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As
is the case with drugs in the Netherlands, the Swiss
trial has been wide misrepresented or inadequately reported
in the media. The following has been prepared using
material from the Embassy of Switzerland, Families and
Friends for Drug Law Reform (ACT) Inc., the Australian
Parliamentary Group for Drug Law Reform and Dr Alex
Wodak.
The Swiss trial was initiated following concern over
increasing illicit drug use and the spread of AIDS,
the incidence of which was the highest in Europe. In
response, the authorities rapidly increased the availability
of methadone treatment, and established needle exchanges,
and made other changes to drug policy. In an environment
of considerable local controversy and after two referendums,
it was decided to conduct a national evaluation of prescription
heroin and morphine. The main objectives were to improve
public health, reduce public nuisance and attract drug
users who had not previously been interested in treatment.
The subjects selected had been users for an average
of ten years, had histories of treatment and relapse
and multiple severe social problems. Two-thirds had
been treated for malnutrition; three quarters had hepatitis
and a quarter were HIV positive.
The narcotics tested in the trial were morphine, methadone
and heroin, for intravenous and oral use. The use of
a cigarette form of heroin was also trialled.
Before the study was commenced, the research protocol
and plan was submitted to the Ethics Committee of the
Swiss Academy of Medical Sciences for approval. Other
groups oversaw that the approved provisions and activities
were observed and checked any side effects of the prescribed
drugs.
At the request of the International Narcotics Control
Board, the World Health Organisation appointed a research
group to appraise the program and the results.
The research program involved two double-blind studies
(the prescribed drug is not known to either the patient
or the therapist], three randomised studies and 11 studies
where the treatment is determined after discussion with
the patient.
A total of 18 treatment centres were established: one
was in a penal institution, the others were all outpatient
clinics. 1146 patients effectively started treatment,
however, by the end of 1996, 350 patients had dropped
out of the study.
The
Outcome
Social
-
Homelessness
declined from 15% to 3%
-
Permanent
employment improved from 14% to 32%
-
Unemployment
fell from 44% to 20%: the remainder lived on benefits
or casual work or were occupied by home duties
-
Debts
during treatment were substantially reduced
-
One
third of patients who were welfare recipients on
admission required no further support
-
Other
patients turned to welfare because they gave up
dealing
-
Originally
only 13% of subjects were not involved in the drug
scene. This increased to 44% during the trial, however,
adequate fresh social contacts had not been made
during the observation period
-
Prostitution
declined from 13% to 6%
Target Groups The program was able to
reach those with a chronic heroin dependency, a history
of failed treatment attempts and deficient health and
social integration to a much greater extent than had
been previously achieved with other programs. Patients
on methadone programs who had previously continued to
use illicit heroin were able to be admitted to the trial.
Health
Status There was a significant reduction in
general health problems over one and a half years, an
improvement in nutrition, and fewer skin conditions
Psychiatric conditions, in particular, depressive states
regressed, as well as anxiety and delusional disorders
Other conditions were monitored and referred to suitable
medical treatment where appropriate
Other
Dependencies
-
Illicit
heroin use rapidly and markedly regressed
-
Daily
cocaine use declined from 31% to 9%
-
Benzodiazapine
use decreased slowly
-
Cannabis
and alcohol consumption hardly declined at all
After 18 months, the continued regular use of cocaine
(5%) and benzodiazepene (9%) proved to be a difficult
problem to manage.
Criminal
Activity
-
Income
from illegal activity decreased to 10% from 69%
-
The
number of offenders and offences declined by 60%
during the first six months (source: police records
and patients)
-
Convictions
declined significantly (source: central criminal
register)
Retention Rate After six months, the retention
rate was 89%; after 18 months, it was 69%. Both these
rates are above average compared to other programs.
In some cases, the improvement in participants' health
and social situation occurred early in the program;
in others, after several months of treatment.
Drop-outs
-
By
the end of 1996, 83 people left the trial to commence
abstinence therapy
-
Of
those who dropped out (excluding, of course, the
above) more than 50% switched to another treatment
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Of
the 1146 patients: 36 died, 17 attributable to AIDS
and other infectious diseases
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Other
causes of death included suicides, accidents and
ODs of illicit narcotics
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There
were no fatal ODs in the study itself
-
The
annual mortality rate in the trial of 1% is low
compared to other studies of treatment of heroin
dependants
Economics A cost-benefit evaluation of the trial
showed a $45 benefit per patient per day. The greater
part of the benefit flows from savings in criminal investigations
and gaol costs, and by improvements in the health of
the subjects.
Government Policy for Reducing Drug-related Problems
This is four-pronged and described by the Swiss as:
(i) repression; (ii) prevention; (iii) treatment; and
(iv) harm reduction
On 28 September 1997, the people in Switzerland voted
on an `initiative' intended to make the Swiss drug policy
much more restrictive (the so-called heroin trial referendum).
The initiative was rejected 71% to 30%. (Participation
was 40% which is about average for Swiss referendums
(voting is not compulsory).)
A number of prominent church leaders opposed the initiative
including the Conference of Swiss Bishops and the Council
of the Federation of Swiss Protestant Churches. Another
referendum is proposed which, if passed, would liberalise
Swiss narcotic drug laws.
The way the trial is currently structured suggests
that it is not the program of the future, but it is
a start in the right direction.
Dr Robert Haemmig, Psychiatrist, Medical Director, Drugs
Branch,
University of Psychiatric Services, Berne, Switzerland.
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