Drug Treatment in Switzerland: Harm Reduction, Decentralization and Community Response

Abstract

This paper first outlines the history of illicit drug issues in Switzerland, and then describes drug treatment services and shifts in treatment concepts. In the last 15 years the drug treatment system in Switzerland has expanded considerably. In particular there has been an unprecedented growth of the non-residential sector and of low-threshold programmes, including methadone treatment, the establishment of injection rooms and controlled drug-prescription pilot projects. In the second part, the paper considers some selected factors that promote or impede changes in drug treatment systems, such as treatment policy and the public response to treatment measures. This is manifested in the influence of community action groups on local programme development.

Changing legislation, illicit-drug-related problem rates over time, varying patterns of funding of drug treatment services and the effectiveness of drug treatment programmes are often considered the most important agents of change in drug treatment systems. However, as experience with alcohol shows, socio-political forces are even more powerful, although often underestimated, determinants of treatment forms (Klingemann et al., 1992). This may apply even more to illicit drug use than to alcohol, since illicit drug use is a highly political and emotive issue in Switzerland and elsewhere.

The dynamics of drug treatment systems therefore cannot be properly interpreted without a consideration of the public perception of drug problems and of local and national drug politics. After a short historical and epidemiological review of drug issues in Switzerland, this paper discusses the consequences of a policy of decentralizing the treatment of drug users, and the influence of community action groups on local programme development.

Illicit Drug Use and Related Problems in Switzerland --
     From the Hippie Generation to the Platzspitz "Needle Park"

In the history of the use of illicit drugs in Switzerland there are a few landmarks, which to some extent continue to influence discussion and fuel controversy about treatment. Although the first legislation on the use of illicit drugs dates back to 1924, they did not become an issue until the "wild 1960s" and the hippie movement, as in many other countries. In 1969, 500 notified users of cannabis were recorded, but very few of opiates. The first illicit-drug-related death occurred in the city of Zurich only in 1972; a very few cocaine cases appeared first in 1974. The second revision of the national illicit-drug laws took place in 1975, and the following years saw a steady rise in the number of notified drug users and of drug traffickers, due to mounting repression by the police.

The early 1980s were marked by the Zurich youth revolution, triggered by a public vote on subsidies for the Zurich opera house and subsequent campaigns for an alternative cultural scene, the autonomous youth centre and expressions of student solidarity with marginal groups, including drug users. Political conservatives tend to attribute developments during the following years mainly to those "youth riots", which they claim opened the gates to misguided tolerance and a policy of raise faire (e.g. SVP- Drogenkonzept, 1993). In the early 1980s the drug scene was infiltrated by the international drug mafia, and after the spread of the open drug scene throughout the city of Zurich it finally settled in 1986 at the Platzspitz "needle park", which was to become notorious world-wide. It was estimated then that there were 3000 heroin users in the Zurich region alone. In the open drug scene the conditions of the drug users deteriorated rapidly, the mortality rate tripling within 5 years (Fig. 1). 1986 was a turning-point in drug policy and in the prevention and treatment of drug use.

Especially under the threat of AIDS, drug policy shifted first to a harm-reduction approach, including a certain tolerance of open drug scenes. Then, in the spring of 1992, under public pressure, this tolerance became exhausted and the police closed the Zurich Platzspitz (for a more detailed discussion see Grob, 1993) and the Bern Kocherpark. Decentralization of treatment and coercion became the order of the day.

Police activities increased considerably from 1990 to 1994 as a result of this new, tough approach (Fig. 2). However, the attempt to eliminate the concentrated drug scene failed; it moved to the Letten site, a closed-down train station, and soon became a core group of 250-300 heavy users and up to 2500 'passing clients', much as at the Platzspitz. Under the pressure of increasing violence, gang wars and public protest, communal and cantonal representatives met with the federal goverrunent in August 1994. With the support of a national programme organization, a three-stage plan for closing down the Letten site--avoiding the mistakes made with the Platzspitz--was presented by the end of the year and put into effect in early 1995, with a stepping-up of raids on dealers by the municipal and cantonal police. These general developments also set the scene for major changes in the treatment system.

