Assisted Treatment for Opiate Addicts – The Swiss Experience
heroin epidemic, starting in the early 70ties, led to an estimated number of
30‘000-40'000 addicts. This elevated prevalence is in line with a high
addiction liability in our population also for alcohol, tobacco and prescription
therapeutic response to the drug epidemic was at first initiated by NGO’s,
setting up Therapeutic Communities of the day-top model. Later on, state-run
clinics and advisory centers were implemented, since 1975 offering Methadon
maintenance treatment. Following the AIDS epidemic (gain with high prevalence
rates), risk reduction measures were accepted and introduced : syringe exchange
schemes, injection rooms, and low threshold day programs. Convicted addicts were
referred from the Criminal Justice System to the Therapeutic System (residential
and out-patient) in increasing numbers.
spite of a good availability of therapeutic options, treatment refractory
addicts were identified in the open drug scenes, responsible for an essential
part of nuisance and drug-related delinquency. The Amsterdam study on injectable
Morphine and the renewed British practice with injectable Diamorphine (Heroin)
encouraged Swiss authorities and experts to prepare a national study with Heroin
assisted treatment to those not responding to the existing treatment system.
and design of the experimental project (1994-1996)
main objectives of Heroin-assisted Treatment (HAT) were :
recruit addicts into HAT who were not effectively reached by other treatment
prevent premature dropping-out of HAT
reduce illegal / non prescribed substance use by HAT patients
improve health status and social integration of HAT patients (especially to
compare the effects of injectable Heroin (Diamorphine), Methadone and Morphine
facilitate transfer of HAT patients to regular treatment programs.
order to determine outcome, the main study was designed as a longitudinal
prospective study (cohort study), complemented by randomized and double blind
sub studies comparing injectable Heroin, Methadone and Morphine. Entry criteria
concerned minimal age of 18, documented dependence duration of minimal 2 years,
documented health and/or social deficits and at least 2 previous treatments that
failed. Also, compliance with the diagnostic, therapeutic and research program
of information were face-to-face interviews by independent interviewers,
observations by clinic staff, and case histories of former treatments,
laboratory findings and police data. The research protocols, instruments and
reports were made by an independent research team, guided by a national expert
committee and evaluated by an international expert committee nominated by WHO.
results of the cohort study
extensive summary of the experimental project was published as a book
(Uchtenhagen et al : Prescription of narcotics to heroin addicts. Karger Basel
establishing Heroin clinics in 14 cities with mixed national/local funding, with
adequate staff and with a high degree of acceptance by authorities and the
population could be assured.
the safety of patients and staff could
be evidenced (no fatal overdose from prescribed substances, no thefts or
deviation to the illegal market, few cases of violent behavior).
consumption of illegal / non-prescribed
substances was reduced significantly (especially the daily use of Heroin and
Cocaine, to a lesser degree the regular use of Benzodiazepines, no significant
reduction of Cannabis use).
was significantly improved. Especially a reduction of depressive episodes
and suicidal ideation, of epileptic attacks, of paranoid episodes was
registered. Also, general physical health and nutritional health improved.
social integration, it may be
mentioned that homelessness was significantly reduced, while reintegration into
the regular labor market proved to be more difficult. Most spectacular was the
reduction of criminal activities according to self-report and police data.
in treatment was
superior to what is observed in other forms of treatment. 60% of discharged
patients could be transferred to a regular treatment program (about half of
those to drug-free programs).
cost-benefit analysis showed
a considerable reduction in costs for medical care and law enforcement; the
benefits per day and patient amount to the double of the daily treatment costs
Main results of the
randomized and double-blind sub studies
comparison of injectable Diamorphine with injectable Methadone and Morphine came
to the following results :
patients into the Diamorphine groups was superior. The groups for Methadone and
Morphine did not reach the expected numbers, as many patients left after
randomization before starting treatment.
was superior in the Diamorphine groups. This was evidenced in the randomized and
in the double-blind studies. High dropout rates in the Methadone and Morphine
groups were mainly due to the extent and severeness of side effects.
the program, as measured by the extent of using illegal heroin and cocaine, was
superior in the Diamorphine groups.
Diamorphine was found to be more acceptable and effective in terms of retention
and compliance than I.V. Methadone and Morphine. Patients doing well on
Methadone and Morphine were allowed to continue this medication; no new patients
however were offered this approach.
first systematic follow-up study, covering a period of 18 months since entry,
was made in 1997. It included 237 patients who entered HAT from 1.1.94 to
31.3.1995. It was published recently (Rehm et al : Feasibility, safety and
efficacy of injectable heroin prescription for refractory opioid addicts : a
follow-up study. The Lancet 158:1417-1420).
study documented highly significant reductions in somatic and psychiatric
problems (during the first 6 months of treatment already, and being stable over
the entire follow-up period). Improvements in the housing and employment
situation, also significant, took more time to occur. Contacts to the illegal
drug scene and living from illegal income were equally reduced (also during the
first 6 months stabilized since). The reduction not only in daily illegal Heroin
use, but also in Cocaine use was highly significant already in the first 6
months after entering treatment. 60% of discharged patients entered a regular
drug-free Ur Methadone program.
analysis showed that improvements in discharged patients were related to time in
treatment. Those who entered a regular program at discharge showed better
results than those who did not. Improvements showed to deterioration with
increasing length of follow-up observation time.
2000, a second systematic follow-up study was made (Güttinger, Gschwend et al,
in press). It included the same patient sample (n=244) and covered a period of 6
years. At that time, 46% of patients still were in treatment. 48% of discharged
patients had entered a regular program. A comparison of those still in treatment
with those who were discharged showed :
highly significant reduction in illegal heroin, cocaine and Benzodiazepine use
in both groups
reduction in Cannabis use in both groups
significant reduction of homelessness in both groups
reduction in unemployment in both groups
highly significant reduction in living from illegal income and in new court
rate of patients who proceeded from HSAT to drug-free treatment programs,
increased during the first year of treatment and slightly decreased since.
Overall, there is no evidence of a general chronification of patients receiving
addicts for whom other treatment approaches had failed, can be recruited und
retained in HAT. Their health status and social integration can be significantly
improved. Improvements are mainly stable, also in discharged patients. Side
effects of prescribed diamorphine are comparatively few and manageable. No fatal
overdose of prescribed substances occurred up to now. About half of discharged
patients agreed to enter regular treatment programs.
results are conditioned to restrictive entry criteria, to strict rules for
running the authorized clinics and to a close monitoring of treatments by
research. Those conditions therefore have been kept when establishing HAT as a
regular treatment option by a Federal Decree. Diamorphine is registered as a
medication for maintenance in heroin addicts.