Proceedings of the Special Committee on
Illegal Drugs
Issue 13 - Evidence (afternoon meeting)
OTTAWA, Monday, February 4, 2002
The Special Senate Committee on Illegal Drugs met this day at 1:30 p.m. to reassess Canada's anti-drug legislation and policies.
Senator Pierre Claude Nolin (Chairman) in the Chair.
[Translation]
The Chairman: I will now call to order again our hearing on illegal drugs. Our witness this afternoon is Mr. Georges Dulex, who is the Head of Criminal Police of the Canton of Zurich. You heard the opening remarks I made to the previous witnesses. You have as long as you like to make your presentation, because we have one hour and thirty minutes. After your presentation, there will be a question and answer period, and if at the end of the meeting some questions remain unanswered, or other questions crop up as a result of your testimony, I will write to you and wait for your reply. The floor is yours.
Mr. Georges Dulex, Head, Department of Criminal Police, Canton of Zürich: Allow me to introduce myself briefly, Mr. Chairman. I am the Head of the Criminal Police of the Canton of Zurich. This canton has a population of 1,200,000 of the total 7,200,000 people living in Switzerland. In terms of urbanization, Zurich is the only really large city in Switzerland. That is not the only reason we talk about drugs in Zurich.
I would like to make an initial comment about drug policy. In the context of what happened over past decades, the police has to acknowledge that we are not alone, in other words that we cannot solve the problem of maintaining public order or dealing with crime with our own resources alone. We have moved from a policy of isolated actions and disciplines to an interdisciplinary, coordinated approach.
As you know, this was a long process. Let me remind you of what happened; you have seen and read about this in all the media. You have just heard about it from the point of view of the legislative and health authorities at the federal and canton levels. As far as I am concerned, I will give you a more practical, less scientific view from the front, the point of view of a police officer.
My views represent only the spirit of my region, the Canton of Zurich, in German-speaking Switzerland. As you know, we have a number of different cultures living together in Switzerland. The francophones, who are somewhat more traditional, and the German speakers, who in past decades have shown a somewhat more generous approach and a Latin temperament.
I am going to speak from the perspective of Zurich, because our city was really involved in this issue in the past. As we all know, until February 1995, our city had the reputation of having been invaded by the drug problem. We had one of the most serious open drug scenes, one of the largest in Europe, with all the negative implications that involves. Journalists and television crews from around the world regularly came to Zurich to report on the place we all remember as Needle Park.
Today, exactly 10 years after the closing of Needle Park and seven years after the final shutdown of the open drug scene, Zurich has regained all its original beauty, if I may say so. The park located close to the main station and to the national museum has been restored to its former charm. For me, this is a concrete demonstration of the progress we have made as a society and as a police force.
If, following these developments, people had the impression that we had changed our policy radically and moved toward complete liberalization — which is something we sometimes hear — this would be incorrect in my opinion. On principle, we police officers still maintain an absolutely strict position regarding any type of trafficking, smuggling, trade in illegal drugs and illegal drug use as well, as provided for in the legislation.
We learned in the past that enforcement measures alone would not enable us to achieve our objective. The drug problem is a challenge facing society and involving all sorts of disciplines and authorities, as I said. That is why we have chosen to adopt what we call ``the third way'', an approach whereby despite our enforcement efforts, we provide drug addicts with the medical and social care they require.
Under this approach, police officers must be able to reconcile strength and dialogue, and repression and assistance. In fact, this is the mandate of the police. In the special circumstances surrounding the drug problem, police officers had to learn this with respect to their approach and their actions, and this was not easy.
In addition, social authorities and organizations also had to learn to accept the strength of our authority. Let us look at the city of Zurich as an example.
How did this situation develop? In some respects, we can see in Zurich the roots of the current Swiss policy, if I may say so. For 15 years, Zurich was characterized by open drug scenes. Initially, these were located along the banks of the Limmat river, where drug addicts gathered. The police tried to clear the paths using a ``hit and run'' tactic, which ultimately was of very little use, because order was restored for short periods of time only. Distrust was another characteristic of this. People from social services and street workers were always involved. They kept their distance from the police, and generally speaking opposed all repressive measures.