Drug Treatment Programmes --
      Service Categories, Treatment Concepts and Modalities

III. a. Non-residential programmes
III. b. Residential programmes
III. c. Prescription programmes --Background and first experiences, 1992-93

As a consequence of cantonal rather than federal authority in many health matters, Switzerland has no truly national system of recording or reporting on drug treatment. Cantonal surveys--or rather, 'informed expert reports'-- conducted first in 1978, and organized by the Federal Office of Public Health, are the most cited source. Table 1, based on the cantonal drug reports of 1978 and 1991 and on the survey of cantonal experts in 1993, gives an overview of the drug treatment services.

Owing to varying response rates and other survey flaws, the numbers of services and clients must be interpreted with caution. However, the numbers of various service categories and differential net growth rates (new openings minus reported closures) have changed significantly over time and can be valid indicators of changing principles and goals of treatment.

III. a. Non-residential programmes

The general trend has been a strong expansion of the non-residential sector. "Drop-ins" and counselling facilities more than doubled between 1978 and 1988 and continued to increase. The 1993 cantonal survey counted 22 new facilities in 1990-92 and, although not all for drug users only, the increase reflected the rising trend. Regrettably, the 1991 report, for 1985-88, did not distinguish between drug-counselling and more diversified social-medical services.

The most notable change has been the increase in low-threshold harm-reduction programmes, particularly in the later 1980s, by 38 between 1978 and 1988 and continuing. The 1993 cantonal survey found a net increase of I I during 1990-92 (Table 1). As the Platzspitz needle park got under way in 1986, and the incidence of AIDS rose, the medical and social conditions of the drug users deteriorated and called for new measures. Treatment had long been based on a time- consuming selection of motivated patients moving from outpatient to mpatient and follow-up services (all with certain conditions for admission and often long waiting-lists), geared ultimately to abstinence. This pattern proved inadequate when drug users were dying in the streets and in need of immediate help, and less inclined to seek treatment, because of the spread of HIV infection (Alvo et al., 1991). Paradoxically, the high visibility and local concentration of the open drug scene, mainly in Bem and Zijrich, resulted in a range of "aid for survival", low-threshold programmes, publicly funded and reaching out to the hea7 users of the open drug scene, who were n yet ready to seek treatment. These programmes imposed no preconditions, such as a period of abstinence, and focused on harm reductio The 1993 cantonal survey confirmed this sh in approach; only 30% of services requir( prior detoxification or commitment to absi nence. However, as costs rose and drug users' home communities were often disinclined to pay for treatment, certain controls, mainly the restriction of services to local drug-users, were applied (Table 2).

More specifically, low-threshold services include shelter, primary medical care, meals, work and needle-exchange facilities, methadone maintenance services for special needs (e.g. 'the lila bus' for 'female sex workers') and-highly controversial-so-called "street rooms" (Gassenzimmer, fixer-cafeteria) where intravenous heroin use under hygienic conditions is tolerated and drug dealing is forbidden.

An example is the Anlaufstelle/Drop-in at Winterthur (canton Zurich), a low-threshold facility but, for political reasons, without a special room for drug use. It is open daily for 6 hours. Meals are taken in a cafeteria-type room; soup, tea, bread and mineral water are free and other meals are cheap. Showers, toilets and laundromats are available. Medical care includes the exchange of syringes and the supply of disinfectant cotton swabs. Drugs are forbidden but an intention to abstain or to accept treatment is not a precondition.

Another example is ZIPP-AIDS, the country's most ambitious needle-exchange programme, launched in Zurich in 1988. It showed impressively how pursuit of abstinence, and even drug use as such, had become secondary issues to the threat of HIV infection and its spread to the 'normal' heterosexual and alcohol-consuming population.

As well as the exchange of syringes and needles, it supplied hygienic cotton swabs and vein creams, condoms, tea and fruit; it provided primary medical care, hepatitis-B vaccination and information on treatment options, as well as instruction in safe sex, hygiene and health behaviour (Hornung et al., 1992). The needle exchange rate (new syringes for old) remained at about 92% during the programme (Hornung et al., 1992). The ZIPP-AIDS services were taken over by municipal services in December 1991.

Thirdly, methadone prescription and maintenance programmes began during the late 1970s; their numbers increased steadily, and almost tripled between 1986 and 1990. They reflected policy cycles from a rather liberal to a restrictive and again a more liberal attitude of legislators and policy makers. Before the revision of the Narcotics Act in 1975, all physicians could prescribe methadone. However, increasing use of heroin induced the legislators to restrict this liberal practice. The cantons were entitled to apply supplementary regulations. Again, the HIV epidemic induced a change. Attempts were made to facilitate the access to methadone programmes and also to use methadone to promote social integration and earlier treatment, even without the prospect of abstinence.

