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Assessing Drug Problems and Policies in Switzerland, 1998-2007
Peter Reuter
School of Public Policy and Department of Criminology
University of Maryland, USA
With
Domenic Schnoz
Institut für Sucht- und Gesundheitsforschung (ISGF)
Zurich
The study was performed under contract to the Swiss Federal Office of Public Health.
1
Inhalt'
Introduction ......................................................................................................................... 2!
Acknowledgements ............................................................................................................. 4!
Executive Summary ............................................................................................................ 5!
Chapter 1 ........................................................................................................................... 12!
Analytic Framework and Institutional Background ...................................................... 12!
Chapter 2 ........................................................................................................................... 17!
Drug Use in Switzerland ............................................................................................... 17!
Chapter 3 ........................................................................................................................... 31!
The Adverse Consequences of Drug Use and Markets ................................................ 31!
Chapter 4 ........................................................................................................................... 38!
Drug Policy as Implemented ......................................................................................... 38!
Chapter 5 ........................................................................................................................... 62!
Policy Analysis ............................................................................................................. 62!
References ......................................................................................................................... 71!
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Introduction
This study aims to describe how the drug problems of Switzerland have changed
over the period 1998-2007, what policies were implemented during that period and to
assess, to the extent possible, how well those policies have worked in reducing the
nation’s drug problems. Funded by the Swiss Federal Office of Public Health (SFOPH),
it is intended to provide a contribution to the global discussion ten years after the
resolutions passed in 1998 at the United Nations General Assembly Special Session
(UNGASS), as well as to the longer-term discussion of drug policy internationally.
There is likely to be particular interest in a study of Swiss drug policy because
Switzerland has been prominent in harm reduction innovations, including heroin assisted
therapy (HAT) and Safe Consumption Rooms.
The SFOPH has published earlier evaluations of Swiss drug policy (the
ProMedDro series) addressed to Swiss policy makers and focused primarily on health
related policy issues. This report differs in three ways from these earlier assessments.
First, the audience explicitly includes officials and analysts outside of Switzerland; thus it
provides more background on the specific institutions of Swiss policy making. Second, it
aims to be comprehensive and balanced in its coverage of policy domains; as a
consequence it gives considerably more attention to the enforcement of drug laws and
what is known about the population effects of those efforts. Third, it is more explicit in
attempting to put the data in a policy analytic frame, since its value for international
debate in 2009 will be enhanced. It does not make any policy recommendations.
The project began November 1, 2007. It relied entirely on data already collected
and was intended to be a synthesis. Most of the data and analyses were from published
sources but the Swiss federal statistics office, provided special statistical analyses for the
project.
Chapter 1 provides background on two topics. First, it gives a framework for
assessing drug policy, identifying the components of the problem and how various
interventions might affect them. Second, it gives a brief description of the institutions of
3
Swiss drug policy, emphasizing the importance of the federal system, with considerable
autonomy for the cantons and their constituent communes.
Chapter 2 presents the available data on patterns of drug use. It distinguishes
between changes over time in general drug use, mostly marijuana, and that of the
relatively small population of problematic drug users. Chapter 3 then moves from drug
use to drug-related problems, such as disease and crime, and describes how these have
changed over time.
Chapter 4 describes Swiss drug policy and how that has changed over the period.
It emphasizes law enforcement issues. Chapter 5 is then an assessment of the changes in
Switzerland’s drug problems and how the various policies and programs may have
affected those problems.
4
Acknowledgements
This study was dependent on co-operation by many officials and researchers.
We particularly want to thank Isabelle Zoder at the federal Bureau of Statistics
(Bfs) who provided us with a number of special analyses of data related to drug
enforcement. We asked many questions and she was unfailingly gracious in responding
to them.
Other officials who provided data were Caroline Bodenschatz, (Swissmedic).
Susanne Schaaf, (ISGF); , Pia Weber, Roger Flury and Erich Leimlehner, (Federal Office
of Police), Verena Maag and Sandra Wüthrich (FOPH), Marlina Galatti (Federal Office
for Statistics / Bundesamt für Statistik [BfS]), Urs Künzi (FOPH), Roger Keller
(Psychologisches Institut der Universität Zürich, Institute for Psychology, University of
Zurich), Ernst Wüst (Federal Office for Statistics [BfS]), Etienne Maffli, Emanuel
Kuntsche and Gerhard Gmel (Schweizerische Fachstelle für Alkohol und andere
Drogenprobleme [SFA]), Uli Simmel, (infodrog); Léonie Chinet (Service de la santé
publique); Bruno Graf (Statthalter des Bezirks Zürich / Governor City of Zürich) Peter
Schüpach (Leiter der Abteilung für Betäubungsmittelfahndung, Stadtpolizei Zürich) and
Geneviève Ziegler, (Adjointe aux questions toxicomanie, SSL - Ville de Lausanne).
Among researchers who provided advice were: Francoise Dubois-Arber (Institut
universitaire de médecine social et préventive (IUMSP), Lausanne), Martin Killias
(Institute for Criminology, University of Zurich / Kriminologisches Institut der
Universität Zurich), , Jurgen Rehm (Centre for Addiction and Mental Health, University
of Toronto) Hugues Balthasar (Centre Hospitalier Universitaire Vaudois Lausanne), Karl
W. Haltiner, (Swiss Military Academy at the Swiss Federal Institute of Technology
(ETH) Zurich), Hans Wydler (Institut für Sozial- und Präventivmedizin der Univiversität
Zürich / Institute of Social and Preventive Medicine, University of Zürich), Jean-Pierre
Gervasoni (Institut universitaire de médecine social et préventive (IUMSP), Lausanne.
Simone Walser and Sandrine Haymoz (Institute for Criminology, University of Zurich
Kriminologisches Institut der Universität Zürich), Carlos Nordt and Rudi Stohler
(Psychiatrische Universitätsklinik, Zurich).
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Diane Steber Buchli of the Federal Office of Public Health was the project
monitor.
Executive Summary
The year 2009 has been a year for reflection on drug policy, as indicated by the
discussions at the UN Commission on Narcotic Drugs in March. Given that Switzerland
has been a prominent innovator in drug policy internationally, the federal Office of Public
Health commissioned a review of how well the nation was doing in addressing what had
been in the 1990s a major health and social problem. This study describes how the drug
problems of Switzerland have changed over the period 1998-2007, what policies were
implemented during that period and assesses, to the extent possible, how well those
policies have worked in reducing the nation’s drug problems. It draws on existing
statistics and primary research studies but offers a specific analytic framework relating
each type of drug control program (prevention, treatment, harm reduction, enforcement)
to particular parts of the drug problem that it can ameliorate. The study also compares
Switzerland’s problems and policies with those of other Western nations.
Drug Use
Cannabis is the most commonly used illegal drug in Switzerland, as it is in almost
all Western nations. Among those born after about 1980 in Switzerland, use of marijuana
is normative i.e. approximately half of young people experiment with it some time during
their adolescence or young adult life. After a long increase, beginning in the 1980s, the
percentage of adolescents trying the drug has fallen since the middle of this decade;
Figure S1 shows the results of one youth survey. This pattern parallels, though belatedly,
the experience of many other Western European nations. Though the trajectory of
cannabis prevalence over time is clear, there are large differences in the figures on
current use from the many different surveys; it is very difficult to estimate what
percentage of the Swiss population is currently using cannabis.
6
Cannabis lifetime prevalence among 15-year olds according to gender: comparison
between 1986 and 2006
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
1986 1990 1994 1998 2002 2006
Year
Percent Used
Male Female
Source: Schmid et al. (2007)
Heroin has been, at least until very recently, the principal drug problem for
Switzerland, as for most Western European nations. In the mid-1990s Switzerland had a
heroin addiction prevalence that may have been the highest in Europe. Switzerland’s
heroin problem has been declining steadily over the last decade. The estimates of the size
of the group are crude but show a reduction from about 29, 000 in 1994 to 23,000 in
2002, the most recent year for which an estimate is available. The aging of the
population in treatment is a reassuring indicator that initiation rates have been low since
the mid-1990s; whereas in 1994 the median age of those in treatment was 26.5 years, that
had risen to 30.5 by 2006. The health of the heroin dependent population has been
improving.
Cocaine use rose during the 1990s and has continued to spread modestly this
decade; police express concern that it has become more private and harder to observe
than before. Heavy use of cocaine is largely concentrated among those who were already
dependent on heroin. No other illicit drug is used by a large share of the youth
population or has been identified as a major source of harms. Party drugs, a cause of great
concern in the late 1990s, has not increased substantially since then.
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Drug Problems
Drug policy is concerned with more than drug use. Indeed, the main focus of
policy making in the last twenty years has been the adverse consequences of particular
kinds of drug use rather than population prevalence. Thus the most important indicators
of the success of the policies as implemented may be measures of drug related harms.
Drug-related deaths, most of which are a consequence of heroin dependence, have
declined since the early 1990s, from 350-400 per annum to 150-200 per annum in this
decade. HIV infections related to injecting drug use have also declined. This may reflect
a modest decline in injecting, as opposed to smoking or snorting, of heroin, a decline in
needle sharing among users because of Syringe Exchange Programs and the lower
population of heroin dependent users.
A distinctive feature of the heroin problem in the 1990s was the emergence,
particularly in the major cities of the German-language cantons, of open drug “scenes”
that caused considerable public concern. These have largely disappeared, perhaps as a
consequence of a combination of factors: enforcement that specifically targeted those
markets, rather than private dealing settings; the availability of drug consumption rooms
that brought a substantial proportion of the users into better controlled settings and the
aging of the users themselves.
Public perceptions of the drug problem have also changed. Whereas three
quarters of the population identified it as one of the five major problems of the nation in
the mid-1990s, that figure had fallen to one eighth by 2007.
Despite the existence of substantial drug markets in Switzerland, there is a dearth
of reference to corruption around drug enforcement. Violence in the drug trade is
occasional but not sustained.
Policy
Drug policy in Switzerland has been more prominent in politics than perhaps in
any other European nation. The topic has been actively debate for twenty years, from the
discussion of the HAT trials in the early 1990s to the long-running debate over cannabis
legislation that may have come to an end with the decisive rejection of reform proposals
in November 2008.
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Swiss drug policy in the last decade has been characterized by a consistent
application of harm reduction principles, at least to the problems of heroin use. Most
prominently, in the mid-1990s, Switzerland pioneered the delivery of Heroin Assisted
Therapy (HAT) which is now a routine element of the treatment system. Under HAT,
heroin addicts who have failed in other treatment programs, mostly methadone, are
permitted to receive heroin in specialized clinic facilities, which also provide other
psychosocial services. More patients are in HAT in Switzerland than in any other nation,
though HAT client numbers have stabilized at a figure of about 5% of the estimated total
opiate-dependent population. The majority of those who drop out of HAT move on to
either methadone maintenance or to abstinence programs; unfortunately nothing is known
about whether the HAT experience enables them to do better in these subsequent
treatment experiences. Switzerland has also developed an unusually accessible
methadone maintenance system, delivered both through clinics and private practitioners;
it reaches more than half the estimated number of heroin dependent persons. Though the
number of patients in methadone maintenance has declined slightly since 2000, the
fraction of the estimated heroin dependent population in such treatment has increased.
Though opiate substitution treatment (OST) still accounts for the majority of
those in treatment, an increasing share of the small numbers in other forms of treatment
are entering because of problems related to cannabis and cocaine.
Switzerland has also been a leader in providing Drug Consumption Rooms
(DCR), intended to allow for safe injecting practices, though other kinds of consumption
are allowed in the facilities. Switzerland also has many syringe exchange programs; the
number of needles distributed annually has been declining since the late 1990s. This may
reflect both the declining number of regular heroin users and a shift to other modes of
consumption.
