Chapter 20 - Public Policy In Other Countries - Switzerland

A harm reduction policy

The recent history of Switzerland’s drug policy began towards the end of the 1960s with the increase in psychoactive drug use. As a result, the cantons developed a first drug policy, which was based on three pillars, namely:

··          the repression of drug use and trafficking;

··          prevention measures aimed at young people;

··          treatment based on abstinence, which at the time already included methadone programs.[1][134]

 

At the beginning of the 1980s, the HIV-AIDS epidemic hit many countries, including Switzerland. There were "open drug scenes" in several Swiss cities, such as Zurich, Bern, Olten and Solothurn. As a consequence, the miserable state of drug dependent persons was becoming increasingly visible contributing to growing concern over the situation. Public and social services were created to help the “addicts” and protect them against HIV and AIDS. Needle exchange programs were set up and “addicts” were encouraged to be vaccinated against hepatitis. The Swiss Federal Office of Public Health (SFOPH) supported many of these services and still does so today, arguing that they help prevent the spread of AIDS. However, the main pillars of Switzerland’s official drug policy remained prevention, treatment and law enforcement.

In the 1990s, Switzerland introduced new measures to reduce the problems associated with drug use and adopted a new national drug strategy. The new strategy introduced another pillar, namely harm reduction, which led to the creation of a four-pillar approach. The role of the Confederation in the area of drug policy becomes more defined and aims to support the efforts made by cantons, cities and communes and by private organizations by providing them with reference material, scientific data and training for professionals.

On February 20, 1991, the Swiss government adopted a program of federal measures to reduce the problems related to drug use,[2][135] currently known as "ProMeDro,"[3][136] and which was based on the concept of harm reduction. The objectives of the program were as follows:

··          to decrease the number of new drug users and to prevent people from becoming drug dependent;

··          to help users overcome their addiction (through treatment and social reintegration);

··          to improve the living conditions and the health of drug users, to reduce harm and to maintain their social integration.[4][137]

 

 

To achieve these goals, the following measures were introduced:

··          primary and secondary prevention measures aimed at young people and awareness campaigns to prevent them from experimenting with drugs;

··          patient management and treatment to help users overcome their addiction;

··          harm reduction, AIDS prevention and social reintegration measures to help addicts cope with their dependency in the best possible health conditions and to ensure that the door to a drug-free life remains open;

··          ongoing training and development programs for professionals (including those working in the areas of sentencing, programs and social services, as well as hospital workers, pharmacists and family doctors) and for people acting as mediators (such as teachers, youth group facilitators, business personnel and parents);

··          the development, co-ordination and regular publication of scientific research on drugs;

··          the evaluation of projects and measures in the fields of prevention, patient management and treatment to help identify any gaps or shortcomings, but also to pinpoint and highlight any progress achieved;

··          the development of new documentation and information services normally provided by the Swiss Confederation; and

··          the co-ordination of measures adopted by the Confederation.

 

These measures mark the beginning of Switzerland’s drug policy, based on a four-pillar approach: prevention, law enforcement, treatment and harm reduction. Between 1991 and 1999, the SFOPH initiated and/or supported approximately 300 projects and programs under the "ProMeDro" initiative at the cost of 15 million francs per year.

Among other activities, the Federal Council asked for a study on heroin-assisted treatment for severely dependent heroin addicts who had failed at other treatment programs. In 1992, the Council passed an order authorizing clinical trials with the medical prescription of heroin, along with a strict scientific evaluation of the trials. The trials began in 1994 and ended on December 31, 1996. The final evaluation report was published in July 1997 and concluded that:

··          heroin-assisted treatment for severely dependent heroin addicts improved their physical and/or psychic health, as well as their quality of life (in terms of housing, work and other areas);

··          participants’ illegal use of heroin and cocaine decreased;

··          the users involved in the program committed fewer crimes (the incidence of theft and property and drug trafficking offences fell sharply).[5][138]

The Federal Council followed the report’s recommendations, and on March 8, 1999, passed the Ordinance governing the medical prescription of heroin authorizing heroin assisted treatment, setting objectives, eligibility criteria, administrative measures and providing for such treatment.

Over the same period in 1993 and 1994, two people’s initiatives were presented with opposite objectives. The first initiative called for a strict, abstinence-oriented drug policy ("Youth Without Drugs"),[6][139] and the second proposed the legalization of drug use ("DroLeg").[7][140] The federal government and Parliament found both initiatives too extreme and recommended their rejection. On September 28, 1997, Swiss voters rejected the initiative "Youth Without Drugs" by a majority of over 70%. On November 29, 1998, Swiss voters rejected the "DroLeg" initiative with a majority of over 74%. By rejecting both initiatives, the Swiss population showed its massive support for the Confederation’s more measured approach to drug policy.

Between the time that these popular initiatives were launched and subsequently voted down, some major events influenced the evolution of Swiss drug policy. In 1994, the violence occurring on the "open drug scenes," from Letten to Zurich, made headlines in the international media. Certain government parties (Socialist, Christian Democrat and Radical) clamoured for decriminalization of drug use, increased access to heroin-assisted treatment, stronger prevention measures and stiffer sentences for drug traffickers.[8][141] The open drug scene in Zurich was shut down in 1995,[9][142] resulting in new co-operation between the Federal Council, canton representatives and the city of Zurich. A joint task force, called the Drug Delegation, was established. This unusual co-operation made it possible to implement measures that would never have got off the ground under more traditional circumstances: the creation of prison spaces in Zurich for drug traffickers, the adoption of emergency federal measures allowing for more drug addicts to participate in heroin-assisted treatment and the creation of centres for the treatment of hard core users.[10][143] Today the "open drug scenes" are a thing of the past.

