ZURICH, Switzerland ? The Swiss drug-treatment policy of offering heroin addicts substitution treatment with methadone or buprenorphine led to a decline in the number of new heroin users, according to a study.
ZURICH, Switzerland, June 2 ? The Swiss drug-treatment policy of offering heroin addicts substitution treatment with methadone or buprenorphine has led to fewer new users, according to a study.
The investigators found little merit to allegations that the liberal injectable-drug policy?particularly the use of harm-reduction measures such as low-dose methadone programs, heroin-assisted treatment, and needle-exchange programs?would prove counterproductive, Carlos Nordt, Ph.D., and Rudolf Stohler, M.D., of Psychiatric University Hospital here wrote in the June 3 issue of The Lancet.
According to the policy's critics, the harm-reduction approach risked making users think that illicit drugs bore no ill effects. Such interventions, the critics said, would increase levels of drug use and lengthen the period of heroin addiction.
To assess the incidence, prevalence, and duration of heroin dependence over previous decades and the change in heroin use, the researchers analyzed 13 years of data from more than 7,250 heroin addicts in Zurich. The patients, from 21 institutions and 309 physicians in private practice, enrolled for substitution treatment with methadone or buprenorphine from 1991 to 2002.
The incidence of heroin use, which started with about 80 new users in 1975, increased to 850 in 1990, and declined to 150 in 2002, the researchers reported.
The high incidence in 1990 was similar to the high levels reported in New South Wales, Australia, Italy, and England, Drs. Nordt and Stohler said. On the other hand, they said, in Zurich a decline by a factor of four in the number of new users was observed within a decade.
As intended by the Swiss drug policy, the period of untreated heroin use was short. Whereas every second heroin user entered a substitution program within two years, it took four years in Italy, they said.
Two-thirds of those who left substitution treatment programs re-entered within the next 10 years, the researchers said. They also reported a low quit rate of 4% a year, which resulted in a slow decline in prevalence. The cessation rate could result from factors such as mortality, abstinence, inclusion in a long-lasting heroin-maintenance, or emigration, they said.
The harm-reduction policy of Switzerland and its emphasis on the medicalization of the heroin problem, rather than seeing it as a rebellious act, appears to have contributed to the image of heroin as unattractive for young people, the researchers said. Heroin seems to have become a "loser drug," with its attractiveness fading for young people, they wrote.
Although the study could not confirm whether or not drug policy has a positive effect on the number of new drug users, the data did not show an increase in heroin incidence as predicted by the critics, the researchers said. "Our model could enable the study of incidence trends across different countries and thus urgently needed assessments of the effect of different drug policies," they wrote.
In a commentary in the same Lancet issue, Matthew Hickman, Ph.D., of the University of Bristol in England, and colleagues wrote that "estimating the prevalence and incidence of heroin use is an uncertain business."
Drs. Nordt and Stohler wrote that the rise in heroin use in the Britain and Australia shows the public-health benefits of the open Swiss policy, Dr. Hickman said. This may be true, he commented, but comparisons with other countries are "necessarily speculative."
While refuting the original criticism?that heroin use might increase?the Swiss analysis raises other questions, Dr. Hickman and colleagues said. For example, did public-health policy have any causal influence on the risk of onset of heroin use, or did the estimates refer only to dependent heroin users who entered treatment? Whether the Swiss policy reduced harm at the cost of prolonging the duration of injecting is an "additional intriguing question," they said.
Heroin use is characterized by multiple periods of relapse and recovery, Dr. Hickman said, but as yet there are no longitudinal studies to follow the life-course epidemiology of injecting heroin. Further studies are required, they wrote, which ideally would focus on various aspects of heroin use-starting, duration, and consequences.