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Harm Reduction and Injection Drug Use:
an international comparative study of contextual factors influencing the development and implementation of relevant policies and programs

Harm reduction in Switzerland

Overview

In the area of harm reduction, Switzerland is best known for its medical heroin prescription programs and its supervised injection sites. Switzerland also has well-developed needle exchanges (including exchanges in prisons), outreach and methadone prescription services, as well as non-abstinence lodging and day projects for drug users. It also has projects to increase the integration of drug users into the workplace, sick bays for drug users and homeless people, and projects that provide assistance to workers in the sex trade. Self-help among injection drug users has also been encouraged. Harm reduction is identified as one of the four pillars of the Swiss federal drug policy.

Research and monitoring studies show that Switzerland has made considerable progress in reducing drug-related problems. The Swiss approach to drug problems has also contributed to the debates about other national and international drug policies.

The policy context for harm reduction

The Swiss federal government's current drug policy was formulated in the early 1990s. It has four objectives:

• To reduce the number of new users/addicts;
• To increase the number of addicts who stop using drugs;
• To reduce damage to the health and social integration of users/addicts;
• To protect society from the harmful effects of drug use and to fight against organized crime.

The federal strategy for pursuing these objectives has four components. The following descriptions of these pillars are provided in a booklet published by the Swiss Federal Office Public Health.

1. Law enforcement

The Swiss Drug Policy relies on the strict regulation and prohibition of certain addictive substances and products. Illicit production, trafficking and consumption of substances regulated by the law can result in criminal prosecution and there are strict controls on the use of narcotics.

The federal government has introduced new, legal instruments against money laundering and organized crime. The new law on money laundering, which has been in effect since April 1, 1998, makes it mandatory for banks to report suspicious accounts to the federal authorities and to freeze the assets concerned. It also extends this obligation to asset management companies, insurance companies, foreign exchange bureaus, lawyers and other professionals.

Switzerland has, however, become quite tolerant of the personal use of cannabis. Recently proposed legislation will decriminalize personal cannabis use and allow for some legal cultivation and distribution - possible through cannabis cafés as in the Netherlands.

2. Prevention

Prevention is considered the most important of the four pillars. The aims of all prevention initiatives are to convince people not to use drugs and to adopt a healthy lifestyle. Certain target groups, such as socially deprived youngsters and migrant populations, and certain social settings, such as schools, youth homes, youth events and sports clubs, receive special attention.

3. Therapy

Those who have become drug-dependent are encouraged to enter therapy. At present, there are approximately 100 specialized, in-patient institutions designed to provide drug therapy and rehabilitation. The declared goal of these therapies is abstinence and social reintegration/rehabilitation. The federal government also supports methadone maintenance and treatment for people who suffer from psychiatric problems and drug abuse.

4. Harm Reduction

The federal government has supported a variety of harm reduction measures, including needle exchange programs, injection sites, and housing and employment programs. These are described below.

Two aspects of Swiss policy are also emphasized in the booklet published by the Federal Office of Public Health:

• Close, coordinated collaboration among all participating services and agencies involved,
  and
• Scientific research and systematic evaluation.

Leadership and coordination for the development and implementation of measures to reduce drug problems is provided by the Federal Office of Public Health (FOPH). This Office has four main modes of action: (1) information development and dissemination, (2) promotion of tested models and innovations, (3) coordination and harmonization, and (4) promotion of quality.

The overall program of measures to reduce drug problems (ProMedDro) is run in cooperation with other areas that fall within the jurisdiction of FOPH such as the AIDS, tobacco and alcohol programs. These share common strategies and projects, particularly with respect to prevention and health promotion in schools, prevention among young people, the health of migrants, drugs/AIDS harm reduction, health promotion in prisons, professional training, and the promotion of high-quality services.

During 1990-1996, FOPH activities concerning treatment and harm reduction included the development and evaluation of a program of medical prescription of narcotics (see below), needs analysis, the establishment of a national coordination centre, support for the opening and reorganization of various residential treatment services, national statistics on out-patients and residential treatment, support for needle distribution and exchange, and low-threshold services.