An interesting example of a low-threshold methadone distribution programme is a pilot project in the city of Zurich begun in March 1992--on the closing of the Platzspitz--by ARUD (Association for Reducing the Risk of Drug Use), a private association. This facility (ZOKL1) offers a computerized distribution programme of several stages which the client can attain while maintaining a high degree of responsibility and initiative. Clients receive a personal magnetic card, like a credit card, choose the methadone dosage within a permitted range (controlled by the computerized system) and draw it into a cup. The system keeps individual records of daily dosages. If a stable dosage is documented over some time, misuse such as methadone trafficking and risk of overdose can be reasonably excluded. The client is then admitted to the next stage and is supplied with methadone for a longer period or for weekends or holidays. Under the conditions of regular urine tests, medical supervision and stable consumption patterns, restrictions are gradually lifted. In its first year it handled 800 clients, of whom 450 stayed on, and many entered high-threshold programmes. Thus, it seems that the aim of retaining as many patients as possible in the programme and offering options and incentives to pursue treatment is being achieved (ARUD, 1993).

III. b. Residential programmes

The 'boom' in non-residential treatment facilities, particularly in low-threshold programmes, was at first accompanied by rising insecurity among those who provided 'classic' inpatient treatment. The use of inpatient facilities in the canton of Zurich dropped by 17% from 1985 to 1986, and plans for a second inpatient clinic were cancelled. A survey in 1989 by the organization of professional drug workers (Verein Schweizerischer Drogenfachleute) of 22 therapeutic communities (254 beds) and residential treatment centres in the germanophone area showed a decrease of 8.2% of clients from 1986 (Kurz, 1990). Client profiles also changed: there were 22% fewer HIV- positive patients in 1989 than in 1986 (Kurz, 1990).

However, specific types of residential facilities showed a different trend: in the canton of Zurich the number of drug users who sought inpatient psychiatric treatment increased by 27% between 1985 and 1991, and those in long-term care facilities by 67%. These increases were due mainly to the opening of several new facilities between 1989 and 1991 (Direktion des Gesundheitswesens des Kantons Zurich, 1992). A national survey (May 1993) of 131 inpatient institutions confirmed these cantonal trends. In particular, the capacity of detoxification programmes expanded by about 67% between 1988 and 1993, and in 1994 a quarter of the drug rehabilitation programmes had been founded during only the previous 5 years and had a high occupation rate (Muhle, 1994).

Even more remarkable were changes in the behaviour and provenance of drug-users seeking treatment. A study comparing samples of patients of three centres in 1978 and 1991 showed that drug users were seeking residential treatment earlier (no change in age of first use, however), and that the proportions of rural as well as foreign patients had increased (Dobler-Mikola & Zimmer Hofler, 1993). The patient intake was therefore much more heterogeneous, and special needs required costly organizational and programme adaptations. In particular, there was, and is, a lack of programmes for ethnic groups, HIV-positive people, women and juveniles (under age 20 years); also there are regional disparities in the treatment supply and insufficient cooperation between treatment centres in different cantons (Muhle, 1994; Obrist, 1993).

Reluctance of treatment institutions to adapt to changing needs of drug users is probably due to funding problems, to difficulties in estimating the demand of specific groups, and especially to the professional orientation of treatment personnel, which influences the intake of clients.

However, there are early signs of a growing differentiation. For example, for 1995/96 the canton Zurich plans a detoxification/triage centre (15 beds) for very young drug users, aged 13-18 years, as an addition to a psychiatric clinic. Also expected are a drop-in for drug users aged 13-16 years as part of the halfway home, Riesbach, and two new training schools/youth homes with 15 beds each for girls and boys, in 1996; and there are funds for a therapeutic community (28 beds) at Richterswil for the tame young age group. These plans are due partly to shifts to new drug-use patterns, such as the increasing proportion of young users who inhale ('chasing the dragon') heroin (1993: 60% i.v., 19% inhaling, 14% sniffing, 7% smoking heroin; Rehm, 1995).

In 1993, for about 25,000 drug users, there was a capacity of approximately 5,000 detoxifications and 1,300 beds for resident therapy (Muhle & Hutter, 1993); see also Ulrich (1994).