Under these conditions, no one could keep up, particularly since there was an inadequate social safety network for people who needed it. Violence was growing all the time. In light of these facts, it is hardly surprising that the scene subsequently moved to the north, toward the centre of town and located in the park near the station. Since the park was bounded by two rivers, the Limmat and the Sils, and by the national museum, the drug scene was isolated from the rest of the city. Our initial impression that this allowed us to control the situation better proved incorrect, because there was an increase in both the social problems and the violence.
Subsequently, the extremely tough and outrageous nature of drug-related crimes, made the people of Zurich feel even more unsafe. Nearby neighbourhoods were increasingly affected by these developments. There were thefts of all types: shoplifting, purse snatching, armed robbery in the street and robbery by gangs. The open drug scene became a place to trade and deal any stolen objects.
Early in 1992, the city authorities could no longer tolerate the situation. As a result, Needle Park was closed down on February 4, 1992. What happened afterwards shows that the coordinated efforts of all the disciplines involved were inadequate at the time.
The problem — the misery — simply moved elsewhere. Drug addicts wandered along the banks of the river and in neighbourhoods close to the city. The situation became unbearable for everyone: residents, businesses and authorities.
The second crackdown led to a new, miserable drug scene on the tracks of a railway station that had been abandoned and not in use for years. This location became the final destination for many drug addicts, sick people and criminals from Switzerland and the neighbouring countries.
The abundance of drugs of all types attracted people from very far away, even beyond our borders. This was the worst time for the police force: attacks involving firearms or knives were common. In the summer of 1994, there were five murders in this drug scene within a few weeks.
In February 1995, a political decision was made to shut down the open drug scene once and for all. In the light of past experience, all the authorities agreed to work together.
This major operation involved the police, as well as social and medical services. This operation can be seen today as the decisive starting point of the current policy — the four-pillar policy — which was described to you earlier.
I will not repeat what you have already heard about the four-pillar policy. It is crucial that each pillar be of equal importance. The whole policy will only work effectively if the people in charge, including those responsible for each profession at the local level, know each other, and accept and support the duties and interests of the other partners.
For example, in Zurich, the authorities promote this coordinated effort by organizing regular interdisciplinary events and providing instructions to all the parties involved. In addition, the head of the police division involved is a member of what we call the ``Canton Drug Commission,'' which is an advisory body to the government of the canton. For their part, the detachment chiefs operate in the context of the interdisciplinary working groups.
We also sponsor special programs such as the heroin prescription program. It is in our interest to monitor these programs closely if we want to be able to distinguish between what is good and what is not, and between truths and lies. With respect to the low-threshold facilities, a police officer must be in regular contact with the people in charge to determine which measures are correct and which are incorrect.
In this context, the police have found that drug abuse in the context of a prescription program remains rare. However, getting additional illegal drugs in the street because of multiple addiction seems to be frequent.
By way of information, the security of social and medical facilities and injection sites does not come under police responsibility. This task is given to private security firms. With respect to steps taken jointly with other authorities, I would mention that since the closing down of the open drug scenes, we no longer tolerate any gathering of drug addicts or questionable individuals in the street. This is part of the joint strategy. There are almost no problems today even at injection sites and the area surrounding them.
In order to ensure that everything works smoothly, police officers tell social services about individuals living in Zurich who are likely to endanger their lives when there are charges for offences under the Narcotics Act. However, all individuals living outside of Zurich are stopped and sent back to the commune in which they live. A special processing centre has been set up for this purpose. This was necessary because many communes and cantons saw no need to take the necessary steps to fight the drug problem as long as their addicts, who live in their community, came under the responsibility of Zurich.
This centre is very important for the police, because it enables us to achieve the following objectives. As a result of the centre, the city and canton of Zurich are no longer responsible for problem individuals who are loitering in our neighbourhoods. The communes and cantons from which these people come are involved and are told that they must take some action. If steps are not taken initially, after the person is sent home a number of times, the community in question is forced to do something. It works through this repatriation on holding centre. In 1995, over 6,500 individuals were evacuated when the drug scene was closed down. Since then, the numbers have been dropping steadily. Last year, 1,700 individuals were sent back to their canton or commune of origin.
This measure is working very well. Today, there are far fewer drug addicts in Zurich from other parts of the country. Drug tourism has dropped. Drug addicts who have experienced the problems involved in being arrested and sent back tend to avoid Zurich now; or else they behave more discreetly and cause little or no trouble.