Simultaneous with the strong emphasis on harm reduction, Switzerland’s police
vigorously enforce prohibitions on drug use and drug sale. Switzerland stands out from
other Western European nations in the stringency of its policing. Total drug arrests
increased substantially in the 1990s and rose slightly in this decade. There was a large
decline in heroin arrests (from 18,000 in 1997 to 6500 in 2006), compensated for by an
increase in cannabis arrests. About 80 percent of arrests are for possession rather than
9
dealing. Switzerland makes more arrests (per capita) for simple possession of cannabis
than even the United States; comparative figures for a number of countries are provided
in Figure S2. However at the other end of the criminal justice system, small numbers are
sentenced to incarceration; out of roughly 40,000 persons arrested each year for drug
violations, fewer than 2,000 receive terms of incarceration. Moreover the total number of
convictions and incarcerations for drug offenses has hardly changed over the period
1990-2006, Fewer than one quarter of those sentenced receive terms as long as eighteen
months. The majority of arrests are for possession of cannabis and result in fines of 250-
300 CHF; these are not even recorded as convictions.
Figure S2
Rate of arrest for cannabis possession per 100,000 population (15- to 64years old)
Two other features of drug enforcement deserve notice. First, a rising share of
those sentenced to prison for drug offenses are foreigners; in 2006 they accounted for
over two thirds of prison sentences. Second, in addition to those receiving prison
sentences, an almost comparable number spend time in prison pre-trial and then receive
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no other incarceration. Pretrial detention serves as a substitute for sentences of
imprisonment but is subject to much less scrutiny.
Policy Assessment
Whether measured by the number of users or the severity of adverse
consequences of drug use, Switzerland’s drug problem has been declining. Prior to 2004
such an assessment would have had to note the continued increase in cannabis use among
youth; now even that has turned in the right direction. Popular opinion reflects this
longer-term change; the drug problem is less prominent and the community strongly
supports current policies.
Should this be attributed to good implementation of well chosen policies and
programs? There are two reasons to hesitate in making such a judgment. First, many of
the desirable trends in Switzerland have occurred in other Western nations with quite
different policies. Second, there is little evidence that drug policy is the principal driver
of these specific changes.
Some other European countries (including the Netherlands and Germany) have
seen a similar decline in rates of heroin addiction and a similar aging of the population
over the last decade, if not longer. The same is true for the United States, which has
adopted very different policies toward heroin users and sellers. Indeed, it is what one
expects to see after an epidemic of any addictive substance that has severe consequences
to the frequent user. Given the differences in the policy approaches of these nations, it
would be hard to attribute this decline of itself to any policy intervention.
The recent decline in cannabis use among youth has also been observed in other
Western nations. Indeed in some other nations the decline started earlier and has been, so
far, larger,. For example, in the U.K. the decline began about 2000 and rates of youthful
cannabis use are now almost one quarter lower than they were at their peak. Similarly
large declines have been observed in Australia and the United States. One might
reasonably ask whether the large number of cannabis arrests, with their intrusiveness in
personal life, serve a public purpose, given that there is a singular lack of evidence in any
country that arrests alone have a deterrent effect, either on the arrestee or potential users
generally.
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However that is not to say that Swiss policy has had no beneficial effects. The
assessment of harm reduction programs should be in terms of their own goals, namely
improving the health and social functioning of those who continue to use, and reducing
the damage they cause others. The continued monitoring of HAT participants indicate
that the gains observed in the initial trials continue; a population of dependent heroin
users at great risk of high rates of relapse, blood borne disease and crime are doing better
in terms of health and crime outcomes. The much larger MMT population also benefits
in the same way. Drug Consumption Rooms may well have contributed to the declines in
DRDs and drug related HIV.
Drug problems have a long trajectory. No democratic country has managed to
shrink its heroin problem rapidly. It is hard to identify programs that have proven
effective in other countries in dealing with a heroin problem that are not operating in
Switzerland. Given that heroin has been by far the most problematic drug for the nation,
that is an indication of a responsive and effective policy implementation.
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Chapter 1
Analytic Framework and Institutional Background
Introduction
Illegal drugs create a variety of problems (e.g. addiction, mortality, morbidity,
disorder, crime) and generate a comparably complex set of responses (prevention,
treatment, harm reduction and enforcement). To describe a nation’s drug problem and
how it responds to that problem requires an explicit analytic framework linking policies
(that is laws and programs) to the various aspects of the problems.
Analytic Framework
Table 1.1 presents a list of 8 phenomena that constitute some of the major
components of what troubles each nation under the rubric "the drug problem". The list
could be expanded but each item of a larger list could be associated with one of the four
categories of sources used here: initiation, dependence, distribution and production.
Table 1.1 Elements of the Drug Problem
Domain
Source
Adolescents dropping out of school
Gateway to other behavioral problems
Initiation
High mortality and morbidity among users
and their intimates
Crime by users
Disorderly conduct of users
Dependence
Large criminal incomes
Violence amongst drug sellers
Distribution
Distortion of source country societies
Production
Some of the problems in the list are not as related to the consequences of drug use
itself as to initiation of the young into drug use. It is the involvement of young people in
the subculture surrounding illicit drugs (either marijuana or “club drugs”) or with the
routine violation of law, and their possible progression to drug dependence that are the
central concerns under that head.
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Another set of problems is caused by the dependence or abuse of drugs--e.g.
spread of AIDS, crimes committed to support expensive illicit drug use--albeit frequently
because of the conditions of use that society has created. Cocaine sells in illegal markets
for about 20 times its legal price; that helps explain the high level of property crime
associated with dependence on cocaine. Use of dirty needles by heroin addicts is partly a
function of the prohibition on unauthorized possession of hypodermic needles
Other problem elements, such as killings of rival drug dealers, are not directly
related to drug use but to the distribution of drugs; the same killings might result if the
state prohibited the sale of popular music CDs. Even if drugs did not adversely affect
behavior, the struggle for market and contract disputes in an illegal setting would
generate violence. Finally, yet others--e.g. the distortion of social and political
institutions in Afghanistan and Burma --are a function of the production of the drugs
themselves.
If it were possible to eliminate illicit drug use altogether, all of these problems
would either vanish or be much ameliorated. But because different elements of the
problems have different sources, they may not move in the same direction at the same
time. For example, initiation may decline sharply even while dependence is worsening;
this phenomenon has been modeled by Caulkins et al. (2004) for cocaine in the United
States. Given that the time from first use to dependence is typically five to ten years, the
decline in initiation will not have effects on dependence and abuse related problems for at
least that long. Indeed, many countries, including the Netherlands and the United States
have had just such an experience within recent decades; five years of low initiation may
be accompanied by little sign of reduction in other drug related problems.
Matching Programs and Problems
The standard, though not universal, classification of programs dealing with drug
problems is enforcement, treatment, harm reduction and prevention, though increasingly
harm reduction and treatment are seen as forming one category “helping users”.. Further
dividing enforcement into the categories of source country control (e.g. crop eradication
and refinery destruction) and domestic enforcement (including interdiction of smuggled
drugs), we can match program types and the dimensions of the drug problem ; that
matching is presented in Table 1.2.
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Table 1.2. Matching Programs and Problem Elements
Program Targets
Prevention -> Initiation
Treatment -> Drug Abuse
Harm Reduction -> Adverse consequences of use
Enforcement -> Distribution
Source Country - > Imports
Programs are evaluated primarily in terms of the targets suggested by this
mapping. Thus primary prevention programs are evaluated mostly in terms of their effect
on initiation into drug use; successful prevention efforts will reduce the percentage of
non-users or experimental users who become regular users. Reductions in drug related
violence are neither expected nor measured because they will occur so far in the future
that it would be impossible to relate them to the intervention. Similarly, treatment
programs are evaluated in terms of reducing the prevalence of drug dependence and the
severity of associated harms and not in terms of their effect on initiation. Harm reduction
aims primarily at the adverse consequences of abuse or dependence. Enforcement has the
broadest potential set of targets; it may, as discussed below, have effects on initiation and
abuse as well as distribution.
Of course programs may affect more than their principal targets; the effects can
be positive or negative. Effective treatment programs should reduce distribution-related
problems by shrinking the total size of the illegal drug market, thus lowering criminal
earnings and, at least in the long-run, violence On the other hand, increasingly effective
treatment may actually worsen initiation problems by removing the most visible and
striking negative role models of addicted drug users. That is not a reason for failing to
provide funding for drug treatment; it merely points to the difficulty of doing only good.
This matching of program types against goals provides a framework for systematic
comparative assessment of programs and policies.
Institutional Background
Switzerland with a population of 7.5 million in 2008, has three levels of
government, all of which are important for drug policy; federal, canton and commune.
There are 26 cantons, ranging in size from 1,300,000 (Zurich) to 15,00 (Appenzell
Innerrhoden). The federal government is not the principal decision maker or operator of
15
programs which are in the competency of cantons. It does however have unique
responsibilities for international aspects of policy, for coordination of activities of the
cantons and for law-enforcement measures concerning trafficking involving several
cantons or foreign countries, as well as trafficking connected to organized crime.
At the federal level the chief executive body is the Federal Council, consisting of
seven members who each head one of the seven individual federal departments. The
presidency of Switzerland rotates among the seven on an annual basis. Perhaps
indicative of the great role of communes and cantons in health policy, there is no federal
Department of Health. The Office of Public Health (FOPH1) is housed within the
Department of Home Affairs. There are advisory councils specifically for drug policy
but the Federal Council itself is the decision maker at the federal level.
Cantons have the principal policy power in general, except to the extent that
federal law specifies otherwise. . Health care is seen as primarily a cantonal function,
though some cantons delegate a great deal of responsibility to the larger cities. Law
enforcement is also primarily a function of lower levels of government, with federal
agencies having responsibility for larger scale trafficking activities. The cantons also
tend, in drug policy matters, to be responsive to federal initiatives.
Illegal drugs have been a prominent issue in Swiss public policy since at least the
mid-1980s, when heroin emerged as a major health problem. The nation has a history of
very active and open debate about drug policy. For example, between 1997 and 1999 the
electorate considered three private initiatives, as well as one prepared by the Federal
Council (Zobel et al. 2003). In November 2008 a major referendum resulted in strong
popular endorsement of existing policies.
Partly this reflects Switzerland’s unique openness to ballot initiatives. Citizens
vote frequently throughout the year on proposals at every level of government: commune,
canton and federal. Any group that collects enough signatures (e.g. 100,000 at the federal
level) can get an initiative on the ballot.
The nation has three major language groups.2 German is the native language of
64 percent of the population, French of 21 percent and Italian of another 7 percent. The
1 The German acronym is BAG; Bundesamt für Gesundheit.
2 Demographic data are taken from the web site www.swissworld.org
16
language differences are associated with differences in culture and attitudes that are
relevant for drug policy. For example, harm reduction has been more readily embraced
by predominantly German speaking cantons.
Over the post-war era there has been a substantial population of foreigners
resident in the country; in 2006 20.6% of the population consisted of persons who were
not Swiss citizens. A growing share of the non-citizen population come from countries
outside of Western Europe. Indicative of the growing diversity of the population of
foreigners resident in Switzerland, 9 percent are classified as speaking some language
other than French, German or Italian. Serb-Croat was the most common language but
only accounted for 1.4% of the total population. Many of those from the Balkans arrived
during the period of wars surrounding the break-up of Yugoslavia. That they came from
countries associated with heroin trafficking is relevant to drug policy; as in many rich
nations, such as Australia and France, immigrant groups from production or trafficking
countries are heavily involved in smuggling and certain aspects of cocaine and heroin
distribution (Paoli and Reuter, 2008).
Switzerland is not a member of the European Union and, unlike Norway, does not
formally collaborate with the European Monitoring Center for Drugs and Drug
Addiction. It is active in the Pompidou Group, an adjunct of the Council of Europe that
is focused on drug issues.
17
Chapter 2
Drug Use in Switzerland
Introduction
As in any Western country in the early 21st century, cannabis is by far the most
widely used drug in Switzerland. Early in this decade Switzerland was among the
nations with the highest rates of cannabis use, reflecting a large increase in prevalence in
the 1990s. However recent data from a number of surveys show a substantial decline
among youth, suggesting that the overall population rates may fall in the future. There is
no indication of any major increases for other drugs such as cocaine, amphetamine or
ecstasy.
Heroin has been the drug most associated with crime, major health problems and
treatment; again this is true of most Western nations with serious drug problems. The
available indicators suggest that the decline in heroin use that appeared in the late 1990s
has continued into the latter part of the current decade. An increasing share of the
treatment population is presenting with cocaine as the primary drug of abuse but this is a
lagging indicator, which probably represents the working out of the prior surge of cocaine
use among heroin users rather than the emergence of a new problem.
Data Sources
Switzerland conducts a number of drug use surveys at varying intervals. It also
collects administrative data from treatment programs that provide important
supplementary information on the characteristics of drug users entering treatment. The
surveys include3:
EPSS [Evaluation of the AIDS prevention strategy]. Part of the ongoing
monitoring of AIDS in the general population, this telephone survey provides data on 17-
30 year olds. It has been conducted 11 times since 1987, most recently in 2007
ESS [The Swiss Health Survey]. A telephone interview, this includes data on 15-
39 year olds. It has been conducted four times, most recently in 2007; only a few 2007
results have been published.
