENEVA and ZURICH, Switzerland — Sarah is a well-dressed, middle-aged English woman living in Geneva with her friendly yellow lab, Maloo. By most accounts, Sarah lives a normal life. She has a couple of adult children, goes on vacations, works part-time with horses, and says she’s lucky because her job never feels like work.
Twice a day, Sarah also walks down the street from her apartment to a clinic where she takes a treatment to stabilize her chronic disease.
She has a substance use disorder, and her treatment includes injectable heroin.
Sarah is one of 1,500 people who are part of a heroin-assisted treatment (HAT) program in Switzerland.
The Swiss were the first to legalize prescription heroin in 1994 under the nation’s four pillar drug policy. The law aimed to curb drug overdose deaths and high HIV infection rates, as well as end the country’s “open-drug scenes.”
One of those four pillars includes new and expanded treatment options for opioid users, including heroin-assisted treatment.
The heroin provision was the most controversial part of the multi-prong Swiss drug policy. Many argued that it would enable drug users or cause more overdose deaths, but that didn’t happen.
The Swiss, in keeping with their national stereotype, kept meticulous records. They found data to support the program through years of scientific study and strict randomized controlled trials before incorporating HAT into the law.
Since then, the number of new heroin users in Switzerland has declined. Drug overdose deaths dropped by 64 percent. HIV infections dropped by 84 percent. Home thefts dropped by 98 percent. And the Swiss prosecute 75 percent fewer opioid-related drug cases each year.
Meanwhile, in the United States, drug overdoses kill more Americans than car crashes, according to the Centers for Disease Control and Prevention. The number of overdose deaths in North Carolina went up in 2017, and an average of four people overdose and die each day.
Dangers of the black market
The Swiss law requires that HAT patients must have at least two years of opioid dependence before starting treatment. They must have tried and failed two other addiction treatments and be at least 18 years old.
The program was designed to treat the small percentage of people with substance use disorder who do not benefit from more traditional opioid substitution therapies, such as oral methadone or buprenorphine.
But the medical directors of the HAT programs in Geneva and Zurich view the program not as a “last-resort,” but as a way to enable people to live quality lives.
When relying on street drugs, users spend a lot of time and money acquiring a product and do not know what’s in it.
When a batch of heroin isn’t strong, there’s a saying among users in Geneva that it’s “the wall of the church.” There are many beautiful, old stone churches in Switzerland, and some dealers scratch off a bit from the sides and mix the powder with the product. Another substance being used to pad street drugs in Switzerland is an animal dewormer.
“Prohibition only makes things worse. You create segregated markets where you have no possibility to control,” said Thilo Beck, psychiatrist and medical director of the heroin-assisted treatment program in Zurich.
“Once you regulate, you have full ability to control prices and accessibility, and you can reach the users,” he said. “In a black market, it’s all hidden. The product is not clean and users don’t know what they use. It’s harmful.”
In 2017, more than 1,200 overdose deaths in North Carolina involved fentanyl, which is often cut into heroin or other street drugs. Even small doses are extremely dangerous as it’s 100 times more potent than morphine.
Providing medical-grade heroin at treatment facilities ensures it’s safe and clean for the users. It also frees up the time previously spent finding the street product, enabling users to focus on things like housing, family and employment.
According to Beck’s data, the group of people moving through the HAT programs in Switzerland are mostly all in the same age cohort. There are hardly any young newcomers.
“It took us about 10 years to come up with opioid maintenance treatment and consumption rooms,” Beck said. “If we would have started earlier, we wouldn’t have the heavily impaired people we are still treating now. We are still treating the generation of the ’90s.”
When HAT programs started, 85 percent of participants were younger than 34. Today, 80 percent are over the age of 44.
Inside a heroin-assisted treatment clinic
Indeed, middle-aged users filled a HAT facility in Geneva one November afternoon.
As the sun set outside, an increased flow of people arrived at the clinic for their second daily dose of heroin. They were polite, but not interested in making small talk in the waiting area outside the injection room.
Some showed signs of withdrawal, pacing the room as they waited for their turn.
In Geneva, patients only have two time frames — the morning and the evening — to get their treatment. It’s not the same in Zurich, where patients come in and out for treatment multiple times a day at their leisure.
An older woman named Flor agreed to a short interview as she waited. She’s been a part of the HAT program in Geneva for 21 years.
“For me, I can say this program saved my life,” she said with a shaky voice. “When you are in the streets, you have life only for this thing, and you cannot find it sometimes. Here, it helps me to have another life and do other things.”
Thilo Beck, who directs the heroin-assisted treatment program in Zurich, talks about the difficulty in convincing his colleagues that using heroin is a viable way to maintain substance users.
When she was young, she studied theater in school. Now, Flor says she been able to get back into acting.
The program also gives her peace of mind, because unlike in the streets, the product is always the same, she said.
Sarah, the English woman, came in after Flor, looking equally jittery. After some quick “hellos,” she went into the injection room and came out 15 minutes later.
Her eyes appeared slightly glazed, but she was more upbeat and ready to walk with her dog to a cafe across the street and chat with a reporter. Over coffee she explained her erratic journey with drugs — both heroin and cocaine — and how she found stability and comfort in the HAT program.