I will now make a few comments about our enforcement activities, which are, of course, our main responsibility. Our two chief objectives are well-known: to reduce the supply and availability of illegal drugs, and to maintain order and public safety. Today, public order is ensured by a much more visible police presence than in the past. Special forces and patrols have been established. Their mission is to prevent the establishment of any new public drug scenes. In this context, I noted the role and importance of the repatriation centre.
The presence and public activities of the police to maintain order are also visible in these statistics on crime that are now being presented. We see this particularly in the case of charges for drug use. Only public drug use is of concern to us. What happens in private is secondary, and is of little interest to us. In light of the circumstances, the possibilities, and also the general opinion on this matter.
Our main efforts are of course focused on areas where there is drug trafficking, smuggling and money laundering. It goes without saying that in these cases operations of a completely different nature are required. In order to uncover organizations and apprehend the people in charge, we need long-term surveillance activities, backed up by technical and electronic support measures. International legal assistance in the area of financial transactions plays a major role in this context. While drug trafficking activities in the Canton of Zurich accounts for a quarter of the total for the country, financial matters are concentrated much more in Zurich, but also to some extent in Geneva and Ticino.
The majority of drug traffickers that are found and arrested are foreigners. Today they make up 54 per cent of the total, whereas the figure was between 60 and 80 per cent at the time of the open drug scene. We must also remember that today foreigners living in Switzerland make up approximately 20 per cent of the population of Switzerland. At the time of the open drug scenes, the figure was only 16 per cent.
The nationalities of concern to the police are mainly from the Balkans: Albania and Yugoslavia are the main countries involved. In Zurich, these people are involved mainly in heroin trafficking. However, people from the Dominican Republic, New Guinea, Guinea and African countries are involved with cocaine.
Given this, it is hardly surprising that heroin seizures occur first at the land border or on the market itself, because drugs are smuggled in Switzerland by truck, bus, car and train. The traditional routes are to the East and from the Balkans.
Cocaine seizures, on the other hand, happen mainly at the international airport of Switzerland — Zurich and Geneva. We are also familiar with the traditional or typical routings in this case. What is the importance of these entry points? As you can see from the statistics, the blue bar shows what happens in Zurich, and the red is the total for Switzerland.
As you can see, most seizures occur in our jurisdiction, in Zurich. Let us take a look at drug trafficking availability. We see that drugs are very plentiful in Zurich. This applies to heroin and cocaine as well as to all other drugs — both synthetic and non-synthetic. As a result, the price is extremely low today. At the moment, the price of heroin is around 40 to 50 Swiss francs per gram, while a few years ago, the price was around 500 Swiss francs. So that shows how abundant the drugs are.
My last comment about the statistics concerns death caused by drug overdose. As we can see, the largest number of deaths — I am still referring to Zurich — happened during the years when we had an open drug scene. In 1993, we saw an initial drop after Needle Park was closed down. This drop did not last very long, because a new drug scene was established.
Since that time, one the authorities decided to no longer tolerate any drug scene and to work in a cooperative, interdisciplinary manner, the number of deaths by overdose have been dropping steadily. You will notice that for the year 2000, there was once again a slight increase; we have no explanation for this development at the moment.
Among the people who died by overdose, the average age is over 30. We noted that between age 26 and 32, the use of so-called hard drugs was particularly high. Young people, on the other hand, used proportionally more cannabis and cannabis products, apparently. This leads me to my final remarks, regarding the liberalization of cannabis or decriminalization, which is the term you use.
I understand that under decriminalization, where there is no prosecution, the activity is permitted. However, if drug use were decriminalized, the question is whether there would be any punishment or not.
The Chairman: The decision would be made by the police officer or the judge.
Mr. Dulex: The decision would be made by the judge, not by the police officer.
The Chairman: That is the distinction between the two.
Mr. Dulex: Whether we like it or not, in our view all drug addicts were once cannabis users. That is why, among the police, there are great differences of opinion. However, it is also clear that the police will play the game if society is in favour of this liberalization. The police have learned that they are there to defend the interests of society and not special political interests or their own interests. As I was saying, there is a difference of opinion on this matter.
The difference is particularly pronounced in the case of liberalizing not only drug use, but also the actions that lead to drug use.
We have trouble imagining how it would be possible to control drug trafficking in the streets or small business in the interest of public order and safety. These matters involve highway safety and work safety issues, which are of great interest to us as police officers.