3 A good summary of many of these surveys is presented in Depreux et al, 2004.
18
SMASH [The Swiss Multicentric Survey on the Health of Adolescents]. The
national survey of the health of adolescents aged 15-20. Respondents fill in an
anonymous questionnaire, Conducted 2 times since 1992.
HBSC is a WHO sponsored survey targeted at substance use among 15 year olds
at their schools. Respondents fill in questionnaires anonymously. It has been conducted
every four years since 1978; the most recent survey is for 2006.
ESPAD [European Survey Project on School children use of Alcohol and Drugs].
This is a school-based survey of 15-16 year olds carried out in 26 to 40 European
countries every four years since 1995. The age range has been increased in recent years
but it remains a school based survey. Preliminary results for the 2007 survey for
Switzerland have been released, covering ages 13 to 18.
The national tobacco monitoring survey also includes a few questions on cannabis
use and on other illegal drugs. There have also been occasional special surveys, such as
the cannabis monitoring survey conducted in four cantons (St.Gallen, Tessin, Waadt,
Zürich) as part of a special Cannabis Monitoring project. In addition to providing
confirmation of the changes in the national surveys, these studies provide more detail
about use patterns.
There are enough differences in methodology among the surveys that it is not
useful to make comparisons across surveys. All analyses of time trends use a single
survey.
Analytic Strategy
The number of drug users in any given year is a function of three factors; the
number of persons who started in prior years, the number who desist from the previous
year and the number of individuals who use for the first time in a given year. A decrease
in the number of current users from one year to the next is the consequence of the number
of users quitting exceeding the number who start.4 The published data from surveys in
Switzerland (as in most nations) provide only data on current use (including frequency
within the past year) and lifetime use. There are no published data on either desistance
4 Ignoring mortality, which is slight in the population age 15-39 that encompasses the vast majority of
current users, even among drug users.
19
or, in most surveys, initiation. The surveys thus allow calculation of the total number of
users but not of the dynamics.
As a substitute for initiation rates for cannabis there are available data on the
percentage of young persons (13-16) who have tried specific drugs (lifetime prevalence),
which may serve as a surrogate for initiation for cannabis at least, since so many users
begin at a young age. Thus in discussing trends in cannabis use, we give emphasis
primarily to the rates of use (which may have begun one or two years earlier) in those
young age groups. Since use of other substances, particularly heroin, typically starts at a
substantially later age, the prevalence among 13-16 year olds is not a good indicator of
the corresponding initiation rates.
Lifetime use rates are also reported both in survey publications and in policy
analyses such as the Global evaluation of the Confederation’s measures to reduce drug-
related problems (ProMeDro) (Zobel et al, 2003). They are of interest as a measure of
attitudes and experience in the general population but they are very much a lagging
indicator of the effects of policy or changes in attitudes. To see this, consider the effect
of a sudden change in attitudes toward cannabis use, perhaps because of new findings
about the effects of the drug on psychiatric morbidity. Assume that no new users started
this year and that half of last year’s users stopped using. Yet the percentage of 15-39
year olds who reported having used the drug at least once would change only slightly; the
39 year olds of last year would be replaced by new 15 year olds, none of whom had used
but this would change the lifetime prevalence by only about one twenty fifth5. Lifetime
prevalence for broad age groups is helpful for tracking changes over a long period of time
but we emphasize other sources for examining changes in periods as short as 5 years.
Finally, we note that there is consistent evidence that surveys underestimate
prevalence of even occasional drug use in the general population. The extent of under-
reporting depends on the setting of the interview, social attitudes in the population and a
host of other variables. The results of apparently similar surveys can be shockingly
different, depending on wording and modality. For example, the World Mental Health
5 Assume that in all cohorts prior to the change, 40 percent of the age group began use at age 15 and no one
started using after age 15. The Life Time Prevalence (LTP) for the age group 15-39 would then be 40
percent in the year before the shock. In that year the cohort which had a 40% LTP would be replaced by
one that had a 0% LTP and for the whole age group the LTP (assuming the cohorts are of equal size) would
fall to 38.4%
20
Survey reports an estimate of 15.3% for lifetime prevalence (LTP) of cannabis use in
France among 15 year olds in 2001-2002; for age 21 the survey reports an LTP of 44%
(Degenhardt et al, 2008). In roughly the same year the ESPAD survey, which includes
15 and 16 year olds, reports a prevalence of 38%. Even if the 16 year olds in ESPAD had
the same LTP as the 21 year olds in the other survey, the two groups together would have
an LTP of about 30%, barely three quarters of the ESPAD figure. We are forced to rely
on self-reports but note that they are not strong measures of sensitive behavior.
Results
Table 2.1 provides the results of the Swiss Health survey for 1992, 1997, 2002
and 2007 for lifetime prevalence estimates for a number of different drugs6. The age
range, 15 to 39, covers the years of active use. There are three main messages from this
Table. First, use of cannabis has become a very common experience for Swiss youth.
Second, very few of the population has had any experience with any individual illicit
drug apart from cannabis; for no other drug did even 5% report an experience during their
lifetime. Third, experience with hard drugs in 2007 was moderately higher than 10 years
earlier.
Table 2.1
Lifetime prevalence of use of specific drugs, 1992 to 2007, by gender
Lifetime
prevalence
of
consumption
of illegal
drugs
among 15-
to 39-years
olds in
Switzerland
for 92/93,
97, 2002, by
gender
Female
1992/93
Female
1997/98
Female
2002
Female
2007
Male
1992/93
Male
1997/98
Male
2002
Male
2007
Hallucinogen
1.2
1.7
3.0
3.8
Amphetamine
0.6
0.8
1.5
1.7
Ecstasy
N.A.
1.5
1.5
N.A
2.8
2.9
Methadone
0.3
0.3
0.5
0.5
Cocaine
1.8
2.2
1.9
3.5
4.3
4.0
Heroin
0.7
0.7
0.5
1.9
1.4
1.3
Hard drugs*
3.3
3.0
4.3
6.0
5.4
8.1
Cannabis
11.1
19.9
21.1
23.7
21.5
33.4
34.2
39.5
Any Drug
11.5
20.4
22.0
33.8
*Hard Drugs were – according to BfS (2009, personal communication) – defined as all drugs other than cannabis.
Source: SFA (1999) BFS: Schweizerische Gesundheitsbefragung , BFS (2004) Schweizerische
Gesundheitsbefragung (for data 2002); BFS (2009) Schweizerische Gesundheitsbefragung (for data 2007)
6 For 2007 data for individual drugs other than cannabis were reported with different age categories than
previously, so it was impossible to present exact comparisons with the earlier surveys for 15-39.
21
Cannabis
Cannabis use increased in the general population very rapidly during the 1990s, as
an increasing share of teenagers experimented with the drug. The latter is well
documented by the HBSC survey, which found that a little more than one in ten 15-16
year olds had tried cannabis in 1986; by 2002 that figure had risen to 45%. This was true
for both boys and girls, though rates for girls are consistently lower than for boys (as is
true in every country). There was a sudden reversal in the middle of this decade; see
Figure 2.1, giving the prevalence rates for 15 year olds over the 22 year period. It is
worth noting that despite the decline from 2002, rates for 15 year olds in 2006 were still
above those in the 1998 survey.
Figure 2.1
Cannabis lifetime prevalence among 15-year olds according to gender: comparison
between 1986 and 2006
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
1986 1990 1994 1998 2002 2006
Year
Percent Used
Male Female
Source: Schmid et al. (2007)
The most recent ESPAD survey for 2007 provides additional confirmation of the
recent decline and its large magnitude. The published results allow for comparisons with
2003 at each specific age (separately for males and females) from 13 to 16 years old; it
expands on what is available from the HBSC survey by providing data on current use
22
rates. The results in Fig. 2. 2 show decreases of roughly one third in many age groups for
both boys and girls
Figure 2.2
Cannabis Prevalence Across Age and Sex
0%
5%
10%
15%
20%
25%
30%
35%
13 Years Old 14 Years Old 15 Years Old 16 Years Old 13 Years Old 14 Years Old 15 Years Old 16 Years Old
Male Female
2003
2007
Source: SFA (2008)
Another youth survey, primarily oriented to tobacco use, for the slightly broader
age group 14-19 showed a similar decline. In 2001-2 the survey found a lifetime
prevalence of cannabis use of 37%; that fell to 33% in 2004-5 and still further in 2007-8
to 28%. (Radtke et al., 2008)
Preliminary results from the National Health Survey shows a similar picture for
the still broader age group, 15-24, comparing 2007 and 2002. The current use rates for
both men and women fell by about one third for both men and women. There is little
change in lifetime rates for cannabis, but that reflects the fact that half of those in the age
group in 2007, were also in the age group in 2002; the lifetime prevalence for an age
group as large as this is a lagging indicator.
Table 2. 2
Rates of consumption of psychoactive substances, ages 15-24, 2002 and 2007
Male
Female
2002
2007
2002
2007
Lifetime Cannabis
36.1
37.2
24.4
22.3
Recent Cannabis
16.3
11.5
7.7
5.1
Other Hard Drugs
3.8
4.8
2.7
2.8
Ecstasy
3.2
3.1
1.4
1.4
Source: BFS (2008)
23
A survey in 2000 (Muller, 2001) found that almost exactly half of 19-24 year old
women reported having tried marijuana; for men the figure was more than two thirds.
Experimentation is indeed the norm for younger cohorts of Swiss adults. Muller also
found that about 20 percent of those who reported use in the prior year, used daily or
more often
The Cannabis Monitoring Survey has been carried out just twice, in 2004 and
2007. It covers the age range 13-29, Table 2.3 shows that for the younger age groups
current use rates declined between 2004 and 2007. For example, for 16-18 year olds it
declined from 16.2% to 13.0%, a relative decline of about one fifth. On the other hand
the fraction who had tried the drug but were no longer used had fallen much less, only
from 26.0% to 25.1%, or about one twenty fifth. Experimentation remains relatively
common but there seems to be a substantial decline in the percentage that continue to use.
Table 2.3
Cannabis Use among 13-29 year olds, by age, 2004 and 2007
Age 13-15
Age 16-18
Age 19-24
Age 25-29
Total
2004
2007
2004
2007
2004
2007
2004
2007
2004
2007
Never Consumed
88.2
89.3
57.9
61.8
41.7
48.0
49.2
42
53.9
56.5
Formerly Consumed
6.6
6.2
26.0
25.1
40.7
39.3
41.8
47.6
32.8
32.3
Current Consumer
5.2
4.5
16.2
13.0
17.5
12.7
9.0
10.3
13.3
11.2
Total
1841
1922
1875
2007
802
1378
501
271
5019
5578
Source: BAG (2008)
For current consumption in a still broader age range, there are data from four
waves of the ESS, which covers ages 15-39. The three earlier surveys show the large
increase from 1992 to 1997 (5.1% to 7.0%; a relative increase of nearly two fifths) that
might have been projected from the data on 15-16 year olds already discussed. However
between 1997 and 2002 the increase was much slower, from 7.0% to 7.5% (a relative
increase of only one fourteenth). There was a modest decline between 2002 and 2007.
This may reflect shortening length of use careers or the exit of earlier non-using cohorts
between successive surveys and their replacement by more drug using younger cohorts.
24
Table 2.4
Current cannabis consumption, 15- to 39-years olds in 92/93, 97, and 2002 (%)
Consumption in the last 12 months
Consumption (in the last week. Base:
consumption in the last 12 months)
1992/93
1997
2002
2007
1992/93
1997
2002
Female
2.8
4.5
4.4
3.6
30.8
31.0
41.7
Male
7.5
9.4
10.1
10.0
38.7
47.7
55.0
All
5.1
7.0
7.3
NA
36.5
42.3
50.1
Source: SFA (2004) BFS: Schweizerische Gesundheitsbefragung 2002.
We conclude this section with a note on data inconsistencies that is important for
making comparisons not over time but across countries, which forms a major part of the
policy analysis in Chapter 5. The problem is in the estimate of current use rates. For
2002 the national health survey produces a current use rate of 4.6% for the total
population age 15-64. It appears that the question used in the questionnaire allows the
respondent to determine what is meant by “current”; in many other surveys the
respondent is asked about use in a specific period, typically the past 12 months or the past
30 days. The manner in which statistics are reported suggests that it is interpreted as a 12
month question.