With respect to treatment and harm reduction, FOPH priorities for 1998-2002 focus on collaboration and coordination, and include the consolidation of the range of therapies into a coordinated system to provide better opportunities to overcome drug dependence. Specific objectives include:

• Reach agreements between the federal government and the cantons regarding the harmonization of funding for abstinence-oriented therapies;
• Improve methadone treatment and increase retention rates in methadone programs;
• Establish the medical prescription of heroin as an option within an integrated system of treatment;
• Improve the treatment of drug dependence in at least one-third of prisons and detention centres;
• Ensure (through promotion and funding) the perpetuation of harm reduction measures within cantonal and municipal drug policies;
• Broaden access to injection equipment;
• Improve harm reduction measures and especially improve networking among those involved in prevention, therapy and the maintenance of public order; and
• Improve harm reduction in at least one-third of prisons and detention centres

Researchers at Lausanne University have completed two extensive evaluations of FOPH measures to reduce drug-related problems. The first covered the years 1990-1996 and the second focused on accomplishments and proposed priorities and activities for the years 1998-2002. These evaluations were commissioned by FOPH and signify the importance attached to evaluation among Swiss policy-makers and policy advocates.

The first evaluation was very positive and resulted in the following general conclusions about FOPH activities over the period in question:

• The FOPH has been very active and innovative in developing and supporting projects relating to prevention, therapy and harm reduction.
• In interaction with the FOPH's partners (cantonal and municipal authorities, professionals, associations, etc.), FOPH collaborators have progressively developed consistent policies in each of its fields of intervention.
• The decision to operate in all fields relating to drug abuse has greatly contributed to achieving general recognition that the problem requires a global approach.
• In the field of prevention, the use of existing experience and abilities has proven more fruitful than the development of totally new projects.
• The FOPH has helped to develop a broad range of therapeutic and harm reduction approaches, thus improving care for various types of drug users. The introduction of innovations in this field (trials involving the medical prescription of narcotics, distribution of syringes in prisons, etc.) has been carefully managed, and depends extensively on fieldworkers.

The second evaluation was also positive and included a number of recommendations concerning future directions. Those of particular interest in the present context were as follows:

• The FOPH should pay particular attention to harmonizing statistics related to drug problems in order to obtain reliable epidemiological indicators. Epidemiological surveillance is essential if an effective health policy is to be implemented in the field of drug abuse, and should therefore be a priority for the FOPH.

• Nearly 50% of heroin users are now treated with methadone: resources must therefore be allocated to this sector, in order to ensure the quality of such treatments and to gain further knowledge concerning them.

• Offering therapies and subsistence aid to drug users is of fundamental importance and the FOPH should make constant efforts to ensure the diversity and accessibility of these initiatives.

• The FOPH's internal co-ordination should be developed so that its partners can refer to clearly defined concepts and methods. In particular, this concerns co-ordination in the general field of prevention, and in such sectors as substitution therapies, subsistence aid and secondary prevention. Those collaborating with the FOPH would find it easier to adjust their efforts if projects or research were subject to competition, and if selection criteria were more clearly stated.

• One of the FOPH's essential activities is to inform its partners and the general population. Through public awareness campaigns, brochures and reports, it is able to develop national co-ordination and encourage the social and political acceptance of dealing with drug problems. The FOPH's work is exemplary in this field, and should be continued.

• The FOPH has also shown great skill in taking the needs of field workers into account. It would be desirable to carry on in the same vein and to ensure ongoing exchanges of information and ideas.

• National co-ordination should be further specified and developed.

• Collaboration with the police should be maintained and strengthened, and the FOPH should ensure that police forces are aware of the health aspects of drug use.

• Finally, continuity in the FOPH's actions is essential if the achievements of the last few years are to be maintained.

Funding for harm reduction under the national drug strategy

Operational funding for public health initiatives to reduce drug-related problems is provided by the Federal Office of Public Health. However, Switzerland has 26 cantons and each has budgetary control over local activities related to the national drug strategy. Not all cantons have voted funds to support either heroin prescription or injection sites. However, one canton that did not vote for heroin prescription did vote funds for a clinic to provide methadone for self-injection.