III. c. Prescription programmes --
Background and first experiences, 1992-93

In 1992 the Swiss Government passed a package of measures to make Swiss drug policy more effective-that is, to reduce drug-related harm and the number of users by 20% within 5 years. This intensified discussion on medically supervised heroin prescription programmes. The most affected cities, such as ZZufich and Bem, had favoured such programmes and the Zurich city council had adopted a political motion for diversified, controlled drug prescription programmes. Growing support also came from most political parties, and from treatment professionals and researchers, partly influenced by the results of such programmes in the English Merseyside region (Strang & Gossop, 1994; Fazey, 1987). Strictly opposed were most of the francophone cantons and right- wing parties. In response to this opposition the government made a landmark decision in May 1992, authorizing pilot prescription programmes with a small numher (250) of chronic drug users, to be conducted and scientifically evaluated until 1996. Proposals were to be submitted to the Federal Office of Public Health by May 1993. The Office, meanwhile, had also laid down the implementing provisions/regulations for the project organizers: voluntary participation of the drug users, minimum age 20 years, at least one consultation a week with a counsellor and one a month with the physician in charge of the project, and except for methadone the injection of the prescribed drug under supervision (see also Uchtenhagen, 1994)In the following months discussions took place about specific drugs and the number of subjects. At first only morphine and not heroin was to be prescribed, and for a very few subjects. After a controversial debate the government compromised, offering those in favour of large programmes at least extended pilot projects, with up to 700 subjects. This decision was backed by survey results from 1991 showing 60% of the population in favour of drug prescription under medical supervision (SFA, 1993).

Drugs, Politics and Treatment --
      Factors Influencing the Development of the Drug Treatment System

IV. a. The dynamics of drug-related problem rates
IV. b. Decentralization and cooperation --Shifting the burden
IV. c. The public perception of drug problems-community response
IV. d. Drug politics at the national level

IV. a. The dynamics of drug-related problem rates

Is the expansion of the drug treatment system simply a function of rising prevalence of drug-related problems? The introduction of low-threshold programmes is often ascribed largely to the spread of AIDS among drug users and the deterioration of their living conditions in the open drug scenes. Switzerland has one of the highest incidence rates of AIDS in Europe, and there has been a substantial increase in AIDS cases among intravenous drug users since 1987. Some improvement has resulted from preventive measures, needle-exchange programmes, injection rooms and other low-threshold services. These first evaluation results legitimize future harm-reduction programmes, and the prevention of HIV infection is likely to continue to influence strongly treatment and prevention policies.

An alleged rise in drug-related crime (e.g. burglary, petty theft) is often used by political parties and other interest groups to call for harsher measures in general, and compulsory treatment and special prison units in particular, while condemning 'leftist, naive laissez-faire attitudes'. A campaign poster used by the conservative Swiss People's Party for the elections in the canton of Zurich (Schweizerische Volkspartei SM became a prominent case and even provoked a governmental reaction (Fig. 3).

However, the national crime statistics do not support this rationale. In 1991, for example, the percentage of drug users among solved cases of burglary and robbery was high (44%-56%), but this reflected only relative ease of arrest by the police. The percentage of cases of drug-related crime coming to the attention of the police dropped from 20% of all crimes in 1990 to 7% in 1994; also the number of drug-related crimes fell by 22% from 1993 to 1994. However, while these statistics belie the problem amplification which results partly from the extensive press coverage of drug-related violence and crime (Widmer & Zbinden Zingg, 1993), a different picture may result from the local concentration and visibility of crime assumed to be drug-related. According to Eisner (1994), such offences as street crime and purse-snatching increased dramatically after 1986 in Zurich neighbourhoods close to open drug scenes, and many residents moved to other areas.

Foreigners dominate the drug trade (87.8% in 1994) and constitute a relatively high proportion of all drug offenders (1994: 36%). Consequently the proportion of foreigners in the treatment system has also risen, posing special organizational problems. Policy makers and the public increasingly denounce the role of foreigners in organized crime and in the open drug scenes. Politicians have connected this problem with the controversial issue of asylum seekers in Switzerland some of whom, under cover of the immigration laws, deal in drugs while officially awaiting the decision of the immigration authorities. Although relatively very few asylum seekers abuse their refugee status, spectacular cases are mentioned in the press and political parties demand stricter control measures.