However the 4.6 % figure is hard to reconcile with prevalence from other surveys,
admittedly with different methodologies. None offers perfectly comparable age ranges.
In the published Tables from the national health survey there are “current rates” for 5 age
ranges 15-24, 25-34, 35-44, 45-54 and 55-64. The 2002 rate for 15-24 was 12.0%. In
contrast, Muller, analyzing yet another survey, reported that for 15-19 year olds the 12
month use rate was 32% and for 20-24 it was 35%. The implied figure for 15-24 year
olds was thus 33-34%, almost three times that of the national health survey. The 2002
SMASH survey, covering the age range 16-20, shows a past 30 day prevalence rate of
about 35%.7 The national survey may accurately portray trends in prevalence but seems
to substantially under-estimate population rates.8
7 The Tables present results for males and females separately and not for the two groups together.
8 A more speculative base for doubting the national survey figures comes from comparison of school
survey rates across countries. As noted later, Switzerland has among the highest rates in the ESPAD
survey, compared to other Western European nations. When comparisons are made for age 15-39, it
25
Use of other drugs in the general population
As already noted, compared with alcohol and cannabis, other drugs are of minor
importance if one looks only at prevalence in the general population. Additionally, of the
five drugs tracked by the HBSC survey of 15 year olds, the long-term trend is either
declining or stable. Only cocaine has shown a long-term and substantial increase that can
also be observed among the population of problematic addicts who in the early nineties
primarily consumed heroin. Note though that use of these drugs generally starts at an age
greater than 15, so this is not a strong leading indicator.
Figure 2.3
Lifetime prevalence of other drugs among 15 year olds
!
"
#
$
%
&
'
(
)
*
"**% "**) #!!# #!!'
+,-. / 0+12 34 5562
7/28,29
:;<<=0>?6;3<8,6.@<2A
B:C
D5/,.@<
Source: Schmid et al. (2008)
Moreover Ecstasy use is substantially higher among certain groups of consumers.
In the party scenes of the big cities in Switzerland such as Zürich, Geneva, Bienne and
Lausanne, experts estimated the proportion of party-people who are under the influence
of ecstasy between 30% and 70% (Sfa 2007a). These estimations are supported by highly
focused surveys (Ayer, Gmel & Schmid, 1997). However, it is unclear whether these
estimates hold for the most recent years, since the prevalence rate among 15-year olds
appears to have a much lower ranking. Perhaps the average length of cannabis using careers is shorter in
Switzerland but the findings are implausible.
26
substantially decreased between 2002 and 2006. According to the latest report
(ProMeDroIII) from the Federal Office of Public Health, about 30% to 50% of the
visitors at the so-called “Techno-Parties”9 show at least a lifetime prevalence of any other
illegal substance than Cannabis (BAG, 2006)."Among this group, ecstasy is the most
prevalent drug, followed by cocaine."
In contrast to ecstasy, amphetamines and methamphetamine seem to spread out
into a broader set of sub-groups of society, not just the Party scene. Speed, which in
Switzerland refers to amphetamines, is used as to enhance performance in work, sports
and the party scene but is also used to control body weight (SFA 2007b).
Heroin
Heroin has been the principal source of drug related harms in Switzerland for the
last twenty years. The fraction of current users in the general population was always tiny,
never more than about 1.5% but the consequences in terms of disease, crime and social
dysfunction were very substantial. Thus a major goal of drug policy has been to reduce
the flow of new users into heroin and reduce the harmful behaviours of those who
continue to use heroin.
Given that the numbers are so small and that the harms are associated with
dependent use, the emphasis is on tracking the change in the number of those who use
frequently. Estimates of this number have been prepared on three occasions, most
recently for 2002. The figures are given in Table 2.5. They are based on three data
series: methadone admissions, heroin related deaths and arrests for heroin possession.
9 Since nowadays the term “Techno” refers to just one particular style of “electronic dance music”, more
accurate descriptions of today are referring to the term “electronic dance music” (see also Chinet et al
2006).
27
Table 2.5
Estimated number of heroin-dependent users 1994, 1998, 2002
Minimum
Maximum
1994
24,000
34.500
1998
21,500
29,000
2002
18.500
25,500
Source: Maag (2003)
These estimates show a substantial decline, approximately 30 percent in the
average of the minimum and maximum, over the eight year period 1994 to 2002. The
error bands however are so wide that this is a heavily qualified conclusion. Yet other
studies bear out the finding that the number of heroin addicts declined after the early
1990s and suggest that the decline has probably continued since 2002.
Nordt and Stohler (2006), in a highly cited study of the Zurich treatment
population, found evidence that initiation into heroin use declined sharply in Zurich after
the mid-1990s. The critical Figures from their study are reproduced as Figures 2.4 and
2.5.
Figure 2.4
Incidence of regular heroin use in the methadone case register for Zurich Canton,
March 2005
Source: Nordt and Stohler (2006)
28
Figure 2.4 shows the sharp rise and comparably sharp fall in the number of persons who
become regular users of heroin in a specific year for the years from 1975 to 2002.
Among those who participated in methadone treatment in Zurich in 2005, only about 200
had started regular use of the drug in 1985. The figure for each year until 1990 increased
substantially, so that in the peak year of 1990 it was 850. In the following five years the
number who became regular users in a specific year fell again to levels below those that
prevailed in the early 1980s.10
The sharp decline in incidence of regular use after 1990 did not lead to a decline
in prevalence until later, as shown in Figure 2.5. This reflects the fact that regular heroin
use is a long-lasting behaviour, as indicated by numerous studies (e.g. Hser et al, 2003).
Few of those who initiated regular heroin use in the 1980s desisted in the 1990s, so even
though annual incidence dropped sharply, it was about 5 years before that led to a decline
in the absolute number of active heroin users. Figure 2.5 shows various estimates of the
number of heroin users in Zurich, which is thought to account for one quarter of all
heroin users in Switzerland.
Figure 2.5
Estimates of problematic heroin use in Zurich, 1980-2010
Source: Nordt and Stohler (2006)
10 Nordt and Stohler do not allow for the possibility of long term dependent heroin users not entering
substitution treatment within a few years. A paper by Kuebler et al, (2000) found that many out-of-
treatment heroin users had been regular users for many years without ever enrolling in methadone
maintenance. Frank Zobel (personal communication) points out that most of the Kubler sample were from
the French speaking cantons, where treatment became readily available somewhat later. It is unclear how
this affects the Nordt-Stohler results.
29
Additional compelling evidence of the decline in new use comes from data on the
age of those in treatment. For example, of those in Heroin Assisted Therapy (HAT), the
average age has risen from 30.8 years in 1994 to 35 years in 2005. In the outpatient
system, which includes methadone programs, clients with opiates as the main problem
substance were on average of age 26.6 years when they entered in 1995 while in 2004 the
average age was 30.7 years; average age increased 4.9 months each year. Further support
may be found also in the data on heroin and cocaine use among clients entering low
threshold facilities (LTFs) as reported in Balthasar et al. (2006). Comparing 1996 to
2006, the percentage of clients who had used heroin in the previous month declined
sharply; by one measure from 66% to 43%, even as cocaine consumption increased from
33% to 65%.
What is striking here is that there was no new surge of initiation, given that the
price of heroin is reported to have fallen sharply during this period. We return to this
later.
Cocaine
Cocaine has been present in Switzerland, as in Western Europe generally, for
many decades but endemic use levels were very low for most of that period. Cocaine use
rose somewhat in the late 1990s.
The SMASH study, which focuses on the lifestyle and health of 16 to 20 year
olds, shows a sharp increase of cocaine consumption. In 1993 cocaine lifetime prevalence
was 1.5% for females and 3.1% for males; in the 2002 surveys those figures had risen to
3.6% and 5.1% respectively. For 15 olds surveyed by the HBSC-study (Schmidt 2003)
the same increase was observed. While in 1994 only 0.9% reported a lifetime prevalence
of cocaine, this proportion has been steadily increasing up to 2.6% in 2006. Among
males, 3.2% had consumed cocaine in the thirty days before the survey.
This still translates into a relatively modest prevalence in the adult population, As
seen in Table 2.1. lifetime prevalence among those aged 15-39 had changed only slightly
over the period 1994 to 2002; for men from 3.5% to 4.0% and for women from 1.8% to
1.9%. For the 2007 survey the only available trend data cover the age range 15-49.
Lifetime prevalence increased from 2.8% to 4.2%; that may be little more than the
disappearance of older cohorts, who came to adulthood before cocaine became available
30
being replaced by cohorts that have had exposure since adolescence. It does not imply
that there has been an increase in use by each new cohort since 1992.
Cocaine is a drug with two faces. On the one hand dependent use of the drug
occurs primarily in the “classic” drug-scene, where a high proportion of methadone users
and/or heavily dependent heroin consumers are also using cocaine and/or crack/freebase
(a derivate of cocaine). On the other side cocaine is a lifestyle drug i.e. in the party-scene
or for some “performance-possessed” people (SFA 2007c). A study from Chinet et al.
(2003) where young people out of the party-scene have been asked about their drug
consumption 28% of the 17 – 20-year olds reported cocaine consumption within the last 3
months.
A cocaine indicator showing a large increase is the share of treatment admissions
for which cocaine is the primary drug of abuse. For the outpatient population other than
methadone patients11, the share rose from about 5% in 1995 to over 20% in 2004. For the
inpatient treatment population the increase was from 10% to over 40% in 2005. This is
consistent with the impression of experts that cocaine dependence has not created a new
group of treatment clients but has primarily changed the drug use behaviour of the
existing client population. The age of cocaine users in treatment has been rising in
parallel with those entering in need of treatment for opiate dependence.
Concluding Comments
The most important recent change is the decline in youthful cannabis use. Might
the downturn recorded in various post 2004 surveys prove more than a temporary blip?
A review of surveys in other nations suggests that changes as large as those recorded in
these youth surveys are rarely one time events but rather the start of longer run declines,
typically lasting a decade or more. There is no forecasting model for this phenomenon
but some evidence of long waves, a phenomenon which has been recognized for many
years in the epidemiology of alcohol consumption (e.g. Skog, 1986).
11 The study does not include methadone patients who receive their substitution therapy from private
physicians; these constitute about 60% of MMT patients.
31
Chapter 3
The Adverse Consequences of Drug Use and Markets
Drug policy is designed to do more than reduce drug use, as discussed in Chapter
1. It also aims, both directly and indirectly, to reduce the adverse consequences of drug
use. These consequences are driven partly by the level of drug use as measured by the
prevalence in the general population but also by its composition across drugs and across
types of drug users. An adult who occasionally uses cannabis will cause much less harm
to himself and society than a college age student who is a regular user of cocaine. A
further factor is the conditions under which the drugs are purchased and consumed; for
example, injecting heroin in a Drug Consumption Room poses less risk of death by
overdose than does injecting in a clandestine setting.
This chapter presents the available data on how certain adverse effects of drugs
have changed in Switzerland over the study period. Data are readily available on some
health consequences, in particular drug-related deaths and AIDS. Much less data are
available on the crime or disorder consequences, which are the other domains of society
that are most affected by drugs, particularly dependent drug use and by the marketing of
drugs. We include the public concern about drug problems as one measure of the
consequences of drug use and distribution; one goal of a state is to reassure the populace
that it is able to reduce public health and social problems.
The indicators of health consequences consistently point to a decline in
Switzerland’s drug problems over the last ten years. The number of drug related deaths in
particular fell sharply from its peak in the early 1990s (when it ranged between 350 and
400) to bout half that level in this decade (150-200). HIV rates have also fallen sharply.
The public concern about drug problems fell sharply.
Drug-related Deaths
Data on the number of individuals who die as a consequence of using illicit drugs
have been gathered for many years from Medical Examiner reports; see Figure 3.1. It is
important to note the substantial limits of these figures. AIDS deaths in which needle use
is the primary source of infection are not included. AIDS deaths with injecting drug use
32
as the primary risk factor peaked at about 300 in 1994 and then fell rapidly and
substantially so that by 2006 the number was less than 25.
Figure 3.1 thus includes only deaths for which the drug(s) were the acute cause.