The current status of specific harm reduction initiatives

Needle and syringe distribution and exchange

Syringes became available in pharmacies in 1987. In 1991, a nation-wide syringe exchange and availability program, including dispensing machines, was initiated. Needle distribution and exchange are now well supported by the police and the general public.

Street-level, walk-in, non-abstinence centres (SBS) are the main sources of injection equipment for drug users. There are currently 25 such centres in Switzerland, spread across 10 cantons, mostly in German-speaking areas. Thirteen such facilities have an injection room. Pharmacies represent the second-largest source of supply, followed by the clinics established for the Swiss Heroin Trials (PROVE program). Although automatic distributors (of which 76 have been installed in Switzerland) make a more modest contribution, this is probably qualitatively important in the event of an emergency.

In 1996, nearly 532,000 syringes were issued to drug users in Switzerland every month, equivalent to an annual volume of 6.4 million. They were distributed through low-threshold facilities (320,000 per month), pharmacies (122,000 per month), automatic distributors (20,000 per month), and the PROVE program (70,000 per month). There were differences among cantons with respect to the numbers syringes distributed relative to the population of young people.

Needle exchange in prisons is described below.

Drug substitution treatment

Methadone

Methadone is widely prescribed in Switzerland. About 18,000 narcotic addicts receive methadone on any given day. Almost all methadone is prescribed for oral consumption, but a few people receive methadone for self-injection at clinics established for the Swiss studies of medically prescribed narcotics.

Methadone maintenance services tripled in number between 1986-1990 in response to a rapid increase in heroin use during the same period (Klingemann, 1993, p. 18). Policies and practices with respect to methadone also became less restrictive and rule-driven during this period. The average length of methadone maintenance episodes has been 28.5 months, but many patients have been on methadone for much longer periods (Swiss Federal Office of Public Health, 1997). One informant described the ideal approach as client-centred where decisions about the dosage and duration are based on clients' needs and aspirations. Those who chose to enter abstinence programs are encouraged to do so, but this is not a goal in all cases. There have been numerous studies of methadone use in Switzerland and these have confirmed its value in a comprehensive treatment system (Swiss Narcotic Substance Commission, undated).

Some of the residential treatment programs are now providing methadone. Doctors who prescribe methadone require a special license and all patients put on methadone need to be approved by the chief medical officer of the canton. This is typically a very quick process taking between two hours and one day. Each canton, therefore, has a registry of people on methadone and this prevents double doctoring. Guidelines for methadone treatment and national guidelines are presently being codified.

Prescribed heroin

Heroin is currently prescribed to about 1,100 people at special clinics established in the mid-1990s to support scientific studies of medically prescribed narcotics - the so-called Swiss heroin trials or PROVE projects. Most prescribed heroin (80% by weight) is for self-injection. The rest is in the form of slow-or fast-release tablets for oral consumption. The Swiss trials are described in other reports prepared for Health Canada and will not therefore be described in detail. These trials were established to assess the feasibility of the medical prescription of narcotics drugs (including heroin, morphine and injectable methadone) to severely dependent and destitute addicts who had not been motivated to participate in other forms of treatment.

The Swiss government concluded that the results of the trials supported the prescription of heroin in some circumstances and new regulations to be enacted will allow the prescription of heroin in situations other than as part of a research project. These regulations may allow heroin to be prescribed outside of special clinics, but this is not entirely clear. Several key informants indicated that heroin prescription has become normalized as an option in the medical treatment of narcotic addiction and that this was no longer a topic of concern to the public or politicians.

Not all cantons with large numbers of injection drug users initially agreed to support heroin prescription. However, a number have since been persuaded to provide such support by the results of evaluations of heroin prescription in other cantons.

Those prescribed heroin must be individually approved by the canton chief medical officer and through the FOPH. Heroin is only prescribed for on-site self-injection. No take-outs are allowed. Patients attend up to three times a day and take their heroin while being observed by a nurse. Some are also prescribed oral methadone and drugs for mental health problems such as anxiety and depression. Social assistance, counselling and psychotherapy are provided based on individual needs and all patients are assessed on an ongoing basis.