However, the most conspicuous 'leading indicator', much reported in the media, is the continuous increase in drug-related deaths from 1985 to 1992 despite all new policy measures (see Fig. 1). Multiple drug use, overdoses of new drugs and suicides of HIV-infected drug users are only a few of the explanations advanced (Bundesamt fiir Gesundheitswesen, 1990). In 1993 the number of drug-related deaths fell for the first time, from 419 to 353, but rose again to 399 in 1994. Also, the drug-related mortality rate of 6/100000 population (1992) is much higher than in the neighbouring countries and this impresses policy makers and public opinion. The political will to introduce changes in the treatment field, such as heroin prescription programmes, is one example. Another effect could be the polarization of public opinion into advocacy of a much stricter policy on drugs and advocacy of total legalization.

Longitudinal data are available from the national surveys of Health Behaviour of School Children carried out in 1986 and 1994, for ages 15 and 16; this is a reference period which basically covers the period between the opening and the closing of the open drug scene in Zurich. These data show an increase in the use of cannabis and stimulants/amphetamines but little use of hard drugs. Thus, even in a time of objectively and subjectively increased access to drugs, the overwhelming majority, of these young people remained resistant to them (see also Le Gauffey et al., 1995).

This overview has shown that the impact of changes in objective problem rates on societal response-the offer of cure, care or controlvaries greatly and depends on public perception of these issues and their political amplification. The following sections, on the new decentralization policy of the city of Zurich and community action groups, illustrate this general point.

IV. b. Decentralization and cooperation --
Shifting the burden

The regional distribution of treatment services and the structure of the treatment system, with its client referral patterns, is a major policy issue. Already in 1991 the Zurich city authorities had declared that "decentralization is the central question" and that the canton of Zurich and other regions in Switzerland should accept more responsibility, given the low proportion of Zurich city residents among the drug users in the open drug scene.

The 'soft phase of decentralization' was undertaken on the eve of the closing of the Platzspitz. After a hearing in 1991, 80% of the communities in the canton had agreed to provide day centres, work programmes and special housing for drug users. Although this agreement yielded positive results at first, progress was too slow for the rapid changes in the city, partly because of community objections and difficulties in finding willing neighbourhoods. The authorities were under strong political pressure and their failure to secure their stated objective of preventing a new open drug scene after the closing of the Platzspitz in 1992 was becoming evident. A new open drug scene, said to be worse than Platzspitz, gradually became established at Letten, a closed-down train station. In this difficult situation the city intensified decentralization efforts. From August 1993, access to the six low-threshold services, including three injection rooms, was restricted to drug users who were citizens of Zurich, a measure enforced against the opposition of social workers and a minority faction of the governing 'green/red' coalition. In an effort to press the other communities and cantons to show solidarity with the city over its problems Zurich, together with the cantonal authorities, also proposed a centre where drug users could be compulsorily detained and then returned to their home communities. In June 1992 an attempt had been made with the establishment of an office of the municipal police charged with the task of expelling drug users who were not Zurich citizens, but with little success. Now a much more extensive effort was undertaken. The city granted the equivalent of about US$300 000 for a detention centre, which would arrange the transfer of drug users to their home communities. A former building of the Zurich University Hospital was quickly transformed, with a capacity of 100 beds for drug users to be detained from 24 to 48 hours before being transferred home. This detention centre was declared to be the cornerstone of the new joint communal/cantonal approach to eliminating the open drug scene. It was closed in April 1994, to be reopened in different premises in August 1994, in accordance with a joint concept and flmding scheme of the city and the canton of Zurich as well as six other cantons. This was an important symbolic step, showing growing solidarity with Zurich and its open drug scene. It was at first strongly resisted by treatment professionals, who opposed its coercive nature, and many communities were reluctant to take their addicts back'. However, an evaluation in October 1994 showed that 60% of all cases detained since the opening of the centre in August 1994 had been transferred to their home communities within 24 hours, an increase of 10% over the rate achieved by the earlier, provisional centre (Klingemann, 1995). Not surprisingly, these measures had no immediate effect on the highly visible open drug scene, the Letten needle-park, and its effects on the neighbourhood became more and more a political issue. With an eye on the cantonal elections of spring 1995, the city council took up the matter of closing the park. By the summer of 1994 it had deteriorated greatly and immediate action became necessary. Determined to avoid the mistakes made in the closing of Platzspitz, the federal, cantonal and municipal authorities adopted a joint strategy for the first time.

