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Heroin for addicts works as Swiss fix

[Times photos: Susan Taylor Martin]
A bin full of used needles at the heroin prescription center in Bern, Switzerland.

By SUSAN TAYLOR MARTIN

© St. Petersburg Times,
published July 31, 2001


BERN, Switzerland -- In an old house near Switzerland's capital city, heroin addicts are getting ready for their midday fix.

A young man with pierced ears cinches a piece of rubber tubing tightly around his arm. The brachial vein bulges out, making it easier to stick in the needle.

The men with him have been shooting up for so many years, the veins in their arms have hardened. One man yanks down his pants and injects himself in the fleshy inner thigh. Another works a syringe into the thin skin on the back of his hand.

They are among the 30,000 or so heroin addicts in Switzerland. There is nothing unusual about their craving for such a highly addictive drug or their methods of taking it.

What is unusual, though, is the setting. This is a Swiss prison and it is the Swiss government -- not a fellow junkie or illegal dealer -- that is supplying the heroin.

* * *

Once filled with hundreds of heroin addicts, Bern's Kochar Park has been cleaned up since Switzerland began its heroin prescription program.

Since the mid '90s, Switzerland has provided pure heroin to a small group of addicted prisoners and hundreds of other addicts who have been unable to kick their habits through more common forms of treatment. Though controversial even in Switzerland, the heroin prescription program has helped reduce drug-related crime, improve addicts' health and slow the spread of AIDS and hepatitis.

It is part of what experts consider the world's most innovative approach to dealing with opiate addictions. The Swiss government also sanctions methadone treatment for heroin addicts and "safe injection rooms," where intravenous drug users can get fresh syringes and shoot up in clean surroundings under medical supervision.

It's all based on a philosophy of "harm reduction" -- reducing the harm that illegal drugs cause to the users themselves as well as to society as a whole.

"We don't waste our energies on drug wars and things we can't change," says Anita Marxer, who runs the injection center in Bern.

"There are people who are addicted, you find them in every corner of the world. ... It's better to accept a problem and deal with it in a pragmatic way than strive for a goal that is impossible."

Switzerland's lead is being followed by a small but growing number of countries disillusioned with "zero-tolerance" U.S. drug polices. That has put the Swiss at odds with the U.S. government, which criticizes the Swiss approach and maintains that "drug use is widespread" among the country's 7.1-million people.

However, the United States' own figures belie that claim. According to the State Department's latest report on global drug trends, marijuana is by far the most commonly used drug here yet is smoked by less than 8 percent of all Swiss -- a rate not out of line with other Western European countries and the United States.

Based on recommendations from a panel of experts, the Swiss government expects to legalize the personal use of marijuana by mid 2003. The proposed revision of Swiss narcotic laws would also legalize the heroin prescription program, a radical approach that has been used in clinical trials since 1994.

The idea was born out of revulsion with the "open" drug scenes that sprang up in the early 1980s. Hundreds of addicts congregated in public areas, including Bern's Kochar Park, near a pleasant residential area, and Zurich's notorious "Needle Park," next to the main train station.

"It's not so easy to be a junkie in a little town so they came to the bigger towns and the scenes starting growing," says Barbara Muehlheim, who heads Bern's heroin prescription center.

At Kochar Park, "there was crime, there was noise, all the dealers were on the scene, they were very aggressive. The police tried to control it, but it was so big. You would see about 50 people in the morning, by evening there would be 500. The whole park was filled up with people sleeping there."

Among other steps to control the drug crisis, the government gave the go-ahead to prescribing heroin for hard-core users as part of a comprehensive program that included counseling and medical care.

Participants had to meet strict criteria: age 20 or older; addicted to heroin for at least two years; a history of failure with other types of treatment; adverse effects of drug use on health and social relationships.

"These people are in an absolutely desperate condition, so you can't put them immediately into abstinence-oriented treatment," says Georg Amstutz of the Swiss Federal Office of Public Health. "The first thing is to stabilize them and treat their diseases and get them in a condition that they can face another therapy that might lead to abstinence."

The program began with centers in Bern, Zurich and several other cities. A year later, in 1995, it expanded to the minimum-security prison in Solothurn, about a half-hour's train ride from Bern.

The decision to include inmates in the clinical trials was based on a reality of prison life the world over: Despite efforts to keep them out, illegal drugs will get in.

"In every prison you will find drugs, some more, some less," says Heinz Stutz, a social worker at Solothurn. "They tried to find out where drugs were coming from, but it's not possible to block everything."

Still, the idea of abetting a prisoner's addiction stunned the guards.

