The best kept secret in the world of addiction treatment and prevention is that we already know how to reduce drug use, addiction, and drug related deaths to a mere fraction of their current rates.
Other countries in the world have already done so, but the United States stubbornly refuses to follow suit. What's worse, the United States in its arrogance claims to have the only evidence-based answers to the problems in spite of the fact that drug use, addiction, and overdose death have been on a steady climb in the US for the past 20 years as a direct result of the drug war and American style addiction treatment. And worst of all, the United States wants to force the rest of the world to follow in its path of failure, despite the fact that some other countries in the world have already solved their drug problems.
Switzerland is a perfect example. In the late 80s and early 90s, Switzerland had one of the largest open air drug markets in the world together with some of the highest rates of drug use, drug dependence, HIV, and overdose death in the world. Today Switzerland has one of the lowest rates of drug related problems and overdose deaths in the world.
Figure 1 compares the rates of initiation of heroin use by young people in Switzerland and in the U.S. over the past 20 years. Swiss data comes from Addiction Monitoring in Switzerland; U.S. data comes from SAMHSA's National Survey on Drug Use and Health (NSDUH).
Figure 2 compares the rate of drug related deaths in Switzerland to the U.S. Swiss data is from Addiction Monitoring in Switzerland; U.S. data was calculated using CDC WONDER. (For details on the definition of drug abuse-related deaths see the note to Figure 2; this is somewhat different from the definition of overdose deaths.)
*Figure 2. Swiss numbers for drug abuse and death rates were calculated by the Swiss governmnet using ICD-10 codes F11, F12,F14, F15, F16, F19, X42, and Y12, therefore I entered these same codes into CDC WONDER to get the comparable US death rates. This yeilds somewhat different numbers than that of overdose death rates, which are calculated with somewhat different ICD-10 codes.
Why is Switzerland Succeeding Where the US is Failing?
Swiss drug policy is based on the Four Pillars of:
- Harm Reduction
- Law Enforcement
Although these four pillars also exist in the US, there is a huge difference in their implementation.
Swiss drug users are given genuine medical treatment in terms of methadone maintenance or other maintenance therapies. Approximately 75% of people with heroin use disorder are in treatment, and approximately 92% of those in treatment are on methadone maintenance. There are no wait lists and methadone is paid for by compulsory national health insurance. For those who do not do well with methadone there is Heroin Assisted Treatment (HAT) where injections are made under medical supervision in a Safe Injection Facility. About 6% of Swiss heroin addicts receive Heroin Assisted Treatment.
Compare this to the United States, where, according to TEDS and NSDUH approximately 61 to 63% of those with past year heroin use disorder received specialty drug treatment in 2012, and only 27.6% of those admitted to treatment received some form of medication assisted treatment with methadone or buprenorphine. Moreover, many of these received methadone or buprenorphine detox, reducing the number who received methadone maintenance treatment to an even tinier fraction.
The standard forms of treatment in the U.S. are things like 12-step programs where people are told to pray to a doorknob to cure their disease or equine therapy where people are told that playing with horses will cure them.-Kenneth AndersonHeroin assisted treatment and safe injection facilities both remain illegal in the U.S. The standard forms of treatment in the U.S. are things like 12-step programs where people are told to pray to a doorknob to cure their disease or equine therapy where people are told that playing with horses will cure them. Moreover, such nonsensical programs can charge from thirty to ninety thousand dollars a month.
The Swiss waste no time on pseudo-scientific programs involving spirituality or playing with horses. What would you think if you had cancer and your doctor told you the cure was to go out and play with horses or pray to a higher power to save you from your disease and that under no circumstances were you to use medication, radiation, or surgery?
The Swiss also have no drug courts. Let's face it; American drug courts are part of the problem - not part of the solution - because in U.S. drug courts, the judges order people to stop taking their methadone under threat of jail and order them into participation in religious organizations like AA, again on threat of jail. Frankly it is not the drug users who belong in jail; it is the judges in U.S. drug courts who are practicing medicine without a license and blatantly violating the first amendment principles of freedom of religion and separation of church and state who belong in jail.
U.S. approaches to prevention are exemplified by the DARE program where cops go into schools to scare kids out of using drugs, in spite of the fact that the DARE-type programs have been debunked as useless or worse by the scientific research.
The Swiss model of prevention is quite different and is exemplified by the following quote from Switzerland’s National Drugs Policy:
Prevention means hindering people starting to use drugs – but that is not all it means. Prevention limited to stopping people using drugs for the first time ignores the fact that a large number of young people try drugs at least once. Prevention today therefore also means preventing the development of a drug habit – in other words, the move from a low risk consumption pattern to a problematic one or even to dependency. In general, the aim of prevention is to guard against the development of health problems, and is thus orientated towards health promotion. Therefore less emphasis is put on the particular substances involved and their legal status (legal or illegal).
In order to make a contribution to preventing drug use and the development of drug dependency, the FOPH continues to concentrate on the target groups of children and young people and their environment. Its strategic emphasis is on conditional prevention (Behavioral prevention vs. conditional prevention). This means that an attempt is not only made directly to influence people’s behavior, but rather indirectly by changing the structures and the general conditions in which they live.
Swiss harm reduction programs are federally funded. U.S. harm reduction programs are not.
Need I say more?
Switzerland’s National Drugs Policy has this to say about the role of law enforcement:
The use of drugs can present a risk to health, which is why drugs should only be available under stringent conditions in keeping with their specific potential to cause harm. Obstacles should be placed in the way of young people in particular to keep them from using illegal drugs. However, for existing drug users, repressive measures can represent a risk to health, in that they contribute to their marginalization. Law enforcement helps to reduce the negative impact of drug use on society by using the appropriate regulatory measures to enforce the ban on illegal drugs. The negative impact of drug use on society must therefore be weighed against these possible negative consequences for drug users themselves.