One finding of the evaluation of heroin prescription in Switzerland was the high rate of retention (89% at six months and 66% at 18 months). This suggests that heroin was popular with addicts. However, no client satisfaction studies have been conducted and the demand for places at clinics has been modest. The requirements to attend multiple times a day and to forfeit drivers licenses seem to make the clinics unattractive to many narcotic users and its appears that the clinics do not always operate at maximum capacity.

Concerns about the scientific validity of the Swiss trials were expressed by a WHO expert review panel (Ali et al., undated), the UN Commission on Narcotic Drugs and some Swiss psychiatrists (Aeschbach, 1998). Essentially the WHO expert panel concluded that the Swiss trials had shown that the prescription of heroin was medically feasible and that the consequences of this treatment to patients and to society may be comparable to other forms of treatment. However, the panel considered that the knowledge base was insufficient to determine the cost-effectiveness and the differential indications for heroin substitution treatment.

The WHO expert panel also drew attention to a number of contextual factors that may have contributed to the outcomes of the Swiss trial and may limit the applicability of the results to other situations:

• High degree of oversight from federal and canton authorities,
• Built-in monitoring for research purposes,
• Novelty of intervention and high-level of public interest,
• Highly qualified, multidisciplinary teams,
• Ongoing staff training and development,
• No take-home narcotics for self-injection,
• Patients required forfeiting driver's licenses (patients could not legally drive under the influence of prescribed doses of heroin),
• Provision of ancillary services,
• Adequate measures to ensure the security of opioid type drugs and the safety of staff and patients.

It is also of note that Swiss towns and cities are small compared with those in many other countries and have excellent transportation systems. This makes it possible for people to attend clinics two or more times a day.

Other substitute drugs

One informant reported that there is some use of buprenorphine but not LAAM.

Supervised injection sites

Switzerland has 30 injection sites. These are facilities where drug users can inject drugs and obtain clean needles, condoms, advice, medical attention, and so forth. These sites are considered legitimate under Swiss law because they do not distribute illegal drugs or allow drugs to be sold or traded. Although they provide aid to people who use illegal drugs, this is not an offence (Geense, 1997).

A detailed description of Swiss injection sites is provided in another report prepared by Canada's Drug Strategy Division (September 2000). This indicates that Swiss injection sites have the following essential features:

• Mobile and or fixed facilities are located in areas with open drug scene mainly involving users who live locally;
• Typically located within a larger centre that includes a cafeteria, counselling room and primary care clinic;
• Open about seven hours a day seven days a week;
• Entry is controlled and restricted, and some staff are principally concerned with security in and around the injection sites;
• Police cooperate by referring addicts to injection sites and do not arrest people with drug paraphernalia in or around the site. Police assist with dangerous and other difficult situations and enforce laws concerning drug trafficking.

The report by Canada's Drug Strategy Division also summarizes what is known about the effectiveness of injection sites from various perspectives. Overall, the evidence indicates that well run and appropriately integrated injecting sites can have a positive influence on the health, social integration and rehabilitation of their clients, and also reduce drug-related nuisances and drug-related crime in their neighbourhoods. There is no evidence that injection sites contribute to increased drug use in the general population or condones drug use. Rather, they tend to reinforce the view of drug dependence as a debilitating health condition that is far from being exciting or glamorous.

Drug user education and outreach

Outreach work is undertaken by a variety of agencies and especially by those offering low-threshold services such injection sites, needle exchanges, drop-in and day care centres and shelters. However, no accounts of outreach work were located.

Harm reduction in the justice system

The FOPH has declared support for the WHO principle of equivalency with respect to the treatment of drug use in prisons and in the community, and has supported initiatives to make this a reality. Despite political and other objections, the office has worked closely with prison managers to ensure that prisoners are provided with information on the risks of drug use and needle sharing, and ways to reduce these risks. Automatic needle dispensers have also been installed in some prison. In other prisons, medical staff exchanges needles with prisoners and also gives out condoms and other prevention aids (e.g., bleach). However, one informant indicated that the situation in any one prison depends very much on the attitude of prison governors. Some are opposed to needle exchanges, but others have been able to implement needle exchange services despite opposition from guards.