In addition to AIDS related deaths these figures exclude for example deaths from liver
failure that might have its origins in injecting drug use that led to Hepatitis C many years
earlier. Nor do the data include homicides that relate to the drug trade. In Switzerland
the second exclusion is probably minor but the exclusion of deaths in which drug use was
the long-term rather than acute cause may have a large effect;
Figure 3.1
Drug-related Deaths, 1987-2007
196
205
248
280
405
419
353
399
361
312
241
210
181
205
197
167
194
182
211
193
152
0
50
100
150
200
250
300
350
400
450
1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
Number of Drug De aths
Source: fedpol (2008) Schweizerische Betäubungsmittelstatistik 2007
Figure 3.1 shows once again the worsening of the problem in the early 1990s, the
reduction in the late 1990s and stabilization since about 2000.
33
HIV
One factor that led to the mobilization of Swiss efforts to reduce drug problems
was the realization that drug injecting accounted for a substantial share of HIV infections
in the late 1980s. As shown in Figure 3.2, the number of injection related HIV infections
fell sharply throughout the 1990s from its 1989 peak and again has been stable since
about 2000.
Figure 3.2
Numbers of newly diagnosed HIV-infections by principal source of infection
Source:
http://www.bag.admin.ch/hiv_aids/01033/01143/01498/index.html?lang=de&bild=19460
Additional information is available on the extent of needle sharing, which is the
link between heroin use and HIV. Clients of Low Threshold Facilities are periodically
surveyed about their risk behaviour. The data in Table 3.1 come from individuals who
report injecting drugs at least once in their lifetime. This criteria gathers about 90% of the
questioned persons in the surveys from 1993 until 2000 and about 75% in the sample of
2006. This itself shows a considerable decrease of clients who inject drugs for the latest
period of survey. Even among heroin users there has been a substantial decrease between
34
1993 and 2006 in the share for whom injection is the dominant; the figure fell from 90%
to 49%. It is possible that this was a consequence of the decline in the price of heroin;
injecting is the most efficient method for consuming heroin and the incentive to inject
falls when the price of heroin goes down. However injection was the dominant form of
consumption for 2/3 of regular cocaine consumers
35
Table 3.1
Development of the consumption of clients from the low-threshold-institutions
(NSE)
Consumption/therapy
1993
(n=1119)
1994
(907)
1996
(n=944)
2000
(n=924)
2006
(n=1156)
Intravenous
consumption
% at least once drugs
injected
89
89
91
90
75.9
% in the last six
moths drugs injected
85
85
66
79
56.1
% new intravenous
consumers (<= 2
years)
30
24
14
7
5.6
Average number of
years of intravenous
consumption
6.7
7.8
8.8
11.8
14.8
Average number of
injections per week
18.9
17.7
13.7
13.6
Intravenous
consumption
at least once
% Heroin consumers
99
99
99
98
?
%Cocaine
consumers
82
91
92
88
?
%Cocktail *
consumers
66
79
85
75
?
Frequency of
consumption
during the
last month**
% regular heroin
consumers
61
63
67
54
44
% regular cocaine
consumers
23
27
31
27
59
% regular cocktail
consumers
16
30
37
25
17
Substitution
treatment
% in methadone
treatment
35
45
45
56
54.5
% in heroin
programs
11
4
3.7
* Cocktail is the mixture of cocaine and heroin
** Frequency of consumption related to the total of the respondents
Regular consumption = several times a week
Source: Die Drogenpolitik der Schweiz. Drittes Massnahmenpaket des Bundes zur
Verminderung der Drogenprobleme (MaPaDro III) 2006-2011 and Balthasar"et"al."(2007a),
36
Crime and Disorder
Though drug related crime and disorder are among the principal consequences of
illegal drugs that concerns the public, there are no systematic data available, either in
Switzerland or any other nation. In the United Kingdom the government has created a
Drug Harms Index in which property crime is a major component (MacDonald et al,
2005, 2006); implicitly this identifies declines in property crime generally as attributable
in significant part to reduced drug consumption. This has been heavily criticized
(Stevens, 2007) and there is no empirical foundation in Switzerland for identifying the
relationship between crime levels and drug use.
Public Opinion
Figure 3.3 shows the percentage of Swiss residents who stated that drug problems
constituted one of the nation’s five leading problems, in annual surveys from 1989 to
2008. From 1989 to 1994 the percentage ranged from 60 to 75 percent. In one year it
fell by half, to about 35 percent in 1995 and then fell by another half over the following 4
years. Since 1999 the figure has ranged between 10 and 18 percent.
It is interesting to speculate first as to why the level of concern fell so sharply
from 1994 to 1999 and then why it stabilized after that. 1995 is not a peak for other drug
problem indicators. The Nordt and Stohler (2006) analysis suggests that 1995 was well
past the peak of heroin initiation in Zurich and probably Switzerland generally. DRDs
did not begin their sharp fall till the following year. Though the principal drug scenes
were substantially cut back before 1995, there may have been a lag in public recognition.
However 1995 coincided with the implementation of the HAT trials; that may have
provides some assurance to the public that the problem would be substantially reduced.
It is also worth noting that ballot initiatives proposing major changes have been
firmly rejected, whether they proposed returning to the pre-1990 emphasis on abstinence
(in 1997) or to essentially legalization of drugs (1998). In 2008 more than two thirds of
those voting approved the statutory form of the “Four-Pillar Policy”, described in Chapter
4.
37
Figure 3.3
Percentage identifying illegal drugs as one of the five major national problems,
1989-2008
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Source: GFS.Bern/Credit Suisse (2008)
The stabilization after 1999 suggests how little role cannabis plays in the public
perception of Switzerland’s drug problems. Cannabis use among youth continued its
rapid rise throughout the period to 2002 and probably 2004; this did not lead to any rise
in concern about the problem; we treat the modest one year spike in 2003 as anomalous.
38
Chapter 4
Drug Policy as Implemented
Switzerland as a nation has been extremely, perhaps uniquely, active in drug
policy. There has been extensive discussion of a range of issues, particularly related to
harm reduction and to cannabis policy. This has involved all three levels of government
and many civil society organizations. There have been numerous ballot initiatives at all
threee levels of government. Switzerland has as a consequence been a leader in
innovation, particularly with respect to harm reduction. On the other hand, efforts to
change cannabis policy, generally in a less restrictive direction, have repeatedly failed,
most recently in a November 2008 referendum initiative.
Since 1990 the Swiss policy has been characterized as “Four-Pillar”. It has
acknowledged that there are separate and distinct roles for four classes of programs:
Prevention, Therapy, Harm Reduction and Law Enforcement (BAG, 2006). When first
enunciated in the early 1990s this was a distinctive national approach. Now, with slight
differences in terminology, it is a fairly standard Western approach.
Heroin Assisted Therapy, the most innovative program in Swiss drug policy, was
adopted before 1998 but the study period has seen it become an accepted and routine
treatment intervention, endorsed in that same 2008 referendum by over two thirds of
voters. Its effects are limited because only about 5% of heroin dependent users enroll in
it; more than ten times as many enroll in methadone programs.
Enforcement of laws against cannabis generates a very large and growing number
of arrests for possession; the figure for 2006 was one quarter higher than in 1998. Heroin
possession arrests declined sharply in that same period; most the fall occurred in the late
1990s. The 2006 figure is only two fifths as high as that of 1998. Cocaine arrests on the
other hand were quite stable over the entire period. No other drug generated a substantial
number of arrests. Over 80 percent of all arrests were for possession charges only.
Most arrests result only in fines. The number of sentences of incarceration for
drug offenses is low, whether measured as a population rate or relative to arrests, and has
slightly declined in the ten years to 2006, even as the number of arrests has increased.
39
This is partly explained by the fact that cannabis possession arrests, which are an
increasing share of all drug arrests, generate almost no incarceration. Foreigners now
account for the great majority of those sentenced to prison.
Prevention
It is singularly difficult to provide a description of “prevention policy” in most
countries because it is so dispersed. The service delivery unit is mostly the school and
there is not much tracking of the level or content of what is provided by the individual
schools. We were unable to obtain specific information that advanced on what was
reported in ProMeDro III.
A recent publication by the Federal Office of Public Health (BAG, 2006a)
identified the particular sources of vulnerability to substance use among youth in
Switzerland. It concluded that rather than tailoring prevention programs specifically to
drug problems, they should deal with the more general vulnerability. It was not possible
to establish whether this has been implemented.
Treatment
We focus here on the nature of programs available, having discussed changes in
the demand for treatment in previous Chapters.
Switzerland is one of a group of Western nations that provide ready access to
treatment services for those who want them and who achieve a high penetration as a
consequence. Others in that group include Australia, the Netherlands and the U.K. The
Swiss treatment sector is unusually rich in terms of the variety of services offered and the
settings in which they are provided. About 40% of substitution treatment occurs in
specialized clinics; 60% of patients receive their drugs from one of 2,500 private
practitioners.
Methadone maintenance treatment (MMT) remains the core service, accounting
for a majority of all treatment episodes, even as the number of persons seeking treatment
for drugs other than opiates has increased. Heroin Assisted Therapy accounts for a much
smaller fraction and is discussed separately below; buprenorphine, which is used
frequently in substitution programs in France, accounted for less than 3% of all
substitution treatments in Switzerland. The modest decline in the numbers receiving
methadone since 2000 (Figure 4.1) is consistent with the decline in the size of the
40
population of drug users dependent on heroin that we noted in Chapter 2. It is still the
case that a large fraction those dependent on heroin were in treatment in the course of the
year. Indeed, comparing the first and most recent year for which estimates of the
number of heroin addicts are available (1994 and 2002), the fraction in MMT rose from
about 50% to 75%.12
Data on treatment other than methadone and HAT is incomplete, since reporting
by services is voluntary.13 The number of in-patient treatment slots is about about
1,00014, making it a small element of the overall treatment sector in the country. The
number of users in outpatient programs other than methadone (mostly providing psycho-
social services) is harder to assess but appears to be less than 6,000.
Figure 4.1
Number'of'persons'in'methadone'treatment
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
197 9 198 0 198 1 198 2 198 3 198 4 198 5 198 6 198 7 198 8 198 9 19 9 0 19 9 1 19 9 2 199 3 199 4 199 5 199 6 19 9 7 19 9 8 19 9 9 2000 2001 2002 2003 2004 2005 2006
Number'of'persons'in'methadone'treatment
Source: Act-info: Nationale Substitutionsstatistik (Methadon)
(http://www.nasuko.ch/nms/db/index.cfm)
12 This calculation uses the mean of the high and low estimates reported by Maag (2003), as given in Table
2.4 above.
13 For in-patient treatment the system is Act-info-FOS , which is operated by the ISGF. For ambulatory
programs the system is SAMBAD, which is operated by SFA
14 This figure does not include inpatient detoxification places, therapeutic communities or day care therapy
programs.
41
In programs other than substitution treatment, there has been a long-term shift
away from heroin as the main drug of abuse of entering clients. For example, in the
relatively small population of in-patient clients, over 60% entering in 1997 were opiate
abusers; that figure had fallen to just over 30% by 2005. The shift was to cocaine; in
1997 for about 15% of entering patients, cocaine was the primary drug of abuse; in 2005
the figure was almost 40%. The same trends hold for psycho-social programs; opiates
were the primary drug of abuse for 80% in 1997 and just under 50% in 2004. For these
programs the growth was both in cocaine and cannabis as the primary drug of abuse.
A case register study in the canton of Zürich by Nordt & Stohler (2006) showed that
“every second person began their first substitution treatment within 2 years of starting to
use heroin regularly. (Nordt & Stohler 2006:1830) The same study concluded that, “The
population of problematic heroin users declined by 4% a year. The cessation rate in
Switzerland was low, and therefore, the prevalence rate declined slowly.”
The cannabis treatment figure remains low relative to other Western nations. The$
EMCDDA$(2007),$on$the$basis$of$data$from$21$of$its$25$member$countries,$estimated$that$
cannabis$was$the$primary$drug$of$abuse$for$20$percent$of$all$treatment$cases,$and$29%$of$
all$first$admissions,$in$EU$countries$in$the$most$recent$year$for$which$data$were$
available.$$The$total$number$had$trebled$between$1999$and$2005.$$Cannabis$admissions$
were$exceeded$only$by$those$for$heroin.$$The$rates$and$rates$of$increase$varied$
considerably$across$countries$within$Europe;$for$France$cannabis$admissions$were$30%$
of$all$treatment$admissions,$whereas$for$some$other$EU$countries$the$figure$was$less$
than$five$percent.15$$In$the$United$States$cannabis$is$now$the$most$frequently$mentioned$
primary$drug$of$abuse$for$treatment$admissions.
All treatment data bases show an aging of the entering population in Switzerland.