Although we have some very specific rules about drinking, and case law to help us and guide us, the same is not true of drug use.
Another point is that Switzerland would become an island within Europe. We are quite prepared to be pioneers, but it would be better to take action based on agreements signed with the countries and societies surrounding Switzerland, because we are quite worried that once again, we could be involved in a new phase of drug tourism. We have our doubts that the rules — to be established by the Federal Council — would be a helpful tool for the police, but we do not know anything for sure for the time being.
Within the police, we wonder whether it is time to take this step. As I said, opinions are very split. This does not change the fact that sooner or later liberalization will happen. That much is clear from the recent history of Zurich.
The Chairman: Your testimony was most interesting.
[English]
Senator Christensen: Since, unfortunately, I was not here this morning to hear the other presentation, some of my questions may be redundant.
Am I making an assumption by saying that, by closing the Needle Park the problem has moved to some place else? The problem has not been solved. The problem has moved out of the park in Zurich to another place. In fact, am I correct in saying that the actual use of heroin and other addictive drugs is not being addressed?
[Translation]
Mr. Dulex: Apparently I was not clear. We have found a solution, and the scene no longer relocates, because there is no longer an open drug scene today. The first initiative at Needle Park was not an interdisciplinary activity, and thus there were no medical or social services available, and the drug addicts who were chased away from the open drug scene wound up on the banks of the rivers and wandered around the neighbourhoods.
The police tracked them down again, and this resulted in a second open drug scene known as Letton. Here is the Letton station on the map. That is where we realized that we had to work together and use an interdisciplinary approach. There has been no drug scene since that time.
If you look at the map, toward the top, on the northeast bank of the river, you will see the Letton station location, where the last open drug scene was located. There have been no further drug scenes since this one was closed down. Initially, after this major operation, we clearly still had some problems in the city, because there were many drug addicts who fled and were wandering around until they were all picked up. The nearby neighbourhoods were the victims to some extent, but in Zurich today we no longer have any open drug scenes as we had in the past.
Obviously, if one looks carefully one can still find parts of the city, with the exception of major commercial, financial and tourist districts, but in the industrial parts of the city, you can still find drug traffickers and users looking for drugs. However, even drug trafficking in the city is no longer of concern to us. This was a decisive change for the police. In the past, when there was an open drug scene, the police could focus their efforts on that scene, and the crime — that is the thefts — that were taking place in the surrounding neighbourhoods. We could focus our efforts on the centre and the surrounding area.
No longer having open drug scenes resulted in total decentralization. Today, the market is located not only in the city; it is also in the country, outside the city. Drug traffickers and users know each other somewhat, and, from the license plates, we see that there are people from western Switzerland and French-speaking Switzerland. We see license plates from Solothurn and Vaud in various districts and towns. We track this, and today, the police have a more difficult job in that they must first find out where the trafficking is taking place. That is why we started by watching drug addicts or drug users or those assumed to be in this group, and we followed a few of them until we found out where the trafficker was located. Then we approached the traffickers and put the two face to face. In this way we achieved our objective more quickly.
[English]
Senator Christensen: Has this fragmentation made it more difficult for those who apply law enforcement?
[Translation]
Mr. Dulex: Yes. A tremendous advantage is that public safety is much greater. People feel reassured and safe, because in the past there were some irrational fears around. When you see drug addicts, you see people who are down and out, in misery. Today, you see virtually no drug addicts in the city, and the residents feel reassured. That is essential.
On the other hand, the job of the police is more difficult, and has become more sophisticated. We can no longer simply go to a place where these things are happening, have a look and pick people up. We have to start by following people and doing some research to achieve our objective. It takes far more staff.
[English]
Senator Christensen: Has it been driven underground?
[Translation]
Mr. Dulex: Yes.
The Chairman: Mr. Dulex, I would like us to back up a little to get a better understanding about the inside workings of the police services. Zurich is the largest European centre in the country, and that is why we invited you and that is why we are very pleased that you accepted our invitation.
I would like to understand what sort of cooperation there is between your services in Zurich and other similar services at the canton level and within other communes, and also with your colleagues in neighbouring countries. I am sure you must work together. I am not asking you to reveal your operational secrets, but simply to give us some idea about the coordinated effort to control drug trafficking and drug use.