Who is in Favor of Addiction and Death?
What are the forces preventing us from adopting sane drug policies which are proven to work such as unlimited methadone treatment, heroin assisted treatment, and safe injection facilities as Switzerland has?
There are a number of multi-billion dollar industries in the U.S. which are dead set against any change in the status quo which could affect their profits and positions of power, most notably those listed in Table 1, graphically illustrated in Figure 3:
Table 1. Addiction Profiteers in the United States
Organized Crime: $100 billion annually in illegal drug trafficking
The Addiction Rehab Industry: $34 billion annually
Federal Drug Control Spending (DEA, ONDCP, VA, NIDA, etc.): $25 billion annually
The Prison Industrial Complex: $75 billion in 2008
There are also billions of dollars involved in asset forfeiture which often comprise the operating budgets of some police departments.
The adoption of sane and effective drug policies in the U.S. would put millions of criminals, DEA agents, prison guards, and addiction counselors out of work and in the unemployment line - where they belong. Better yet, it would eliminate the leeches who suck up all the resources by owning and/or directing such agencies. No wonder there is push back with hundreds of billions dollars at stake.
The adoption of sane and effective drug policies in the U.S. would put millions of criminals, DEA agents, prison guards, and addiction counselors out of work and in the unemployment line - where they belong.-Kenneth Anderson According to NIDA, the average cost for 1 full year of methadone maintenance treatment is approximately $4,700 per patient. NSDUH estimates the number of people with past year heroin use disorder in 2013 at 517,000; the cost of putting them all on methadone is only about two and a half billion dollars--about one one hundredth of the costs of our current failed programs.
Although in the case of the addiction treatment industry it must be concluded that an even greater force than greed in preventing progress is superstition and 12-step religious dogma. Rehab expert Anne Fletcher tells us that rehab programs which she contacted were almost universally opposed to medication assisted treatment and found that abstinence was the only acceptable goal, clearly ignoring the science that saves lives and setting their clients up for relapse and death instead of a normal life on medication.
U.S. Policy and Official Position Statements
Just to be fair, I contacted some of the major players in U.S. drug policy and treatment to get their official position statements on heroin assisted treatment and safe injection facilities.
The agencies I contacted were the DEA, ONDCP, Hazelden/Betty Ford, and NIDA. These are their responses:
The DEA neatly sidestepped the question by not answering it at all in this email:
Mr. Anderson, the Drug Enforcement Administration does not take a position on these two issues. Our mandate is to enforce the provisions of the 1970 Controlled Substances Act which lists heroin as a Schedule 1 drug based on the determination that a) heroin has a high potential for abuse, b) heroin has no currently accepted medical use in treatment in the United States, and c) there is a lack of accepted safety for use of heroin under medical supervision.
The ONDCP actually asked me if heroin assisted treatment meant methadone and if safe injection facilities meant needle exchange. I am a bit shocked by this lack of even rudimentary knowledge of drug treatment options. After I explained what these really were, they sidestepped with this reply:
The Obama Administration is committed to a science-based drug policy with a balanced approach to public health and public safety. For example, we have been working with law enforcement and other first responders to expand the use of naloxone, a life-saving medicine that reverses opioid overdoses. We have also worked to increase access to medication assisted treatment to help individuals sustain their recovery from opioid use disorders. The Administration believes syringe service programs play an important role in reducing infectious diseases such as HIV and can provide points of contact for individuals who need treatment for substance use disorders.
Hazelden/Betty Ford promised me a statement but never bothered to get back to me despite a half-dozen additional emails and phone calls I made to them. Apparently death from heroin overdose is too low on their priority list for them to bother talking about.
Finally there is NIDA, with whom I had the following rather lively exchange - one that clearly indicates NIDA believes only research done in the United States at NIDA by Nora Volkow is "evidence-based" and that anything from foreign countries like Switzerland is pure shit...regardless of the fact that the Swiss programs are working and the U.S. programs are leading to nothing but increased addiction and death:
NIDA: NIDA does not have any funded research in this area, so we’re not able to comment on this practice. We did come across this European Monitoring Centre for Drugs and Drug Addiction report on heroin-assisted treatment, but the studies cited are all European.
KA: Then I will say that NIDA refuses to comment and that NIDA's refusal to endorse HAT is one major contributing factor to the reality that the USA has a staggering number of overdose deaths which have been steadily increasing over the past two decades when at the same time in Switzerland the rate of overdose has fallen precipitously over the same time period.
NIDA: That would be inaccurate. NIDA believes that the most effective approaches to drug addiction treatment are evidenced based. To that end, NIDA has developed a research-based guide, “Principles of Drug Addiction Treatment,” which outlines some of the essential components of drug addiction and its treatment based on 30 years of scientific research. The evidence is strong in finding medication assisted treatment to be very effective in helping patients recovery from opioid addiction. NIDA’s Director Dr. Nora Volkow highlights this point in a blog post found at this link and in this Perspective piece in the New England Journal of Medicine.
The only way that we will ever see change, stop our children from dying of drug overdoses, and turn back the increasing tide of addiction is for all of us to start screaming at the top of our lungs to the press, the government, and the rehab industry, a-la Paddy Chayefsky's Network, "WE'RE MAD AS HELL AND WE'RE NOT GOING TO TAKE IT ANYMORE!"
We need to switch from policies and treatments that are based on the hatred of drug users to those that are based on love for drug users.