Sarah tried heroin for the first time at age 18 but said it was too expensive. Her heroin use became consistent in the late 1990s, when she was in her 30s and heroin was cheap.
“I stupidly started using again with a friend,” she said. For the first six months, she used heroin off and on. She said she did “something stupid again” when she asked for the dealer’s phone number.
For the next five years, she divided up her weekly stash into daily packets and managed to keep her full-time job and care for her small children. But she knew she didn’t want to stay reliant on it. So she went to rehab and stayed four months.
“I knew I wasn’t cured,” she said. “Two days after I went back on the stuff.”
She tried rehab again, this time for a whole year. Sarah says she was lucky to have supportive friends, family and an apartment to come back to after. She found another job, but after a few months went back to using.
Then she experimented with cocaine and said it was “100 times worse than heroin.” She was able to lead a somewhat normal life with heroin. Sarah set boundaries and rules for herself while using heroin. She would not use at work or in a public bathroom. Instead, she used the drug consumption room during her lunch break. But all the self-discipline went away with cocaine.
At one point, she lost everything and was living on the streets for a few months.
“I got together with people to find places to sleep. You don’t want to be outside on your own,” she said. “It was stupid, because I had lots of things going for me. I had people there for me, and still, I can’t seem to go without it.”
She said she had to stop using cocaine because it was just too difficult.
“One limit I set was that I would never sell my body. But had I spent another two months on the street, that would have been it. And if I had done that, I felt like I could never get up again.”
Sarah has gotten up every time she’s been down. But she hasn’t been able to shake the heroin. She said it acts as an antidepressant for her.
“It puts a lid on your emotions and makes life easier to deal with,” she said.
Seven years ago, she got into HAT and says it “has helped me tremendously.
“The aim is not to get you off the stuff, but to get you help and get your life back,” Sarah said.
She said the biggest difference before and after the program is time and stress.
“Going back to the streets frightens me now. Maybe it’s my age,” Sarah said. “It never struck me as being dangerous before. It didn’t seem to bother me much.”
She’s considered a substitute for heroin. She frequently goes back to England to visit her mother for holidays and takes oral morphine instead.
Getting the data
Because no other countries had authorized prescription heroin, Switzerland’s HAT programs started as scientific trials from 1994 to 1996.
The randomized controlled trials included 1,000 participants in 17 places, including new and existing opioid substitution clinics and prisons across Switzerland. The data was externally reviewed by the World Health Organization, the United Nations and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA).
The Swiss trials prompted five other major heroin prescription studies, and now there are HAT programs in Denmark, Germany, Luxembourg, the Netherlands, the United Kingdom and Canada.
“History has taught us that the introduction of effective interventions in the drugs field can sometimes, at first, seem counter-intuitive and be viewed as controversial,” wrote Wolfgang Götz, director of EMCDDA, in the organization’s 2012 review of heroin-assisted treatment studies and programs across Europe.
“This is not simply a case of giving heroin to heroin addicts,” Götz continued. “Rather, studies have looked at the use of heroin as part of a highly regulated treatment regime, targeting a particularly difficult-to-treat group of patients.”
The European Monitoring Centre review found some promising trends. HAT program participants use less street heroin and illegal drugs than in the control groups treated with oral methadone.
Other consistent findings were “improvements in general health, psychological well-being and social functioning, as well as major disengagement from criminal activities, such as acquisitive crime to fund continued use of ‘street’ heroin and other street drugs,” the review stated.
Countries with lengthier follow-up studies (up to six years) had high patient retention rates.
The annual cost per HAT patient ranges from 12,700 euros a year in Switzerland to 20,400 euros in the Netherlands. These are much higher than the annual cost of oral methadone treatment, which is 3,500 euros per patient in Germany and 1,600 a person in the Netherlands.
The increased cost is due to the high staffing need at heroin treatment facilities. Most HAT programs require multiple staff members present at all times. And most programs do not allow the same take-home dosages allowed with other opioid substitution programs. So clinics must be open 365 days a year for extended morning and evening hours.
However, Switzerland changed the law in 2010 to allow two days of oral heroin take-home doses for stabilized patients.
The European Monitoring Centre determined that HAT programs result in significant savings to society, particularly in the reduction of costs from criminal justice proceedings and incarceration of drug users.
Building public trust
Beck, the medical director of the heroin-assisted treatment program in Zurich, said that when he goes to conferences in North America, his U.S. colleagues express interest in drug consumptions rooms and HAT programs but say they need to conduct trials first.
“I say, ‘We have already done it! We did the trials, and we have 20 years of data,’” he said.
There will always be moral objection to these kinds of programs, Beck said. There are people in Switzerland who hear all the evidence and data for HAT but will not support it.
“They just don’t like it,” he said. “They think it’s not good.”
Rita Annoni Manghi, medical director of the the HAT program in Geneva, said she, her colleagues and patients met with community members at coffee shops to explain what they were doing.
Neighbors around the HAT facility were scared of the program and thought it would lead to more drug use, she said.
“We opened the door and said come visit and see what we do,” Manghi said. “And now they say that they have less problems around here since we are here. This work is very important to change the minds of people.”