Switzerland: Swiss Say Yes To Doling Out Heroin

On each is a candle and a kidney-shaped dish. Inside the dish are a syringe, some cotton, a spoon, Band-Aids and a rubber tourniquet. Mirrors line the walls to be used by junkies who must shoot up into their necks because their arm veins are gone. A medical practitioner stands ready, if needed, to provide instruction in the proper injection of heroin or to intervene in the case of an overdose. Addicts return several times a day to such “safe-injection rooms” to receive their high-quality fix at little or no cost, sometimes with a cup of coffee. And all thanks to the Swiss government.

The Swiss government has authorized the controlled distribution of prescription heroin since 1994 and it was approved by Swiss voters in a June 1999 referendum after a furious campaign based on Swiss government reports. Never mind that those studies were deeply flawed, say independent analysts, including the World Health Organization, or WHO.

Now, despite the emphatic claims of independent agencies that Swiss drug policy has been a failure, some are advocating that the United States follow the Swiss example.

There is a libertarian-populist streak in the American political temperament to which this sort of thing appeals.

Rep. Tom Campbell, the Republican senatorial candidate seeking to unseat Sen. Dianne Feinstein in California, tells Insight that although he is not endorsing any such proposal, “if a city wants to try what was tried in Zurich, it should have the freedom” to do so.

But even some recovering addicts are dubious about this approach.

Former heroin addict Jerome Hunt of Atlanta tells Insight that safe-injection rooms involve “exploitation of freedom” and “an incentive to remain addicted.” He adds that heroin is “a tool of self-destruction, whether it’s free or whether you have to steal to get it. It’s fueling an allergy that’s going to make you break out, no matter how you get it. It’s going to lead me to the same consequences that it has led me to over and over and over again.

That’s just the nature of addiction.”

Nevertheless, the advocates of legal venues for heroin use have no doubts. Ethan Nadelmann is the executive director of the Lindesmith Center, a New York-based think tank funded by billionaire George Soros and dedicated to liberalizing drug policy.

In an interview with Insight, Nadelmann calls the Swiss heroin-prescription experiments “extremely successful” and proposes that, “at the very least, [we should] try them here to see if they’d work.” Nadelmann invokes the Swiss example as a “harm-reduction” guide for treating hard-to-reach addicts.

The idea is that abuse of narcotics is here to stay and that policies must be developed to deal with the reality by seeking to minimize harm to drug users and to society itself.

The Swiss experiment was a response to the widespread marketing and use of drugs in public spaces such as railroad stations and Zurich’s “Needle Park.” The feasibility of prescribing and supervising self-administered heroin injections to more than 1,000 persons in safe-injection rooms was evaluated in 18 projects from 1994 to 1996, often known as the Swiss drug trials. Although these projects were officially authorized on condition that they be studied scientifically, physician analyst Ernst Aeschbach of Swiss Doctors Against Drugs writes that the principal impetus was “political pressure to devise a plan for easy and unlimited access to heroin” and other drugs.

The Swiss federal Office of Public Health and the experiment’s directors were praising the results even before the end of the test period.

The public was informed that almost every possible measurement showed a plus — that drug use stabilized, crime was down, health and social functioning of addicts improved, the death rate plummeted and society was saving money.

The Swiss were promised that the forthcoming report from WHO would corroborate all of this.

At the request of the International Narcotics Control Board, or INCB, the WHO had convened an independent evaluation by experts to study the integrity of the Swiss projects.

When the long-awaited report was released in April 1999, the WHO experts pronounced the studies deeply flawed.

These flaws have been corroborated by Aeschbach and Yale University’s Sally Satel, both physicians who state flatly in the Journal of Substance Abuse Treatment that “the Swiss heroin trials cannot be considered a valid experiment.” Aeschbach and Satel point out that the scientific method of these trials was faulty; the sample of participants was not representative; the verification of outcomes was inadequate; and finally, the doctors note, even the Swiss report itself cites negative consequences.

Nadelmann responds by attacking the critics.

He tells Insight that the INCB is “a corrupt and dishonest body [which has] lost sight of its basic mission — which is that drug control should be about public health.” With scant mention of the WHO findings, he and the Lindesmith Center continue to tout the alleged successes of heroin-maintenance projects, using experts from Switzerland now in other countries attempting to transplant the Swiss model.

Nadelmann cites the work of Ambros Uchtenhagen, the head of the Swiss program, whose summary of the drug trials was published by Lindesmith in 1997. The summary does not mention that the scientific protocols set up to use double-blind and randomized studies to compare the effectiveness of heroin with other narcotics such as morphine and methadone were discarded after 42 days. This raises grave suspicion since, in a double-blind study, neither researchers nor participants know which substance is received by the subject. The WHO report reveals that both parties in the Swiss trials were aware of which substances were injected.

According to Aeschbach, participants thus may be “choosing” their own drugs, eliminating the possibility of being randomly assigned to a group.

Even Nadelmann’s publication confirms that “the trial quickly determined that virtually all participants preferred heroin, and doctors subsequently prescribed it for them.” In the end, the ratio of heroin users to those of morphine and/or methadone became 8-to-1, respectively.

Initially the target group or sample was to include only the “severely addicted” who were more than 20 years of age — addicts of at least two years duration who had failed in at least two other treatment programs.

As the study progressed, these criteria were not met. For instance, 49 percent of participants had not had any inpatient therapy for their addiction, while another 26 percent had only had one therapeutic experience. Their state of health at the time of recruitment was classified as “good” or “very good” in 79 percent, with 80 percent deemed to be in a good nutritional state.