"We felt a little overrun by the system," says Yeli Schleup, the guard supervisor. "(The inmates) were being punished for drugs, that's why they were here and now the state of Switzerland is giving them heroin."

photo
Otto Krummenacher, serving time in a Swiss prison for drug dealing, takes his heroin orally because the drug has hardened his veins.
Although the simple possession of drugs is rarely prosecuted, Switzerland has cracked down on drug traffickers. Most of Solothurn's 76 inmates are doing time for drug dealing, and 12 are so seriously addicted themselves that they qualified for the heroin prescription program.

Three times a day, they head to the prison offices, in a 17th century house, to get their fixes. The injection room is clean and bright, with a big bouquet of fresh flowers. A nurse removes the heroin from a wall safe and gives each prisoner a premeasured, individualized dose.

With brusque efficiency, the first three men take small squares of disinfectant-soaked gauze and swab the areas where they will inject themselves. They find a vein, shoot up, wipe away little trickles of blood and leave. The whole process takes no more than five minutes.

A fourth prisoner, Otto Krummenacher, mixes his heroin with water and drinks it. His veins are "too hard" to inject, he says.

Now 44, Krummenacher started drinking beer at 14 or 15 and moved on to heroin, whose relaxing effect helped his chronic insomnia. Although he occasionally smoked marijuana, he scoffs at the argument that it is a "gateway" drug that inevitably leads to heroin addiction:

"In the beginning it can be alcohol or marijuana or TV -- it can be anything."

Krummenacher held jobs for a time but found "it was too much to organize heroin and keep working." To support his habit, he bought heroin in Zurich and sold it in his native Lucerne. Twice he was arrested and put on probation; the third time he was sentenced to 39 months, but will have to serve only 24.

A half-hour after taking the drug, Krummenacher acts no differently than before. He has been using heroin so long "it doesn't change my mind," it only gives him what he describes as a warm, relaxed feeling.

Like other inmates in the heroin program, he is not allowed to drive prison vehicles or use heavy machinery. However, he can work in the prison garden, tend its small herd of cows and assemble lamps, which the prison makes under contract with a private company.

On his furloughs, Krummenacher visits friends in Lucerne and gets his heroin from the prescription center there. After he is released from prison, he plans to move to Morocco, where, he says, he can live well on his monthly disability check from the Swiss government.

"Maybe," Krummenacher says, "it's a way of life to take drugs."

Despite initial skepticism, the prison guards have come to believe the heroin program makes sense for hard-core addicts like Krummenacher.

"In time we saw that their health was getting better, they were pretty calm afterward," says Schleup, the guard supervisor. "They have different behavior, they are interested in different things instead of thinking only about drugs and where they would get them."

At the "safe injection room" in Bern, Switzerland, an instructor shows employees how to administer CPR in case a heroin addict accidentally overdoses.

* * *

In 1997, three years after the clinical trials began, a panel of experts concluded that Switzerland's heroin-assisted treatment "is useful ... and can be carried out with sufficient safety."

Specifically, the study found:

In the first six months of treatment, the number of crimes committed by participants dropped about 60 percent.

The percentage of those with permanent employment more than doubled, from 14 to 32 percent.

Participants saw improvements in physical health and a decrease in psychiatric problems, including depression. Babies born to addicted mothers were normal and healthy.

After withdrawal from the program, addicts' use of illegal drugs increased somewhat "but remained clearly below the initial level." By the end of the first two years, 83 people had decided to give up heroin and switch to abstinence therapy.

"The economic benefit of heroin-assisted treatment is considerable," the study said, noting the reduced costs of treating disease and imprisoning addicts.

The program remains highly controversial. Even those who acknowledge its successes say it might not work nearly as well in other countries.

"The positive developments (in Switzerland) are the result of complex measures, supported by a sophisticated social and health care system and impressive financial resources, and not the result of any isolated element of the drug control policy," says a report from the International Narcotics Control Board, the United Nations' drug-control arm.

"The Board therefore encourages other countries examining the Swiss experience to consider its complexity."

Opposition continues in Switzerland itself. Most of the 21 heroin prescription centers are in German-speaking parts of the country, where the "open" drug scenes became such a blight on Zurich and other big cities. Heroin treatment remains controversial in the French- and Italian-speaking cantons, which are more conservative and had less of a visible drug problem.

But most Swiss endorse what they see as their government's middle-of-the-road approach. In the past few years, voters have soundly rejected extreme proposals, one that would have legalized all drugs, another that would have adopted a policy aimed at total abstinence.

"Swiss drug policy was made with doctors, social workers, police, cantons, everybody sitting at the same table," says Amstutz of the Office of Public Health. "That's one of the very important points -- everybody was involved. We reached a national consensus on drug policy that successfully passed the test of national popular votes.

"We've heard many criticisms for many years and we can only say we're convinced our policy is a good one for Switzerland."

-- Susan Taylor Martin can be contacted at susan@sptimes.com.

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