The decentralization of treatment as well as aid for survival was stepped up considerably and finally reached a take-off phase. In December 1994 the canton had reserved funds to help the communes provide treatment facilities, and promised to pay a third of the cost of drop-ins and similar facilities. New drop-ins or half-way homes were also opened by private, religiously orientated, organizations. There are also new efforts to establish 'social district networks'/ 'social holdings' to provide an organizational umbrella for various kinds of social assistance, including help for drug users, which so far is not part of the legal arrangement and financing scheme of the district communes.

Related to the decentralization of treatment programmes, and most notable, is the considerable extension of heroin prescription programmes after the Letten closing. In 1995 the federal goverrunent approved an extension of up to 800 places for chronic heroin users. This also includes new programmes in prisons and hospitals as well as fewer intravenous methadone and morphine trials.

IV. c. The public perception of drug problems-community response

Treatment policies such as decentralization or diversification and the successful introduction of harm-reduction measures or low-threshold programmes depend largely on favourable public opinion and the cooperation of local communes and concerned neighbourhoods.

Drug problems rank very high among the most pressing domestic issues, taking second place after unemployment. A representative population survey on the drugs issue conducted in spring 1994 showed-like earlier surveys in 1991-strong support for drug treatment and prevention measures, in particular for injectionroom and controlled prescription programmes (increased from 59% to 73% and 64% to 70%, respectively; Klingemann, 1995). However, these figures can be misleading and conceal significant group-specific/regional differences. Most Francophone cantons, largely unlike the gerinanophone, still firmly oppose any liberal tendencies, a polarization which the above data do not show, but which influences the allocation of services and programmes. Also local community response and opinion eventually influences political-party platforms, community action and the 'cure, care or control' policy mix.

Events in the city of Zurich connected with the closing of the Platzspitz and the Letten needleparks illustrate this more concretely. After the Platzspitz was closed the drug scene moved, despite strict policing and control, to the neighbouring Kreis 5/Industrial district. A strike by schoolchildren, and protests by the local population, who felt threatened by rising crime, and by shopkeepers, who were losing customers, led to even more repression; in June 1992 the canton agreed to send in cantonal police to support the municipal police. Nevertheless, community resistance, organized by a community action group (1), peaked in November 1992 when the group hired private security forces to police the area and to accompany schoolchildren.

As a 'solution', the pressure group proposed 'to keep these miserable and chronic users permanently off our streets', by 'committing them to closed institutions under the provisions for involuntary civil committal' (Fursorgenscher Freiheitsentzug), a demand supported by rioit-wing conservative parties calling for 'closed, useful and simple drug clinics' (2) and the private foundation 'Switzerland without Drugs'.(3) However, the Zurich city council (4) decided to step up efforts to 'drain' the users from the quarter to low-threshold institutions outside the industrial quarter by opening three additional injection rooms instead.

Before the closing of the Letten needle-park, the citizen action group again asserted itself, calling for tough and immediate action against the open drug scene. Well aware of the discontent in the population of Letten (city district 5, with a high percentage of foreign residents) and steady complaints from concerned school-boards in the area, the group confronted the city govemment with an ultimatum in October 1994: unless the authorities closed Letten within 3 months, a prepared plan, 'Drugs out', to close the open drug scene by private initiative would be carried out with the help of doctors, dogs and private detectives. About 4000 group members had already raised sufficient funds (US$180 000) for this plan, which eventually was called off when the city took action. This 'organized community response' and fear of increased self-justice (5) contributed to the political action finally taken. At the same time it augured ill for the future decentralization policy on treatment, a cornerstone of the official action plan. In the event, efforts to step up the diversification of treatment services and to open new programmes in other communities of the canton after the closing of Letten were impeded and delayed by local resistance.

IV. d. Drug politics at the national level

The previous sections have highlighted a number of major political events and 'battle lines' during the last 10 years: liberal vs. restrictive policies in the different language regions; solidarity of the cities and pressure for decentralization- the increasing acceptance of the harm-reduction approach; in 1991 the adoption of a national drug programme and the first national drug conference; in 1992, first attempts to close Zurich's and Bem's open drug scenes; the Federal Govermnent's authorization of heroin prescription pilot projects in June 1993; the first national 'drug summit' in 1994, leading to the Letten action plan, together with the landmark decision to step up the heroin trials; and, finally, both the closing of the scene and the second national drug conference in early 1995.