Mr. Dulex: At the local level, we have an act pertaining to the communes. Law and order and public security are the responsibility of the communal police department. I do not want to go into too much detail, but, generally speaking, in Switzerland every canton has a cantonal police department.
The big communes and cities usually have a municipal police department. This municipal police department is primarily responsible for security whereas the cantonal police department looks after criminal investigations. In the canton of Zurich, the municipal police department looks after law and order: these are the police officers you see in the public areas. The police in uniform are always city police officers but the criminal investigators come under us, the canton of Zurich.
Since the communes do not have any municipal police services — like us, the canton of Zurich — they are also responsible for communal policing. At the national level, we work with the jurisdictional chiefs. In matters pertaining to security and public order, there is, first of all, the Conference of Ministers of Justice and cantonal policing. Then there is the Conference of Swiss cantonal police commanding officers, which are the chiefs of police and, at a lower level, there is the Swiss Association of Criminal Investigation Chiefs of Police. Switzerland's 26 cantons are part of this association, as is the principality of Lichtenstein.
We discuss problems and set the rules for cooperating in various sectors. These rules of cooperation are set for the Association of Chiefs of Police and for the Conference of Commanding Officers. In matters pertaining to financial assistance, which also depends to some extent on the citizens living in the cantons, the issues are generally brought to the attention of the Conferences of Ministers of Justice and cantonal policing.
As regards other countries, we have a task force known as the ``South-West Group.'' We regularly meet with police officers from Germany, Switzerland and France. We are also cooperating with the Austrian authorities, but since we share a border with Germany, we are most interested in cooperating with Germany and France.
Bilateral contracts are forthcoming. As regards the whole issue of European policy, since we are not part of the European Union, we have established bilateral contracts. In our contract with Germany, we have defined in great detail how we will cooperate to fight crime in all sorts of sectors. This is more or less how we operate.
The Chairman: Our research indicates that between 1991 and 1994, on average, 50 per cent of the investment you made to deal with ``drug'' problem — approximately 1 billion Swiss francs — was earmarked for law enforcement and other similar services. Has this percentage remained unchanged since 1994?
Mr. Dulex: These are national figures that pertain to several activities that cost money. I would not say that this is representative for policing, and I am not in any position to tell you what percentage pertains to drug-related work, but not 50 per cent. The percentage is clearly lower because we have other problems.
The Chairman: Did this percentage — 50 per cent of the cost of the national anti-drug program — represent the cost of policing, on average, for the period between 1991 and 1994? Has that been maintained?
There has been an increase in charges over the past few years. Is this because you have a greater number of personnel, and consequently more financial resources?
Mr. Dulex: We have not had an increase in personnel. If the number of drug use charges has increased, it is simply because we have to be very strict and active in the public areas in order to achieve the present level of calm.
These activities are not very time consuming nor are they very expensive. What costs us a great deal more are the secret investigation operations. If our statistics for trafficking are clearly lower, you can presume that we have a lot more work.
Today our resources are being used a lot more to deal with what we call ``organized crime'', but this is not really organized crime as originally defined. This is gang crime, commercial crime as we say in Switzerland. If this were organized crime, this would be something that involved clans, mafia-type organizations that do not really exist in our country.
Naturally, we have contacts and liaisons for financial matters. Our significant financial industry is also the hub or intersection for shady dealings. We invest much more in that particular sector.
I would say that our activities today are the same, but I could not tell you whether or not the percentage has remained the same. I do not know the figures.
[English]
Senator Christensen: I have one follow-up to that question. As a result of the closing down of the open drug scene, did the government introduce new legislation that you, as the police force, could use to help you in your efforts?
[Translation]
Mr. Dulex: We do not really have any new legislation that deals with the drug problem directly, but we do have new legislation on serious crime. At the federal level, we have had, since the beginning of this year, a criminal investigation police service for the so-called major cases, the cases involving organized crime. First of all, we have to set this thing in motion and now things are only just getting underway, but that had no direct bearing on the drug problem we had in Zurich.
What is new is this holding centre for processing people to be sent back to their commune. We did this under the current legislation and not as result of new legislation.
[English]
Senator Christensen: They were required to go. Did they have a choice?
[Translation]
Mr. Dulex: The apprehended people, yes. They are arrested and once their identity has been established and confirmed, they are sent back to their respective communes which then assume responsibility for them. We charge the commune for the cost of repatriating these individuals. The commune has something to do and must react.