This is least surprising for HAT, where the average age of new and re-entering enrollees
in 1995 was 30.7 years, compared to 35 years in 2006.16 For psycho-social programs the
median age of enrollees increased from just over 25 in 1995 to almost 30 in 2004. This
15$The comparisons offered here are only for the longer-term EU countries (the 15 members in 2004, before
additional members were admitted), since most of the new members were still in transition in terms of drug
use prevalence.
16 Excluded were those who stayed in the program without break and who thus aged by one year each year.
42
was not the result of a change in the composition of the drugs used by the patient
population because there was some aging for all three drugs: opiates, cocaine and
cannabis. The aging was least for cannabis and started only after 2003.
Heroin Assisted Treatment
The numbers in Heroin Assisted Treatment (HAT) has stabilized at a much lower
level than MMT, about 1,200. Figures for HAT 1999-2005 are given in Figure 4.2 . The
trials which provided the basis for the introduction of HAT as a regular option for heroin
dependence were completed in 1997. The system grew by more than 50% in the
following four years but then leveled off. There are few unfilled places (capacity
utilization was at 91% in 2005) but the general view of experts is that there is no unmet
demand for this specific treatment service. The cantons of Bern and Zurich account for
70% of the total number of HAT patients; these two cantons account for only 30% of the
country’s population and probably less than half the number of heroin dependent users.
Though hardly controversial any longer in Switzerland, as confirmed by an
overwhelmingly positive vote in the November 2008 referendum, HAT continues to be
the subject of skepticism in many countries; see for example the comments of McKegny
(2008). It is thus worth briefly presenting the available evidence on the outcomes of
HAT, particularly those less well known studies that have appeared since 2000, long after
the trials were completed.
43
Figure 4.2
Most valuable is the study by Rehm et al. (2001). Two findings are of particular
interest. First, patient retention was much higher for HAT than for MMT; at the three
year mark nearly half of those who entered were still in the program whereas typically
half of MMT entrants drop out within the first two years (e.g. Del Rio et al, 1997).
Second, Rehm, et al. found that more than 60 percent of those who left HAT did so in
order to take up another treatment option. Most of those seeking other treatment went
into a methadone maintenance program (60 percent), but almost 40 percent went into an
abstinence program. There are no studies of how well these former HAT patients
perform in these other programs but it is important that HAT enrollment is for so many
patients a transitional rather than terminal state. Figure 4.3 updates a key Figure in
Rehm et al.; they had data only through 6 years beyond entry, whereas these data
extending the follow-up to 12 years at which point 20 percent still remain in HAT.
44
Figure 4.3
Source: ISGF: HEGEB-Monitoring, 2006
Figure 4.4 shows that since 2000 most of those leaving the program go to some
other form of treatment, with an increasing share going into methadone. Outcomes in
terms of employment and social functioning show substantial gains but in a population
that has been drug dependent for 20 years or more, there is still a great deal of psychiatric
morbidity and other dysfunction. There has been no systematic effort to update the costs
of HAT provision; most HAT programs now also provide methadone so that one cannot
simply take the total HAT program budget and divide by the patient population. The
Office of Public Health estimated that the program costs per day in 2005 were between
50 and 70 CHF (BAG, 2006). If the benefits were as estimated for the trials in the 1990s
(Free, 2001), this represented a net benefit of 26 to 46 CHF.
45
Figure 4.4
The central question is why HAT attracts such a small share of all Swiss heroin
addicts. In no year have more than 1,300 patients enrolled, less than 5% of the estimated
heroin dependent population. Even taking into account that many have dropped out to try
other treatment programs, it is unlikely that as many as 10 percent of Switzerland’s 23-
29,000 heroin addicts have participated in the program at any time. Why do so many
resist the lures of essentially free heroin? The answer may be that the drug is provided,
by a policy decision, in a way that makes it clearly medicine rather than recreation; there
may be more fundamental barriers to higher uptake rates. This is discussed further in
Chapter 5.
Harm Reduction
Switzerland may have a greater array of harm reduction programs than any other
country. It was an early adopter of Drug Consumption Rooms, intended to provide a
safer setting for those who would use drugs, particularly injecting drugs. It has many
Syringe Exchange Programs (SEPs), while HAT is a major innovation, now being
46
implemented by an increasing number of other countries in conscious imitation of the
Swiss program (Fischer et al., 2007).
Clean syringes are distributed through Low Threshold Facilities (LTFs) which
provide methadone with few of the usual program requirements of MMT; LTFs are
intended to reduce the extent of heroin use and needle sharing among active heroin users.
Syringes are also distributed by pharmacies. We were unable to obtain data on the total
number distributed by all sources.
As noted by Zobel et al. (2003) in the review of ProMeDro covering 1998-2002,
there had been a substantial drop in the number of syringes in 1995; from about 6.4
million syringes in 1993, the LTF distribution total fell to 3 million in 1995.. Zobel et al.
conjectured that this might represent enrollment in the first HAT programs. The decline
seems larger than could be accounted for by that factor alone. Assume that 1,000 users
entered the program in 1994 and that each of them injected 14 times per week, a 1996
figure reported in Gervasoni and Dubois-Arber (2007; p.14). Each user would account
for 700 needles per annum and the total number of needles required by the 1,000 would
be only 700,000, barely 20 percent of the observed decline. We are however unable to
offer any other credible explanation, though the reduction both in the number of heroin
dependent users and the switch to non-injecting modes may have contributed.
47
Figure 4.5
Syringes exchanged at Low Threshold Facilities, 1998-2007, by whether an injection
room was also available
Source: infodrog (personal communication)
Pharmacies appear to be playing a declining role in the distribution of syringes.
Samitca et al. (2006) examined the role of pharmacies in dispensing needles in the canton
of Vaud (whose capital is Lausanne). Whereas in 1996, shortly after the opening of the
LTFs, the pharmacies dispensed 15,542 per month (60% of estimated total) the number
had fallen to 8,520 in 2003 (20% of the total).
Apart from needle exchange, there were 13 drug consumption facilities (DCF) in
7 towns in Switzerland in 2003 (Zobel and Dubois-Arber, 2004), at which users can
inject and smoke their drugs under the supervision of trained medical personnel. Those
personnel do not inject the users but give advice about how to do so safely and offer
access to medical and social services.
This Report has given little attention to variation within Switzerland. However it
is impossible to discuss harm reduction without noting that there are strong regional
differences. German speaking Switzerland has been much more willing to accept
innovations such as needle exchange, and injecting rooms than has been either the French
or Italian-speaking cantons.
48
Enforcement
More detail is offered on this aspect of Swiss drug policy than on others because
it has received less attention in prior assessments.
Arrests17
We start by noting that the term arrest is not commonly used in analyses of Swiss
drug enforcement. Instead prior reports such as Zobel et al. (2003) present data on
“charges for drug use”, separating out those charged by drug type, whether they have
ever been arrested before or whether the charge is for trafficking or possession. Cannabis
is not treated any differently from other drugs in Tables in these Reports. It has been
argued (Maag, personal communication) that cannabis possession offenses should be
treated differently since most such arrests are handled with a simple fine and do not result
in a criminal record. We believe that the term arrest is simpler and conveys nothing more
serious than does “charges for drug offenses” and that this Report is following prior
practice in including cannabis possession offenses/arrests along with other charges.
The number of persons arrested for drug offenses more than doubled through the
1990s, from 14, 500 in 1990 to 32,000 in 2000 and then stabilized over the next six years;
in 2006 the figure was just over 34,000. Almost 90% of those arrested are male. About
half of those arrested in 1990 were aged 18-24; the share in that age group has declined
steadily over the following years, so that it was just 40% in 2006. The age group whose
share has grown is 35-39; from 4% in 1990 it had risen to 9% in 2006. The relevant
numbers are presented in Figure 4.6
17 We note that there are three different concepts that can be used for measuring arrests; offenses (or
charges), arrests (events) and persons. If an individual is arrested for possession of both cannabis and
cocaine; that is two offenses (or charges) but one arrest event. If an individual is arrested twice within a
year that will generate two arrests but one person arrested. While our preference is to use Persons, as a
more meaningful measure of intensity of enforcement, in many instances we were only able to obtain
information on offenses.
49
Figure 4.6
Number of persons arrest for drug offenses, by age, 1990-2006
Source: BfS (personal communication)
For measures of the composition of arrest by drug type we do not have person level data
and must use the number of charges; there is an average of about 1.5 charges for each
arrestee. The data by drug is given in Table 4.1, covering only arrests for drug
consumption, which account for more than 80 percent of all arrest charges. It shows a
large decline for heroin (about 60%) occurring between 1996 and 2001; from 2001 to
2006 the decline was quite slight. Cocaine arrests fluctuated around 9,000 throughout the
period.
Arrests rates persons
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
up to 17 years
18-24 years
25-29 years
30-34 years
35-49 years
50-65 years
50
Table 4.1
Drug Possession Arrests by drug type, 1996-2006
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Cannabis
24062
26219
28141
27744
31339
32580
36216
33204
36961
35735
34138
Heroin
17764
17808
15870
13450
11721
9579
7022
6960
7002
7074
6468
Cocaine
9620
10515
10398
9880
8664
8206
8577
9252
9994
10060
9570
Party Drugs
2417
1619
1059
916
1627
Ecstasy
1353
798
775
952
84
Other
1849
3137
3104
2994
3464
2707
2765
2874
3058
3684
3319
Source: fedpol
Figure 4.7 shows the aging of the drug using population that we noted in Chapter
2. Amongst those arrested for consumption offenses, the share that were under 18 fell
sharply from 2002 to 2006.
Figure 4.7
Possession charges by age, 1986 to 2006
Source SFA (2007)
The aging is also reflected in the median age of those arrested for specific drugs,
as shown in Figure 4.8. For opiates the median age rose from about 25.5 in 1994 to about
0
5000
10000
15000
20000
25000
86
87
88
89
90
91
92
93
94
95
96
97
98
99
00
01
02
03
04
05
06
Year
Number Charged
Under 18 Years Old
18-24 Years Old
25 Years Old or Older
51
32.5 in 2006. Cannabis arrestees are much younger and the median age was stable at
between 22.5 and 23.5 for most of the period. Starting in 2003 the median age rose, so
that by 2006 it was over 24 for the first time.
Further evidence of the decline in the scale and openness of heroin dealing is
shown in Figure 4.9 which shows the change in dealing arrests by substance. In 1993,
near the height of the open drug scene in Zurich and Bern, opiate dealing arrests peaked
at 5,731. Since then the number has fallen steadily and substantially, so that by 2006 it
was barely 20% as high, at 1,265. There have been more recent and modest declines in
the number of dealing arrests for both cocaine and for cannabis.
Figure 4.8
Median age of possession arrestees, by type of drug, 1990-2006
The age profile of arrests shows again the concentration among young men. As
indicated in Figure 4.10, the population rate (per 100,000) is far higher for 18-24 year
olds than for any other age group. Figure 4.10 shows the rates for each age group for the
two years 1997 to 2006; the rates are slightly higher for 2006 than for 1997 for all but the
youngest age group.
52
Figure_4.9
Source: BfS (personal communication)
These Figures again show how much drug dealing is a young man’s business.
Figure 4.10
Number of arrests for dealing with cannabis (population rate per 100'000)
0.00
20.00
40.00
60.00
80.00
100.00
120.00
140.00
160.00
180.00
12-17 years 18-24 years 25-34 years 35-49 years 50+ years
1997
2006
Source: BfS (personal communication)
Number of arrests for dealing according to substances
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Cannabis
Stimulants
Opiates
53
Conviction, Sentencing and Incarceration
Arrest is just the first step in law enforcement. It is a sanction in itself but a
modest one compared to incarceration. The many arrests generate few sentences of
incarceration. The vast majority of those arrested for cannabis possession were fined
250-300 Swiss Francs by a local magistrate. Their conviction does not even appear in the
counts of convictions, which only involve the results of proceedings in higher courts.
This explains the fact that recorded convictions each year are only about one sixth as high
as the number of arrests.
In no year did more than 2150 individuals receive prison sentences. Indeed, even
as a share of convictions for drug dealing the incarceration figure is modest, typically less
than one third. The modal sentence is some form of supervised release, roughly
equivalent to probation in the United States; such sentences typically account for 40
percent of all sentences. Figure 4.11 shows the number of convictions and the numbers
receiving prison terms.