The future development of the drug treatment system will probably also be affected by political developments associated with legislative changes, international drug politics, national partyplatforms and plebiscitary pressure. Two current popular drug-policy initiatives (ensuring the people's right to propose changes to the Constitution) would change considerably the treatment response if approved by referendum.

Partly as a reaction to the first national drug conference and the public discussion of prescription programmes, the 'Youth without Drugs' initiative was launched in December 1992 by a committee representing mainly right-wing parties and comprising many well-known sportsmen. Its aim was to oblige the government to pursue a drug policy based on abstinence and the strict application of the law. The proposed changes to the Constitution (Article 68) would 4. exclude further controlled prescription experiments and methadone maintenance programmes, end attempts to differentiate between soft and hard drugs, and focus prevention programmes on deterrence only.

The campaign evoked a strong popular echo. In only 6 months (12 months ahead of the official deadline), the initiative had exceeded, by about 40 000 signatures, the minimum legal requirement (100 000). Familiar political patterns were repeated: the francophone cantons contributed about half of the signatures, while the gerrnanophone gave only modest support, mainly from Bem and Zurich. Should the Swiss people vote for the initiative, probably in late 1996, all low-threshold programmes, even free-needle programmes, would end and, at least according to the first draft of the initiative, there would be more federal subsidies for new treatment centres. Thus, an expansion of residential treatment and more closed facilities could be expected, unless funds are not forthcoming, for economic reasons.

'For a reasonable drug policy--tabula rasa with the drug mafia' is another popular initiative, with opposite goals, proposing the legalization of use of all drugs and a state drug monopoly, like the existing alcohol monopoly for spirits. It proposes the addition to the Constitution of a new article, stating that 'the consumption, production, possession and purchase of narcotics for individual use only is not prohibited', complemented by provisions for prevention, product information, age lin- Lits for drug use and advertising restrictions (Art. 32 (new) of the Constitution). The initiative, launched in May 1993 by the Association for the Legalization of Drugs (Droleg), is backed by the Social Democrats and the Green Parry and by numerous health-related organizations, such as the Association of Parents of Drug Dependent Youths. The official text of the initiative contains the controversial sentence, 'Drugs that are used for non-medical purposes need not be prescribed by a doctor', and many anti-prohibitionists believe that this exclusion of medical control will cause the rejection of the initiative in the popular vote.

One consequence for drug treatment of this initiative would be a general strengthening of funding for drug treatment. The legislator decides the tax charges on drugs/narcotics. The Federation and the cantons receive half of the net revenues each. Specific legislation will determine the percentage to be used for drug prevention, research and the reduction of drug-related problems. Short-term goals are the establishment of new injection-rooms and other low-threshold services and there would be controlled distribution of heroin.

Both initiatives have proved extremely controversial. The legalization initiative and its proponents are strongly attacked by the right-wing camp, who condemn any ldnd of drug distribution programme, with such slogans as 'assistance to homicide' and 'experiments with humans' (typical of the 'youth without drugs' camp; Chenaux, 1995).

Both camps cite the experience of other countries--Japan and Sweden, or Britain and the Netherlands--as it suits them. Switzerland as a signatory of the UN Narcotics Convention of 1961 is not absolutely free to import heroin for the trials under way. With the doubling of the number of prescription programmes, the estimated quantity of heroin needed rose from 117 kg to 203 kg for 1995. In March 1995 the International Narcotics Control Board (INCB) approved the additional import of 86 kg heroin, but insisted on no further extension of the distribution scheme and the participation of the World Health Organization in the evaluation of the trials. The Swiss health authorities are aware of the difficulty, and first reflections on the possibility of producing the heroin in the country can be found in the official bulletin of the Federal Office of Public Health (Office federal de la sante publique, 1995). Plans for a treatment system including wide-scale heroin prescription would also provoke intervention by international bodies such as the International Narcotics Control Board, defending the principles underlying the American 'war on drugs'. Proponents of the initiative for a drug-free society 'Youth without drugs'--normally not very internationally minded--have already made use of this ally in the national policy debate.

Discussion

This paper began with a review of the history of drug issues in the country from the hippie generation to the Platzspitz needle-park and the closing of the Letten in 1995. After an outline of the databases available it described drug treaunent services, mainly from the last 10 years. It concludes with a discussion of factors that influence the development of drug treatment systems. Such factors include drugrelated-problem rates, the public perception of drug problems, the elimination of 'pull-effects' of open drug scenes by a policy of decentralization, political ideologies and international political influences.