Perhaps the costs involved in repatriating these individuals were higher than they should have been had the communes taken precautions and done something for their drug addicts. Nevertheless, these were merely snags that occurred at the start and we no longer have these problems today.
At the beginning, when people were sent back to their commune, these communes found themselves in a very new situation. This may sound ridiculous, but it illustrates to what extent everybody was impacted. At the time, the communes were tempted to pay for the offender's way back to Zurich, because in Zurich, there were treatment centres. So we would pick them up again in public areas and send them right back.
[English]
Senator Christensen: Are there support systems in the communes where they will receive treatment?
[Translation]
Mr. Dulex: The other cities, cantons and communes are now feeling increasingly concerned about the situation as well and are doing something.
The Chairman: A witness we heard this morning explained that the non-enforcement measures taken in your sector, or your region of the country, did not match those of the other regions of the country. If you send a drug addict back to a region that does not have as many services as your canton, is the canton of origin responsible for this individual rather than the canton that sends him or her back?
Mr. Dulex: That is very accurate.
The Chairman: Has the public pressure you were under in the early 1990s not had an impact on the other cantons to compel the local authorities to take action?
Mr. Dulex: Yes. The open scene was eliminated ten years ago. Since then, the other communities have been affected repeatedly. Today, the problem in our region is no longer as big as it was ten years ago.
The Chairman: Is the elimination of the open scene still causing repercussions in the other regions today?
Mr. Dulex: The other regions preferred not to have any drug problems. However, they realized — as did the politicians — that drugs were part and parcel of their society, just like illness, that we could not wipe it out and that we would have to learn to live with it. That is what we have done. This awareness has led to a change in attitude towards the problem, even in the police force.
The Chairman: You are very interested in the identity of the users and in injection treatment clinics that use heroin for treatment purposes. How do you explain this concern?
Mr. Dulex: At the start, we wanted to know just how effective the proposed methods were and we simply wanted to help those working in the various fields. We therefore offered to accompany the drug addicts. Despite all of the programs that are offered, no one was able to keep drug addicts under observation 24 hours a day. That was one problem. Under the program, the patient arrives in the morning, leaves and then comes back at noon. He leaves once again and then comes back in the evening. What does he do in the meantime?
We were not provided with the exact identity of the patients or individuals in treatment, and that is what we asked for at the beginning. Our idea was simply to help them and not to bother them or use the data for enforcement purposes.
Since that was not possible, we requested that individuals participating in this type of program be at least issued an identity card certifying that they were part of the program. Consequently, if they were apprehended in the street, we would know that they were part of the program.
We would know why the patient always had drugs, methadone or any other substance in his or her possession. Had this type of substance been found on any other individual, we would not have been able to let him go.
The Chairman: Have you observed a decrease in crime linked to drug use or triggered by the financial requirements of drug dependency?
Mr. Dulex: The decline has been very clear. In the past, neighbourhoods close to the open scene were living in outright fear. The citizens were concerned. Today, they can go out and feel safer. The thefts that I alluded to, such as those involving swarming, are clearly occurring less frequently in these neighbourhoods than in the past.
The Chairman: The problem still exists, but has there been a significant decline?
Mr. Dulex: Yes, indeed.
The Chairman: You give a great deal of priority to the citizens' sense of security. We do as well. In the neighbourhoods where these clinics have been set up you have observed an appreciable decrease in drug-related crime. However, has the appearance of drug addicts changed? Are they better dressed? Do they fit in more with the crowd or are they more marginalized from society?
Mr. Dulex: Externally, I do not think that the drug addict at the peak of his career or at the low point of his existence has changed. Nevertheless, there is more assistance for the drug addict today and we do not see them so often now as we did in the past. Since they have all been sent back to the communes and other cantons, they are fewer in number. You only see them rarely. They are being treated by society.
If you observe the comings and goings at a local injection centre, you will see who comes in and who leaves and you will be able to tell, today as in the past, who is a drug addict and who is sick, perhaps. But they do not look as though they are as down and out as they were in the past. They are not so spent. There is a lot more medical and social assistance for them. They are even given job opportunities. And, as a result, the problem is less evident.
The Chairman: In Switzerland as in North America, a new drug, Ecstasy, has made an appearance over the past few years. You two must have seen these rave parties where young people take this substance. What approach has been taken to this situation?