Figure 4.11
Convictions and Sentences for drug offenses, 1990-2006
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
Number of People
Convictions Unsuspended Prison Sentence
Source: BfS (personal communication)
54
Sentences also tend to be fairly short. As shown in Figure 4.12, in no year was
the average length higher than 18 months and it has been declining since 2000; in 2006
the figure was less than one year. The fraction receiving more than 18 months has
steadily declined over the entire period from roughly four in nine to less than one quarter.
Figure 4.12
Average Length of Sentences and percentage greater than 18 months
0
100
200
300
400
500
600
700
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Year
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
40.00%
45.00%
50.00%
Mean Sentence Length (days) Percent Sentenced to More then 18 Months (%)
Source: BfS (personal communication)
Pretrial detention, in which an arrestee is detained while waiting for disposition of
charges, is a source of incarceration that gets little attention. However as Figure 4.13
shows, it accounts for a non-trivial share of the total. Many more individuals spent time
55
in jail pre-trial than receive custodial sentences post-trial (3,114 compared to 1,884 in
2006), though of course the average time is shorter. This implies that a substantial
number of those who spend time in jail are never sentenced to incarceration and do not
show up in the prison statistics as drug offenders. Little is known about who receives
pretrial detention, in particular whether a non-Swiss citizen is more likely than a Swiss
citizen to be locked up before the disposition of his case.
Figure 4.13
Number and length of pre-trial detentions for drug offenses, and share of detainees
not subsequently sentenced to incarceration 1990-2006
Source: BfS (personal communication)
Of those incarcerated for drug offenses, the vast majority for selling rather than
possession, most were not Swiss citizens. The share of all drug prisoners that were not
Swiss citizens has risen sharply since the mid-1990s. Figure 4.14 also shows that the
share from the former Yugoslavia, which was substantial at the time of the conflict in that
region has now fallen greatly.
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
Year
0
20
40
60
80
100
120
140
Number receiving Pre-Trial Detention
Pre-Trial Detention Not Resulting in Prison (days)
Mean Time in Pre-Trial Detention (days)
56
Figure 4.14
Source: BfS (personal communication)
Seizures
The police also make substantial seizures of cocaine and heroin each year and
have also occasionally seized large quantities of cannabis. Data for the three drugs is
presented in Table 4.2. The cocaine and heroin series are noisy, as is true in most
countries, because a small number of large seizures account for a high fraction of the
total. It is not clear, for example, that much should be made of the fact that heroin
seizures doubled from 1997 to 1998 or even that cocaine seizures fell sharply for the
three years 2001-2003 and then rose to a new height for the period 2005-2007.
The cannabis seizure series may have more information in it because it is not
dominated by a small number of large seizures. From 2002 to 2006 the quantity seized
fell sharply each year, so that the 2006 figure was scarcely 12% of that for 2002; the
upturn in 2007 still produced a seizure figure lower than any other from 1997 to 2005.
This decline in recent years may represent the diminution of open sale and use of
cannabis as the fate of the initiative for reducing the restrictions on cannabis was resolved
Commitment into jail or measures for main offence against narcotics law, according
to nationality
0
100
200
300
400
500
600
700
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Switzerland
Area of former Yugoslavia
Turkey
Others
57
negatively; that appears to have led to more discreet behavior on the part of users and
sellers. Moreover, the police started targeting open hemp selling around 2004.
It is also useful to assess the scale of seizures against the size of the market. This
can be done for heroin, using international figures on typical per user annual consumption
discussed in Paoli, Greenfield and Reuter (2009). Applying their figure of 30 grams of
pure heroin per user to the 22,000 estimated heroin dependent users for 2002, the most
recent year for which an estimate is available (Table 2.4), total consumption would be
660 kilograms. Using the average seizure of the three year period 2001-2003 to remove
noise associated with single year figures, 245 kilograms, it appears that the police seize
more than one quarter of shipments targeted18 at heroin users in Switzerland. Though
every element of this calculation is speculative, particularly the per user estimate19, it
does suggest that enforcement against heroin markets may impose substantial costs on
dealers. Some of the decline in heroin seizures may represent the falling number of
heroin addicts, from a mean estimate of 29,000 in 1994 to 22,000 in 2002.
Table 4.2
Seizures of Cocaine, Heroin and Cannabis, 1997-2006 (kilograms)
Cocaine
Heroin
Cannabis
1997
349
209
7,283
1998
251
404
15,001
1999
288
398
8,459
2000
207
372
19,572
2001
169
228
11,424
2002
186
209
23,211
2003
189
300
13,356
2004
361
178
6,179
2005
283
256
4,898
2006
354
231
2,694
2007
404
135
4,015
Source: Fedpol
18 Seizures of 245, divided by the sum of consumption (660) and seizures (245).
19 No studies report average pure heroin consumption by heroin users outside of treatment studies. The
Paoli, Greenfield and Reuter figure is based on a small number of studies of use by treatment clients
concerning the period before they entered treatment. The figure is likely to be sensitive to price but there is
no systematic information that would allow specific adjustment for Switzerland in 2002.
58
Cross-national comparisons of cannabis enforcement
Cannabis dominates Swiss policing of drugs, though it may account for a small
share of serious prosecutions and incarceration. To gain a sense of the intensity of Swiss
cannabis enforcement, we made comparisons between Switzerland a number of other
countries with high rates of cannabis use. We compared rates with two different bases;
total number of past-year cannabis users (Figure 4.15), as measured by the closest
available population survey, and the total population (Figure 4.16). Both comparisons
should be taken as approximations because, as noted in Chapter 2, there are differences in
methods used in the population surveys; e.g., nations that use in-person surveys will
capture a higher share of actual use than those that rely on phone interviews. Moreover,
the documentation of the criminal justice statistics are also not so clear that we are certain
that the same measure (charge, arrest, person) is being counted in each country. The very
low figures for the Netherlands reflects the 1970s decision in that country to end
prosecution of those in possession of small amounts of cannabis.
59
Figure 4.15
Rate of arrest for cannabis possession per 1,000 consumers (15- to 64 years old)
0
20
40
60
80
100
120
140
160
per 1,000 consumers
Germany
France
Netherlands
Austria
UK
Australia***
Switzerland
Source: EMCDDA (http://stats06.emcdda.europa.eu/en/elements/dlofig03a-en.html), BfS
(personal communication), Australian Institute of Health and Welfare (2007), statitistics on drug
use in Australia 2006, Canberra: AIHW cat. no. PHE 80 (http://www.aihw.gov.au/).
With these caveats, it nonetheless appears that Switzerland has a very high arrest
rate for cannabis possession by both measures. The arrest rate measured against the
number of users is particularly striking; Switzerland appears to have a rate that at about
14%) is more than twice as high as the next highest country (Austria). However we think
that this may reflect an underestimate of the estimated number of past year users; as
noted in Chapter 2, though there are many indicators of high rates of cannabis use among
youth relative to other European countries, the broadest national survey of adults
produces quite low rates of population use compared to those same countries. Thus more
attention should be given to the comparisons in Figure 4.16. What is interesting to note
here is the very similar rates for the five of the other comparator countries, all except the
Netherlands; the rate falls between 200 and 320 per 100,000 population.
60
Figure 4.16
Rate of arrest for cannabis possession per 100,000 population (15- to 64years old)
Source: EMCDDA (http://stats06.emcdda.europa.eu/en/elements/dlofig03a-en.html), BfS
(personal communication), Australian Institute of Health and Welfare (2007), statitistics on drug
use in Australia 2006, Canberra: AIHW cat. no. PHE 80 (http://www.aihw.gov.au/).
Concluding Comments
One measure of outcomes is notably missing in this analysis, namely the price of
drugs. Effective enforcement should make drugs more expensive and harder to obtain.
The only available price series (themselves unofficial) report the highest and lowest
prices observed by the police for each drug each year. These ranges are so broad as to
have little information in them. For example, the range for cocaine in 1996 was 70-250
CHF and in 2005 was 50-200 CHF. Even though both the high and low figures had
moved down, it is impossible to assess whether the average price had changed,
particularly since purity is not reported. In reporting elsewhere, statements have been
made that the price of heroin and cocaine have fallen substantially over the long-term but
specific figures could not be obtained. Declines for cocaine and heroin have been
61
reported over various periods for many western European countries and for the United
States.20
Thus the most basic measures of the effectiveness of drug law enforcement are
missing. The incarceration rate of dealers is probably low, given the size of the heroin
using population. However it may well be that the goal of enforcement is to keep dealing
from creating disorder and public disturbance, in which case high incarceration risk for
dealing is not a good measure.
The high percentage of incarcerations accounted for by non-Swiss citizens is on
its face troubling. In other countries there is evidence of drug enforcement that has
disparate impact on marginal groups. For example, Home Office figures show that 14%
of those arrested for drug offences in England and Wales in 2003/4 were of black ethnic
origin though black people were only about 2% of the English and Welsh population.
Furthermore, those black people who were arrested were less likely to be cautioned and
more likely to be charged, sentenced and imprisoned than their white counterparts. The
result was that black persons were 14 times more likely than white to be incarcerated for
drug offenses (Reuter and Stevens, 2007).
We obtained no information that enabled us to assess whether there was disparate
impact of sentencing of foreign born drug offenders in Switzerland. As noted previously,
in many Western countries immigrants from transshipment countries have a prominent
role in the importation of cocaine and heroin (Paoli and Reuter, 2008). The sentencing
data may reflect no more than effective policing in which the criminal justice system
appropriately deals with a population of offenders that includes many foreign born.
However the much higher rate of incarceration of this group deserves further analysis to
assure that the law is indeed being applied equitably.
20 For Western Europe, price data can be found at http://www.emcdda.europa.eu/stats08/pppfig1. For the
United States price data through 2007 are presented in ONDCP (2009).
62
Chapter 5
Policy Analysis
The previous chapters have described a range of problems that have declined
considerably between 1998 and 2007. Cannabis use, after rising sharply among youth
over a fifteen year period, has suddenly fallen sharply in roughly the second half of this
decade. The epidemic of new heroin use came to an end in the early 1990s and there is
no sign of a re-initiation of that epidemic, even though the price of heroin may have
fallen substantially; the number of heroin addicts is steadily declining and an increasing
share of them are in treatment. Frequent use of cocaine seems to be largely confined to
the population that was previously heavily involved with heroin. Open drug scenes
largely disappeared. It is worth noting though that the large gains were most attained by
the year 2000; since then there has been more stability than marked improvement.
During this same period there was considerable continuity in policy. Heroin
Assisted Therapy became a routine part of treatment but the numbers enrolled did not
increase much; methadone maintenance enrollment actually began declining recently but
this should be seen in the context of a reduced population of users dependent on heroin,
so that treatment penetration may actually be rising, as it did from 1994 to 2002. Harm
reduction programs expanded modestly in terms of services and locations. The police
became still more aggressive in their enforcement activities against cannabis while heroin
arrests declined sharply. Incarceration numbers, which probably matter more, hardly
changed.
This characterization of Swiss drug policy is arguably superficial. There may
have been improvements in implementation that are not captured here. For example, it is
possible that prevention programs became more effective or that the police developed
better tactics for their enforcement activities. However there is no specific indication of
such improvements.
Moreover the trajectory of policy does not fit all that well with the change in drug
problems. For example, there has been no specific change in cannabis policies around
2004 that might account for the abrupt downward turn in cannabis use rates among youth.
This was a time when an ambiguity in policy toward cannabis was resolved; a strong
63
movement for relaxing laws governing both the possession and distribution of cannabis
was defeated. Observers agree that this changed attitudes in the general population, as
well as reflecting popular concerns that had been increased by evidence of rising THC
content of cannabis. Foe example the open smoking of cannabis joints in public transport
became much less common. However it is hard to describe this as a change in policy as
opposed to a change in population attitudes. Arrests and penalties for cannabis use did
not change, though the police did close hemp shops that had become very open in
distributing cannabis, reflecting uncertainty about potential policy change.
If it is correct that policy as practiced did not change much, why was there an
improvement in Switzerland’s drug problems? The answer is that many factors other
than policy make a difference in both how many individuals use drugs and in the way in
which drug problems manifest themselves. That is not to say that policy is unimportant
but that its effects are captured not at the most easily-measured levels of numbers of users
or even of Problem Drug Users (PDUs), the term preferred by the European Monitoring
Center on Drugs and Drug Abuse. The effects are most likely to be found at the much
more difficult-to-measure level of reduced consequences of adverse effects both on users
and society.