Finally, in October 1998, the program of federal measures to reduce the problems related to drug use (ProMeDro) was renewed for a four-year period. The Confederation set a budget of 18 million francs per year to run this program and staffed it with 15 positions from the Federal Office of Public Health.[11][144] The main priorities for ProMeDro from 1998 to 2002 are as follows:

··          to strengthen the Confederation’s commitment to primary and secondary prevention and early intervention to prevent addiction;

··          to consolidate the range of treatments in a co-ordinated system, thereby increasing the likelihood that addiction can be overcome;

··          to consolidate harm reduction and social integration measures;

··          to establish and operate effectively a national epidemiological monitoring centre based on the focal points REITOX model of the European Monitoring Centre for Drugs and Drug Addiction;[12][145]

··          to forward, in an effective manner, the findings of epidemiological studies, scientific research and evaluations to experts and decision makers;

··          to implement a process to foster quality management throughout the entire ProMeDro program, tailored to the needs of the different fields, useful to and used by more than half of the addiction agencies and decision makers concerned (Confederation, cantons, communes, private institutions);

··          to ensure optimum co-ordination and organization for various commissions and forums, mainly for the Conference of Canton Delegates on Drug Addiction Problems and the National Drug Liaison Committee.[13][146], [14][147]

 

The Confederation has thus set itself up as a political hub for drug policy and national co-operation

 

First pillar: prevention

Prevention measures are aimed primarily at achieving three objectives:

··          to prevent drug use among individuals, especially children and youth;

··          to prevent the problems and harmful effects related to drug use from spilling over onto the individual and society;

··          to prevent individuals from going from casual drug use to harmful use and addiction, with all of its known consequences.

It should be pointed out that the most notable change in prevention has been a transition from the concept that prevention was a matter of preventing someone from ever trying drugs to today’s concept of preventing the health and social problems related to drug use, thereby integrating the person’s social network and environment as well.

 

Second pillar: treatment

In Switzerland, there are many types of in-patient and out-patient treatment available to people suffering from drug addiction. The objectives sought through treatment include:

··        breaking drug “addicts” of their habit;

··        social reintegration;

··        better physical and mental health.[15][148]

 

As mentioned earlier, heroin assisted treatment has been a recognized type of therapy in Switzerland since 1999. By the end of 1999, there were already 1,650 treatment spaces reserved for hard-core heroin dependent persons in 16 treatment centres. In addition, during the same period, approximately 50% of opiate addicts (estimated to be 30,000) were being treated with medically prescribed methadone, compared to 728 individuals who were receiving this type of therapy in 1979. Those individuals addicted to one or more drugs also have access to in-patient treatment based on abstinence, to a limited number of spaces in transition centres, specialized withdrawal units or clinics, and treatment institutions, as well as out-patient consultation centres.[16][149] In March 1999, there were 100 institutions providing in-patient withdrawal and rehabilitation treatment in Switzerland, for a total of 1,750 spaces.[17][150]

 

Third pillar: harm reduction

The first so-called "low threshold" coping skills institutions made their appearance in Switzerland in the mid 80s. Their purpose was to reduce the health and social risks and consequences of addiction. First and foremost, these institutions gave drug dependent persons a roof over their heads and were often equipped with cafeterias, showers and laundry facilities. They provided addicts with someone who would listen and talk to them. These facilities have evolved over the past ten years and now incorporate medical support for harm reduction (for example, prevention of AIDS and other infections, needle exchange, out-patient medical care, etc.) and social support (street work, soup kitchens, emergency shelters, low threshold centres, etc.). The Swiss Federal Office of Public Health supports many harm reduction projects as part of ProMeDro. Such projects include:

··        needle exchanges for drug addicts and inmates;

··        injection sites (a statutory notice makes such sites legal);

··        offers of employment and housing;

··        support for women who prostitute themselves to buy drugs;

··        consultation services for the children of drug-addicted parents.[18][151]

 

Furthermore, the cantons, communes and private institutions also provide such programs. In 1995, the SFOPH established a central service to support certain social assistance agencies, particularly those with low thresholds, and to advise the cantons, communes and private institutions on planning and funding harm reduction programs. Drug “addicts” have access to such programs without having to meet any particular prerequisites. The objective of these harm reduction services is to limit as much as possible the negative consequences of addiction so that the “addict” is able to resume a normal existence. In addition, these measures are aimed at safeguarding and even increasing the addict’s chances of breaking the drug habit.[19][152]

 

Fourth pillar: enforcement

The primary goal of enforcement is to reduce supply and to fight the trafficking of narcotics, the illegal financial transactions related to such trafficking (for example, money laundering) and organized crime. Users are not the number one target of police operations in Switzerland. Enforcement of the federal Narcotics Act is, to a large extent, the responsibility of the cantons, although the Confederation does monitor the situation closely and can call for and carry out police investigations into drug trafficking. It should be noted that canton and commune laws on policing differ and sometimes result in varying interventions. Furthermore, the drug milieu changes quickly and the methods used to fight drug-related problems are improving and adapting to this milieu.[20][153] These methods include:

··          focussing enforcement activities on the manufacturing of drugs, trafficking and money laundering;

··          assigning more officers to the "drug police" and making greater use of specialists from other sectors (finance professionals);

··          intercantonal and international cooperation (agreements with police forces from neighbouring countries);

··          accelerating and improving the processing of information (networking systems and access to the police department networks from many European countries);

··          improving cooperation between the police and the private sector (banks, chemical industries, etc.);

··          improving police effectiveness and making greater use of front-line liaison workers;

··          strengthening the legal structure (for example, policing legislation, witness protection).[21][154]