Mr. Dulex: Groups of young people in Switzerland do this too. It is a little bit of a trend. As far as I can see, and I do not know whether or not I am accurate, in Zurich the current problem is less of a concern to us than it was five years ago.
We also have Thai pills — we have all of that — but we were more concerned about the problem at the beginning, perhaps because it was new. What concerns me more, is the fact that today we have a change in attitude. It seems to me that there has been a change in attitude amongst drug addicts, in the attitude towards hard drugs like heroin, but especially cocaine, or amphetamines and pills.
In the past, the drug addicts took drugs to escape, to leave the scene, to have their flash, whereas today this no longer seems to be the case. It is more about being on top of your game all the time. And in the young dynamic professions — I did a small personal experiment, using my family, since I have a son who trained in a bank and, through him, I heard a lot about what is going on with young people. In these very dynamic professions where the young people are under constant pressure — the stock market comes to mind — this is almost like their daily drug, their daily diet.
There are places where they meet. We have spots in Zurich that we know very well. There are many very pretty, very pleasant restaurants in the vicinity but there is one spot where the young people meet. They line up outside in minus 10- degree weather and that does not stop them, as long as they can get in. These drug addicts no longer display their culture in the outside world. We did not know who they were. They are absolutely involved. They have jobs, they have professions, social life, the whole bit. This is no longer the drug addict of yesteryear. I did not know whether this is a trend that we do not see until the last minute, but right now this is something that is quite troublesome.
The Chairman: You have, in fact, described the effects of opiates versus the effects of cocaine, cocaine derivatives and amphetamines which stimulate much more than tranquilize.
However, in Switzerland, cocaine appears to have reached just one very specific segment of society, a segment that can afford its addiction. In North America, it is different. We have cocaine users that do not have the means to support their addiction and this is why you have neighbourhoods affected by this plague.
You gave us your opinion on cannabis. Before dealing with the issue of cannabis, I would like to go back to policing activities. You showed us two tables and here I refer to a table which assessed a 15-year period of charges for drug use and another one which showed charges or criminal proceedings resulting from drug trafficking.
When you look at the two tables, you can see that there has been a clear increase in charges for drug use, however, as regards trafficking, the changes have been less drastic. How do you explain this difference?
Mr. Dulex: As regards drug use, I told you that special forces had been established to maintain peace and order in Zurich in particular. There are permanent uniformed patrols in the streets to maintain peace and order and prevent any new scenes from cropping up. That explains the increase for the Canton of Zurich. We also have had some influence on the other cantons, and we have served as somewhat of a precursor. We are a little bit like the pioneers.
As for drug trafficking, do not rely on the figures. Our operations have become much more difficult. Today everything is more organized, more clandestine and more secret. We deal with ethnic groups that make the task even more difficult. In Switzerland, heroin trafficking is in the hands of people coming from the Balkans, the Albanians, the Yugoslavs, the Roumanians. These are clans, ethnic groups that we can no longer infiltrate as we did in the past. In order to do this, you need to use nationals with the same citizenship, people that we do not have in Switzerland.
In Switzerland, we are debating the need to have special legislation to do that. A federal act is currently being drafted for secret investigations, which would provide us with legislation that is better adapted to today's police practices and which will also give us more means. Today we have requirements for interpreters that we did not have in the past. We dealt with dealers from our society. Today, they are foreigners.
In the case of heroin or cocaine, we are simply dealing with other nationalities. In order to reach the objective, numerous operations are required. Today's investigation is far more complex and costly than it was in the past. This explains why the number is not increasing.
The Chairman: Could you repeat the important dates? In 1992, the open scene was shut down?
Mr. Dulex: February 4, 1992, shutdown of Needle Park.
The Chairman: Ten years ago today.
Mr. Dulex: Ten years ago today. And then there was, in 1995, the second red arrow at the top: Letton. This also took place in February, but in 1995.
The Chairman: I will try to put the charge curves into perspective.
Mr. Dulex: I cannot show you that here because I did not think that we would get to these facts, but if we take the general statistics curve on crime, not just drugs but all crime pertaining to property and assault, you will see that the crime rate has grown since 1992.