In 15 years Switzerland's drug treatment system has expanded considerably, particularly as regards non-residential services and lowthreshold programmes; the latter include methadone maintenance with no obligation of treatment, injection rooms and the controlled drug-prescnption trials begun in 1993 and expanded in 1994/1995. Residential treatment, after initial decline, has also grown and is adapting to gender- and age-specific client needs. The harm-reduction approach is widely accepted and permits a variety of treatment forms. What factors bring change in the drug treatment system?

First, variations in drug-related problem rates are associated with changes in treatment policies and services. One effect of the open drug scenes, with the rising incidence of AIDS and steeply rising mortality rates among drug users, was the expansion of non-residential services and consequently better conditions for drug users and less drug-related crime. Thus, the link between changing problem rates and society's response in terms of treatment depends on the public visibility of problems.

Secondly, with the closing of the open drug scenes, decentralization of services became an essential part of policy. It favours regional services, including controlled heroin trials and preventive measures such as needle exchange. Increased communal responsibility is likely to lead to more involuntary treatment, but also to the faster growth of treatment networks in the cantons. Despite the coercive elements of decentralization (forced return of drug users to the it home communes; exclusion from treatment in other communes) it is soundly based on Swiss traditions and beliefs, which emphasize communal responsibility and autonomy.

Thirdly, representative surveys suggest that public perception of drug problems and drug treatment has little influence on policy. Rather, the local concentration and nuisance of open drug scenes and the high absolute level of drug problems strongly determine community response and attitudes to different forms of treatment, even if national statistics point to problem amplification. It is the local community response--not the general 'treatment friendly' climate of public-opinion polls--which, in time, influences politicians and determines community action and the 'cure, care or control' policy mix finally adopted. More specifically, the differential acceptance or rejection of specific drug treatment services, such as heroin clinics, in neighbourhoods is an important intervening factor between policy and practice.

Finally, the current popular initiatives 'Youth without Drugs' and 'For a reasonable drug Policy-- tabula rasa with the drug mafia' may transform the nature of the drug treatment system. The former, a campaign for a 'drug-free society' would stop the low-threshold programmes and expand residential involuntary treatment. The latter initiative, proposing a state drug monopoly, would increase funds for drug treatment and harm reduction. Currently therefore there is much instability but also innovation at all levels. Political changes occur rapidly and drug treatment is not like a closed system within society, subject only to inter- and intra-organizational changes.

It remains to be seen how much national drug policy and the drug treatment system will be influenced by the country's economic condition, the transformation of open into 'hidden' drug scenes, the evaluation of the controlled drug distribution projects under way, the public votes on the opposing popular initiatives in 1996 and 1997, and international organizations such as the International Narcotics Control Board.

Acknowledgements

This research was partially supported by the Swiss Federal Office of Public Health (grant no. 8048). The author would like to thank James Gallagher for his linguistic editorial help and Ren6e Girardet for her critical secretarial support.

Notes

1. Aktion betroffener Anrainer [Action of concerned neighbours) founded in 1991 by a business lawyer, counting 4000 members, mostly business people, and supported by the influential local citizens association of the city quarter no. 5 and its president, a Christian Democrat.
2. More specifically, an initiative in the Zurich city council by the Swiss Care Parry in September 1992 as well as the 'Guidelines for drug clinics' of the SVP (Schweizerische Volkspartie) party can be mentioned.
3. In September 1992 this foundation opened a private rehabilitation centre with 16 beds, strictly abstinenceorientated, and inspired by the much disputed treatment organization 'Le Patriarche'.
4. With a social democratic/left-liberal majority iri contrast to the conservative majority in the cantonal administration.
5. In December 1994, flyers were detected calling for the 'First Federal New Year dealer-hunt', and more and more citizens were armed, started to patrol the streets and 'played sheriff.'

References

Alvo, K., Hornung, R. Tschopp, A., Fuchs, W. & Schaub, N. (1991) Intravenoser Drogenkonsum und Aidspravention. Ergebnisse einer Befragung von 223 Drogenbenutzerlnnen am Zurcher Platzspitz [Intravenous Drug Use and the Prevention of AIDS. Results of a survey among 223 drug users at the Zarich Platzspitz needle-park] (Zurich, Institut fur Sozial- und Prav-entivmedizin der Universitat Zurich).