Only two detailed accounts of prison needle exchanges were located. The first was a report on the installation of automatic syringe dispensaries in a small (85 bed), women's prison where many of the inmates were sentenced for drug-related crimes (Nelles et al., 1998). Six dispensers were installed in different wings and they dispense one new syringes in exchange for used ones. Prisoners who have previously used drugs by injection are, on admission, provided with a dummy syringe on admission and this can be used to obtain a real syringe from the automatic dispenser. Dispensers were freely accessible, but hidden from general view. Prisoners also had access to condoms and were given lectures and counselling concerning drug use and harm reduction.

During a 12-month evaluation period, 5,335 syringes were distributed (0.2 per inmate day). None were used as weapons and no prisoners or prison officers were injured by discarded needles. Needle-sharing (based on self-reports) was virtually eliminated and despite high rates of blood-borne infection on admission (HIV 6%, hepatitis B 47%, hepatitis C 30%), no prisoner was found to have become infected while in prison. There was no evidence that drug use increased during the evaluation period, but most of those who used drugs regularly before admission continued to do so while in prison.

The second report of the use of automatic syringe dispensers in a Swiss prison concerns a small (100 bed) semi-open prison for men serving sentences from a few weeks to several years (Nelles, et al., undated). The results were essentially the same as for the women's prison. Consumption of drugs did not increase, syringes were not used as weapons, there were no incidents of needle stick injuries, sharing of syringes among prisoners greatly decreased, there were no new cases of HIV or hepatitis C, injection site abscesses did not increase, there was a decrease in drug-related sanctions, there was a decrease in overdoses and suicides, and staff acceptance of the program increased.

Methadone treatment can also be initiated on admission to prison. However, the range of treatments provided to injection drug users in prison have been described as varying widely from one prison to the next (Gervasoni, 2000). Follow-up after leaving prison is also described as insufficient in that prison medical services are not systematically informed when a prisoner is released.

Those receiving heroin from special clinics can continue to receive heroin for self-injection if they go to either of two large prisons. A few prisoners have also been prescribed heroin for the first time on admission to these prisons. Prisoners enter a special room to receive a syringe of heroin from a nurse. The nurse observes while the prisoner self-injects but does not usually assist.

Factors influencing harm reduction policies and practice

Swiss drug policy is influenced by a large number of stakeholders: international partners, the federal government, the cantonal (or state) government, the local communities, and private pressure groups. Supply reduction is the main objective of the Swiss police and juridical system, and this is where most resources are allocated. Demand reduction through preventive and therapeutic measures are largely in the competence of the 26 cantons of the country, which are each responsible for the application of the federal laws. All cantons, therefore, have organs and political structures concerning drug use. Important cities as Bern and Zurich also have substantial power and independence (Haemming, 1992). Besides cultural differences between the Swiss-German speaking part of Switzerland and the French-and the Italian-speaking parts, this independence explains the widely divergent drug policies of Switzerland. Each action taken by the federal government relies on a process of consensus building, which usually takes time and effort, to achieve a certain harmonization of the widely divergent interests of different stakeholders (Rihs-Middel, 1995). Nevertheless, Swiss drug policy over the last 10 years can be characterized by rapid change, and political willingness to experiment.

Trends in injection drug use

Switzerland experienced a significant increase in injection drug use and related problems during the1980s in the context of a growing restlessness and rebelliousness among Swiss youth, and the infiltration of the established drug scene by the international drug Mafia (Klingemann, 1998). Charges filed under the narcotics law for use or trafficking involving heroin or cocaine increased from 3,412 in 1980 to 11,590 in 1990, and drug-related deaths (mostly from heroin) increased from 88 in 1980 to 281 in 1990.