Only 2 percent were in “very bad” psychological condition.

According to Aeschbach, the volunteers’ overall good health casts doubt on the categorization of these persons as “severely addicted.” Moreover, 18 percent of the sample did not qualify as heroin addicts according to a prescribed criteria of usage, and some 61 percent of participants should not have been included since they were in active treatment programs which had not yet proved unsuccessful.

The alleged positive outcomes attributed to the Swiss drug trials become less conclusive the more they are scrutinized. Many of the reports of reduced crime were in fact “self-reports” from the addicts themselves. Such measurement, without verification, is not scientifically valid.

Also HIV/AIDS testing was not done consistently; thus, the rate of infection could not be determined accurately. And urine testing to check for drug usage was performed only at expected times, making it an unreliable modality for assessment.

While addicts reported improvements in their health and social functioning, there was no control group that received social services but did not take narcotics. As Aeschbach and Satel record, the heroin trials spent almost five times more per patient for social services than is spent on those receiving standard methadone treatment.

And the WHO report concludes that it was not possible to determine whether any positive effects were the result of the heroin maintenance itself or of the psycho-social care.

A summary booklet of the WHO findings graphs drug-related deaths from 1986 through 1998 and explains that these data “very clearly show that the reduction in the number of drug-related deaths is chronologically correlated with the closing of the drug scenes and not with the distribution of heroin to addicts.”

Generally speaking, the studies failed to provide “convincing evidence that, even for persistent methadone failures, the medical prescription of heroin generally leads to better outcomes than further methadone-based treatment.” In the Geneva project, two-thirds of those assigned to a waiting list for the heroin-prescription trials chose not to enroll six months later since they had been stabilized on methadone.

In the words of the WHO panel, “[T]his indicates the need for extreme caution in the prescription of heroin” and suggests that the need for such prescriptions may be lessened if more efforts are made to engage patients in methadone-type programs.

One of the consequences of the Swiss heroin projects has been the marked reduction in the number of people enrolling in residential treatment facilities. In some instances, the caseload decreased by 50 percent. Abstinence-oriented clinics also reported a drop in registration, which forced some to close.

Given the finding that heroin maintenance could not be found to produce better outcomes than more conventional abstinence-oriented treatments, the closing of such treatment facilities is viewed by many as a negative by-product of the experiments.

In response to the Swiss trial data, Dan Schecter, a spokesman for the White House Office of National Drug Control Policy, tells Insight, “Sure. [Take] people who are hard-core addicts and put them in a medicalized environment where they’re getting more-frequent access to medical care [and], of course, you’re going to see some positive outcomes from that. But compare anything they’ve achieved through these heroin-stabilization programs with what drug treatment achieves, and there’s no comparison whatsoever! There are ways to go that achieve much better outcomes by many orders of magnitude compared with simply enabling an addict to be a heroin user.”

For instance, Schecter points to a 1997 study by the National Institute on Drug Abuse in which methadone treatment reduced heroin use by 70 percent during one year, while illegal activity decreased 57 percent among outpatient participants. In addition, a 1998 long-term study of treatment effectiveness by the Substance Abuse and Mental Health Services Administration evaluated outcomes for a national sample of 1.1 million individuals. Five years after discharge from treatment, it found 21 percent fewer users of any illicit drugs.

Longer stays in treatment predicted greater decreases in alcohol abuse, drug use and criminality.

Even if the science of heroin maintenance should someday yield valid findings, the practice of harm reduction which underpins heroin by prescription would remain problematic to many. Satel, for example, has written of “the raw truth about harm reduction [as] the public-policy manifestation of the addict’s dearest wish: to use free drugs without consequence.” And, according to Schecter, “The source of harm is the nature of heroin and what it does to the human brain.

It’s not due to a moral failing on the part of someone, or necessarily to weakness.”

Indeed. A heroin addict of 30 years, now with almost 10 years in recovery, shares his experience with Insight. “I loved being on drugs, I loved it,” he says. “My [dream] was that I was going to be in a rocking chair and have me a home-care nurse who gave me my injections twice a day. But I was ‘dead,’ dead. I didn’t [have an] interest in anything, only heroin.

All I wanted to do was use it.” Now drug-free and working, this former addict claims to have everything he really needs. “I have those things because I stopped using and got back with you guys in this real world.

I used to stand on the street corner saying, ‘Look at that sucker having to go to work in the morning.’ No! We were the suckers, the ones that was using.”

According to Patrick Holzmann, a Swiss surgeon and activist against liberalizing his country’s drug policy, rehabilitating the addict requires abstinence. To him, it stands to reason that a tolerant atmosphere toward drug use, emblemized by the safe-injection room, only will increase the number of persons who try drugs.

In turn, the more people who experiment with drugs, the more who will become addicted.

Holzmann, who also volunteers his time to help prevent the spread of AIDS, denies the claims that new AIDS cases went down with the drug trials and cites the WHO report that, at any rate, inadequate testing made this impossible to prove.

In the end, Holzmann characterizes shooting rooms as “paint over rusty iron.”

The Swiss organization Courage to Take a Moral Stance, known in Europe by the acronym VPM, was at the forefront of the attempt to dissuade the Swiss public from adopting the so-called harm-reduction program.

Its president, Florian Ricklin, is a psychiatrist who is discouraged by the failure of efforts to persuade the Swiss to vote against the program in last year’s referendum. Ricklin tells Insight: “The whole world thinks the Swiss model works, but it doesn’t really.

It’s crazy what we are doing here in Switzerland.”

MAP posted-by: Don Beck