Since a large share of all users of drugs in the general population use only
cannabis, variations in cannabis prevalence are a good indicator of drug use generally.
The experience of other countries shows that large shifts in prevalence of cannabis use in
particular can occur in a relatively few years. For example, in the United States, past
month cannabis use among 18-25 year olds fell from 35.4% in 1979 to 21.8% in 1985
and then to a low of 11.1% in 1993; by 1999 it had risen 16.4% (Johnson, Bachman and
O’Malley, 2003). There are no changes in policy or law that have been offered to
explain these large changes.
Moreover the end of the heroin epidemic and the aging of heroin addicts since
1995 in Switzerland is also a phenomenon that has been observed in the United States,
albeit 20 years earlier. Even with a sharp decline in prices over a long period, there has
64
been no reigniting of the heroin epidemic since the mid-1970s and the U.S. heroin
population continues to age.21
The following section makes more detailed comparisons with other countries to
increase understanding of how much changes in recent years in Switzerland might be
attributed to policy choices.
Comparisons with other Western Countries.
Cannabis use has become normative behavior in many Western countries. That is to say
in countries such as Australia, Britain, Canada and the United States, roughly half of the
population of those born since about 1970 or 1980 (depending on the country) has tried
the drug at least once. In this company, Switzerland is among the highest but does not
stand out from others.
. There is a good deal of evidence that cannabis use among youth has declined in
recent years. For most Western countries that decline started between 1998 and 2002.
Switzerland is late in that respect. However the reductions in Switzerland have been
relatively large.
The strongest data for cross-country comparison come from ESPAD, the school
based survey, since the same methodology is used in all countries. For the United States
we use Monitoring the Future (MTF) for 10th grade students, who are roughly 16 years
old; the MTF questionnaire is similar to that in ESPAD, as are the data collection
procedures. The results are shown below, using the 2003 ESPAD data and the MTF of
the same year since the 2007 ESPAD data are not yet published for most countries.
Focusing on lifetime prevalence among this age group (which is not very different from
current use, because they are so young22), Switzerland has the second highest rate, behind
the Czech Republic and just a little more than the France, the United Kingdom and the
United States. Given the potential differences in population characteristics (e.g.
willingness to report illegal behaviors) it is better to think of this set of five countries as
21 This can be seen for example in the Drug Abuse Warning Network, which tracked the number of
admissions to Emergency Departments related to specific drugs. For heroin the share over the age of 35
increased from 47% in 1990 to 57% in 2002, the final year the system operated in a consistent fashion.
22 For example, in the HBSC survey of 2006, 65.8% of 15 year old boys reported use of the cannabis in the
previous twelve months. Only 9.8% reported that they had used the drug some time in their life but not in
the past 12 months.
65
forming a single high rate group rather than focusing on the relatively small differences
between them. This group has notably higher rates than three of Switzerland’s near-
neighbors (Germany, Italy and the Netherlands), each of which in turn has a much higher
rate than Sweden or Poland.
For this age group, the prevalence of other illicit drugs in Switzerland is lower
than in the other nations in that group. Switzerland’s youthful cannabis users have used
the drug more often than those in any other country but again the differences with the
other high rate countries are quite modest, hardly of public health or policy significance.
!"#$%&'()&*+,%-+.%&/012&13%&".452&)'6)7&8%"0&4$/3&+5&)9&:104;%"5&<415-0+%3&"5/&-=%&
>?@&A9BBCD&
$
Source: www.espad.org; Johnston, O’Malley and Bachman (2003)
It is also possible make comparisons of prevalence of drug use in the broader
category 15-39. The comparison is not as close, as there are substantial differences in
methods used (phone, in-person, mail) and in the wording of questions. These can have
substantial effects. Nonetheless the comparisons are worth considering. Table 5.2 gives
lifetime prevalence figures, which is the only measure available for all the countries; as
noted in Chapter 2 it is a lagging indicator. Switzerland is no longer one of the leading
$
Cannabis,$
%$used$
Cannabis,$
mean$times$
per$student$
Cannabis,$
mean$times$
per$user$
Any$other$
illicit$drug$
%$
Czech$Republic$
44$
7.3$
16.6$
11$
France$
38$
7.3$
19.2$
7$
Germany$
27$
4.4$
16.3$
10$
Italy$
27$
4.9$
18.1$
8$
Netherlands$
28$
5.0$
17.9$
6$
Poland$
18$
2.2$
12.2$
7$
Russia$
22$
2.1$
9.5$
4$
Spain$
36$
X$
$
9$
Sweden$
7$
0.2$
2.9$
3$
?E+-F%0$"5/&
GB&
H(G&
9)(B&
7&
Turkey$
4$
0.6$
15.0$
3$
United$Kingdom$
38$
7.6$
20.0$
9$
USA$
36$
7.5$
20.8$
20$
66
countries for cannabis prevalence; note that in this instance, the datedness of the Swiss
survey relative to those of other nations would make it look higher, given that Swiss rates
were generally declining at this time.
Table 5.2
Lifetime Prevalence of Cannabis use, aged 15-39, 8 nations, ca. 2005
Year of study
Cannabis
Cocaine
Ecstasy
Denmark
2005
49.5
9.1
5.3
Germany
2006
37.5
4.9
5.6
Netherlands
2005
32.3
4.9
8.1
Portugal
2007
17.0
2.8
2.6
Sweden
2004 (cannabis 2006)
19.1
0.8
0.6
Switzerland
2002
27.7
2.9
2.2
United Kingdom (England &
Wales)
2006/7
41.4
12.7
13.0
United States
2005
47.7
13.6
10.5
Source: Various household surveys
Figure 5.1 shows the trends in cannabis use in different countries for youth in
varying age ranges. The purpose is not to compare absolute levels but to suggest that the
trajectory is similar to that recently observed in Switzerland. Though this pattern is by no
means universal there are many countries for which there was a sustained upturn through
much of the 1990s and then at least a stabilization if not decline near the end of the
decade suggests that popular culture may be an important influence. Certainly it is
difficult to identify any policy intervention that is common across these countries; a more
extended discussion can be found in Room et al, 2008).
67
Figure 5.1
Changes over time in youthful cannabis use, Life Time Prevalence in 6 countries
0
10
20
30
40
50
60
70
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Dutch 12-17
US 12th grade60
Swedish conscripts
Israeli conscripts
Norwegian 15-20
Switzerland 15
Source: various surveys
The aging of the heroin dependent population
Nordt and Stohler (2006) present evidence on the trajectories of heroin epidemics,
as measured by incidence, in three other countries in comparison to Switzerland. For
Australia, England and Italy the published data show a much less sharp downturn in
incidence of heroin use at any point during the period 1980-2000. Indeed, for Australia,
which suffered a severe heroin epidemic in the 1990s, there was no downturn before the
supply side intervention that led to the “heroin drought” that began suddenly at the end of
2000. We supplement Nordt and Stohler’s data by offering evidence from treatment data
that similar patterns have been observed in other countries.
68
The Netherlands experienced a sudden upsurge of heroin use in the 1970s (with
many non-natives involved) but very low rates of initiation since 1980. Thus in 1989 the
median age of those in treatment in Amsterdam was 32; in 2002 the median age had risen
to 43. (National Drug Monitor 2003). The United States shows a similar pattern in terms
of age, even though that nation has a much lower share of heroin addicts in treatment and
is much more aggressive in use of incarceration against the heroin dependent.
The United Kingdom offers a contrast. The epidemic lasted perhaps twenty five
years, with estimated incidence rates rising almost continually throughout that period
(Reuter and Stevens, 2007). As a consequence it is hardly surprising that the median age
of those entering treatment for heroin dependence are much younger (30 in 2004) than
their Swiss, Dutch or U.S. counterparts.
What might explain this pattern? Thirty five years ago Hunt (1974) developed a
model that predicted just this sudden rise and decline. The underlying behavioral model
has been well exposited by Kleiman (1992). When an addictive drug first becomes
available, what is most conspicuous is its attractive qualities. Those who try it are
enthusiasts for the drug and persuade friends to try it, so that initiation rates rise rapidly
just as they do in an epidemic of influenza. At some stage the negative effects of the
drug become more prominent. This has two effects. First, some current users become
less enthusiastic about promoting it to their friends. Second, more non-users are aware of
the negative effects; more of the “non-infected” become “inoculated”, to continue the
epidemic analogy. This is the spirit of models developed in recent years by Jonathan
Caulkins and colleagues.23
The test for policy during the upturn in an epidemic is whether it can (1) reduce
the number who initiate in the course of an epidemic or (2) the percentage who go from
experimentation to regular use. To achieve the first goal the government might create
programs that alert those of high risk of initiation to the dangers of heroin which could
lead to the epidemic of initiation peaking at a lower level or peaking earlier and/or
accelerating the speed of the downturn. To achieve the second goal the government might
try to reach current users of heroin with tertiary prevention programs.
23 For a brief overview of their work see Caulkins (2007). A technical example is Caulkins et al., 2004.
The work is most developed for cocaine, for which better data have been available in the U.S.
69
Given that the downturn in heroin initiation in Switzerland was around 1990,
attention has to focus on interventions around that time; those in the early 1990s might
not have influenced the timing of the decline but might have increased its speed. Heroin
Assisted Treatment could not have made a difference since it did not become fully
operational till 1994 and the numbers enrolled were slight. Moreover, as a program
dealing with chronic heroin users, it does not directly affect initiation. It would only do
so to the extent that it led to a reduction in drug selling activity, since so many of the
HAT clients were themselves previously active sellers as well as users, selling in order to
finance their own illicit consumption. This effect was observed in one of the studies
conducted during the heroin trials (Killias and Aebi, 2000) but the numbers entering HAT
were probably too small for that to account for a major decline in availability.
Descriptions provided in other documents (e.g. von Aarburg and Staufbacher,
2004) indicate that the late 1980s and the early 1990s were an era of intense police
pressure against the open drug scenes in which heroin was distributed. Zurich’s
Platzspitz, the most prominent and large open drug market, condoned by the police
though without any explicit regulation, was closed at the end of 1991. It was replaced by
a small market in the “Letten” area nearby; that was effectively closed by the end of
1993, following long efforts by the police. During this period numerous programs were
started that provided a variety of services (some harm reduction, some prevention) to
current users.
The open air scenes included both experienced users and curious experimenters.
It is entirely possible that their closing did have an effect on initiation rates but there is no
convincing design that would allow an identification of that specific linkage.
Hence the effect of policy on the timing of the downturn in heroin initiation
cannot be assessed. What needs to be assessed is the effects of policy since then, which
are aimed less at the initiation rate than at (1) accelerating desistance and (2) reducing the
adverse consequences for those who continue to use and to the communities around them.
While again it is impossible to provide even a rough quantitative assessment of
the gains achieved by policy in Switzerland in these respects, since the mid-1990s, what
can be said is that there has been no hesitation to try plausible innovations, to collect data
as to their effects and to make decisions on the basis of those data. That has been less
70
true outside of the German speaking cantons, where there continue to be resistance in
particular to harm reduction programs.
Concluding Comments
A principal goal of this study was to assess the success of interventions aimed at
reducing drug problems in Switzerland. The assessment of harm reduction programs
should be in terms of their own goals, namely improving the health and social
functioning of those who continue to use, and reducing the damage they cause others.
The continued monitoring of HAT participants indicate that the gains observed in the
initial trials continue; a population of dependent heroin users at great risk of high rates of
relapse, blood borne disease and crime are doing better in terms of health and crime
outcomes. The much larger MMT population also benefits in the same way. Drug
Consumption Rooms may well have contributed to the declines in DRDs and drug related
HIV.
Drug problems have a long trajectory. No democratic country has managed to
shrink its heroin problem rapidly. It is hard to identify programs that have proven
effective in other countries in dealing with a heroin problem that are not operating in
Switzerland. Given that heroin has been by far the most problematic drug for the nation,
that is an indication of a responsive and effective policy implementation.
With respect to cannabis, the other principal topic of policy making in
Switzerland, the assessment has to be more cautious. Though cannabis use is decreasing
in many countries, it is unclear that any nation has found interventions that have
contributed to this. This raises a question about the desirability of the high rates of
cannabis possession arrests in Switzerland. In a legal system that, unlike the Netherlands
and the U.K., does not allow police to use discretion, it is hard to avoid high arrest levels
without legal change. Swiss policy makers have considered reducing the stringency of
penalties for cannabis possession but public opinion has not been supportive. It is not
clear that there are any other policy options that would make a difference in that respect.
71
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