Initially the response was to try to contain drug use by tolerating use within limited geographical areas. However, as one informant indicated, the policy was not well thought out and should not be construed as one of harm reduction. The assumption seemed to be that containment would limit the spread of drug use and also make it easier to provide services to users. In Zurich, this policy contributed to the rise of the so-called "Needle Park", which at its peak was estimated to include 3,000 heroin users. The park became a public embarrassment for the Swiss and clearly contributed to increased trafficking and to a variety of public health and public order problems. Drug-related arrests tripled from 1990-1994 (Klingemann, 1998). When police activity in the park was first intensified, a core group of 200-300 addicts moved to an abandoned railway station. For a while these and about 2,500 occasional drug users continued to congregate in and around the station area and to cause problems for the police and public. However, as a consequence of more assertive police activities, the forced relocation of addicts to their home cantons, and the establishment of decentralized low-threshold and other services, the open drug scene was radically diminished.

The Zurich park and other open drug scenes were major factors in the development of new drug policies and contributed to an increase in a variety of prevention, treatment and harm reduction initiatives. In order to avoid the mistakes of Needle Park, the Swiss government agreed in 1992 to take over some responsibility for drug problems - a responsibility that until then had largely rested with the cities.

Needle Park and other open drug scenes also contributed to public and media discussion of alternative drug policies and to the development of two radically different proposals that were ultimately rejected in national referenda. The first, called "Youth Without Drugs", placed more emphasis on attempts to deter drug use, the elimination of any distinction between "soft" and "hard" drugs, and the closure of drug substitution and low-threshold programs. The second proposal was for the legalization of all drugs and the creation of a state-controlled drug monopoly. Neither proposal received widespread support.

More recently cocaine use has increased in some parts of Switzerland and some of those who were prescribed heroin continued to use cocaine at least at the time of the Swiss trials. Key informants considered that cocaine use poses special challenges and one saw cocaine use as an unsolved problem.

Trends in the rates of HIV and other infections among injection drug users

Relatively high rates of HIV/AIDS (over 30%) were found in some samples of intravenous drugs users tested during the 1980s. These high rates were a major factor in the development of harm reduction initiatives in Switzerland and the expansion and liberalization of methadone prescription. Rates of HIV/AIDS have been much lower in recent years (8-16%), although still higher than those in recent samples of injection drug users in the UK.

High rates of hepatitis C were found in samples of intravenous drug users tested in the 1980s (up to 90.6%) but these were also much lower in more recent samples (see table 4).

No specific objectives or priorities specific to hepatitis C are noted in a recent review of FOPH plans for 1998-2002 (Gervasoni et al., 2000).

Attitudes of service providers

Many providers of more traditional, abstinence-oriented programs have been concerned that the expansion of methadone services, the prescription of heroin and the emphasis on harm reduction undermine addicts' motivation to seek help from these programs. There is some evidence that this has occurred particularly with respect to abstinence-based residential programs. Traditional programs have therefore become more flexible and have been willing to adapt to accept clients stabilized on methadone. Others have become more specialized in treating people with specific problems such as dual diagnoses.

The availability of general health and social services

Switzerland has highly developed health and social service systems that have supported efforts to integrate and rehabilitate injection drug users who continue to use illegal drugs, as well as those who are on methadone, legally prescribed heroin and those who become abstinent. Since 1991, the federal government has also supported a variety of projects designed to connect injection drug users with health and social services. These include low-threshold lodging and day care projects for drug users, projects to ensure integration in the workplace, street work and counselling projects, sick bays for drug users and the homeless, assistance for female sex workers, and fostering of self-help among drug users.

Attitudes of police

Police have generally been very supportive of low-threshold methadone and other harm reduction initiatives and have cooperated with health and social service providers in the implementation of the four-pillar policy. However, a key informant study conducted as part of the evaluation of the FOPH plans for 1998-2002 noted the following obstacles to cooperation between the police and health and social services:

• police have been made to feel insecure in their role due to general social changes;
• development of drug policy is ahead of that of legislation. Several of those interviewed pointed out that the implementation of the legal provisions is difficult, and a revision of the narcotics law is seen as urgently necessary;
• differences between cities and rural regions. The police often have dual functions in rural areas as both representatives of the law and as "social workers". For a clear division of roles, the necessary social and health infrastructure needs to be available, but this is often not the case in rural areas;
• lack of a round-the-clock social services;
• limited scope for exchanges of information due to official secrecy, privacy laws and data protection laws that inhibit the flow of information between the police and health and social services.

The same report cited the following as beneficial to collaboration:

• Continuing education,
• Leadership training,
• Pilot-projects,
• Selection of staff who are open to the constant rethinking required in the drugs field,
• Regular and transparent information (via in-house journals, staff publications, etc.),
• Attention to the needs and views of front-line staff.

Police are seen as contributing to prevention, treatment and harm reduction in many ways, including:

• Dealing with organized crime
• Arrests of drug dealers
• Disruption of the open drug scene
• Referring addicts for treatment
• Supporting injection sites and needle exchange programs
• Involvement in public education, professional education and education in schools.

User groups

Self-help among injection drug users is encouraged under the confederation's four-pillar drug policy. However, it is not clear this occurs. No key informant spontaneously mentioned user groups and one said that there are a few user groups, but that they are not as organized or influential as in the Netherlands.

Europe

Switzerland is not part of the European Union, but is involved in multi-national efforts to prevent drug trafficking. However, it is not clear if or how Swiss policies with respect to treatment and harm reduction have been shaped by the considerations of the EU or its member states. A made-in-Switzerland tone is evident in written accounts of Swiss policy and some key informants for this and other studies of Swiss drug policy were proud of Switzerland's independent and innovative approach.

Those involved in Swiss drug policy development and evaluation have encouraged other countries to learn from its experiences. To this end, the FOPH supports a multi-language Web site on drug policy and has produced several reports in English, French and German versions. In 1999, the Federal Office of Public Health also sponsored an international conference focused on the heroin trials and this was attended by participants and observers from other European countries and elsewhere.

Research and evaluation

Documents on Swiss drug policies and statements by key informants indicate that these policies have been informed by the results of various types of research and evaluation, including (1) studies and informed critiques of law and order approaches to drug problems, (2) empirically-based projections of the consequences of the unchecked spread of HIV/AIDS among injection drug users, and (3) evidence for the effectiveness of methadone maintenance.

Reports of the benefits of heroin prescription based on practices in Liverpool (MacGregor and Smith, 1998) also had a strong influence over the establishment of the Swiss heroin trials or the PROVE project (Klingemann, 1998). A literature review prepared by Dr. Annie Mino (Mino, 1997), which concluded that there was a need for further study regarding controlled distribution of narcotics, convinced the Swiss Council of Ministers to develop and circulate a proposal outlining possible amendments to medical prescription practice to include narcotics. The response from the community was positive and led to the establishment of the PROVE projects.

Research and evaluation feature prominently in all statements about Swiss drug policy and especially those from the Federal Office of Public Health (FOPH). FOPH supports monitoring, research and evaluation and has also commission two independent evaluations of its own work in the area of drug abuse (see above).

Research on the prescription of morphine and heroin-impregnated cigarettes led to the abandonment of these practices. The evaluation of the heroin prescription trials has clearly informed subsequent decisions to make heroin prescription an option in the medical treatment of heroin addiction. However, the widely recognized need for further research on heroin prescription has resulted in further Swiss research on this topic.

Nonetheless, Swiss studies provide substantial support for the wisdom of current approaches. Thus, in the last few years:

• the incidence of HIV and hepatitis infections has been noticeably reduced,
• mortality from overdose has been noticeably reduced,
• the open drug scenes have been eliminated,
• the crime rate connected with obtaining drugs has been substantially reduced, and
• the number of drug addicts in treatment has almost doubled.

Public opinion and the media

The drug problem has regularly sparked controversy in Switzerland. During the early 1990s, the open drug scene was a major concern to the Swiss population and headline news on many occasions. Public pressure to do something about drugs was clearly influential to the development of new drug policies.

As noted above, there have been several referenda on drug policy issues, and in 1997 there was a referendum that called for a strict, abstinence-oriented drug policy and the closing down of the heroin prescription clinics. This was rejected by 71% of voters (41% turnout) and this was seen as evidence for wide public support for the government's pragmatic four-pillar approach. Public support is likely to have been influenced by the obvious effects of new policies on the open drug scene and by favourable media reports of the results of the evaluation of the narcotic prescription trials. These reports did not apparently pay much attention to criticisms of the evaluation by the WHO expert committee (Gervasoni, 2000).

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