Following the shutdown of Needle Park, in 1993, you have a clear decline. It went back up in 1994, reaching a peak in 1995 when the scene had moved to Letton station. We then had a continual increase which shows to some extent the effectiveness of our operations in this context. There are other reasons to explain the decline: there was the Balkan War and the subsequent emigration of nationals from the Balkan countries. A lot of so-called refugees came to Switzerland who were not, for the most part, refugees. They came seeking asylum and that was one of the consequences. We have observed this. The present decrease in the crime rate that we have experienced, up until a year ago, also coincided, in our opinion, with the return of the so-called refugees.
The Chairman: In your police department in Zurich, law enforcement pertains to the enforcement of laws against all crimes. If we were to try to set the drug enforcement activities apart from the other criminal activity sectors under your jurisdiction, what percentage would they account for?
Mr. Dulex: To give you an overview, the criminal investigation police organization says that there are five specialized divisions in the fight against complex crime: economic crime, crime against individuals, property crimes, drugs, et cetera. Three out of a total of 25 units specialize in drug enforcement, each unit having about 20 individuals on staff, each supported by observation, surveillance, technical ground support units. Once the preliminary investigations have been conducted, you have to do the observation work. We have specialized divisions that do this in the field, but we have about 60 investigators.
The Chairman: What is the percentage of a total budget of X, the percentage allocated for the fight against all drugs and all activities ranging from consumption to the suppression of trafficking, is it 20 per cent, 50 per cent of the total police services provided?
Mr. Dulex: Out of 600 employees, 60 people, plus supporting operations, between 15 to 20 per cent. This is a ballpark figure.
The Chairman: If you would like to send us information to support this statement, please feel free to do so.
Mr. Dulex: Our financial activities, generally speaking, represent salaries.
The Chairman: For a few minutes, I will try to compare the effectiveness of enforcement on the whole issue of consumption. I will begin by providing you with some approximate Canadian figures.
In Canada, less than 2 per cent of all drug users are criminalized; their actions lead to police action and wind up before the courts. This is a very small number, 2 per cent. What is the figure in Switzerland?
Mr. Dulex: I cannot provide you with any figures, but I would presume that the number is very small as well because there is a lot of private clandestine consumption that does not get included in the statistics. This is a black figure.
The Chairman: Thirty-seven thousand charges were laid in the year 2000. That is a tremendously high number for a population of 7 million, given that we know that drug use in Switzerland is not as high as it is in North America. This figure is relatively high. This is why we would appreciate your assessing the information and providing us with your results.
Mr. Dulex: I appreciate that Switzerland has a population of 7 million, but Switzerland is a small hub in the centre of Europe where we have a tremendous amount of movement, day after day. A large number of what we call French, German and Austrian nationals come to work in Switzerland and then leave. We are simply a crossing point in Europe. This explains why the 7 million are not representative of the percentage you gave.
The Chairman: There is a floating population which is included in the 37,000 charges laid in 2000.
Mr. Dulex: A large percentage of these charges pertain to foreigners.
The Chairman: We saw that in the data.
Mr. Dulex: I was only able to provide you with data on traffickers because we monitor it.
The Chairman: That's interesting. We will write you in order to obtain greater clarification in this area. I would like to go back to the issue of cannabis. Earlier, you gave your opinion on the new proposed measures. You appeared to be very positive about the theory stating that cannabis was a gateway drug leading to harder drugs.
Do you have any scientific data that prompts you to make such a conclusion?
Mr. Dulex: No. In our opinion, this is a fact. We say this based on what we know and from those we have dealt with regularly who have gone down this road. This is based on our experience and this is why I said this. I have no scientific basis and I do not want to quarrel with studies. In the field, the people you meet, the people you stop or apprehend, have gone this road.
The Chairman: Cannabis or similar products were, for these people, gateway drugs, everything started with that. We have no scientific data to support this theory. We have heard experts from several countries and this theory cannot be supported. On the contrary, it can be concluded that this is not a gateway drug. However, as you have pointed out, most heroin users have taken cannabis at one time in their life.
Mr. Dulex: It should be noted, however, that in our young people, we have a relatively high average of deaths caused by overdose.
The Chairman: I believe it is declining.
Mr. Dulex: It should be mentioned that there are a larger number of older people taking hard drugs. It is not quite as frequent among the young people we are dealing with.
The Chairman: The significant decrease for Switzerland as a whole is not as pronounced in the case of Zurich. Is there any explanation for this? In 1991 you reached a high point with 116 drug-related deaths. The present figure is 50. That is a 50 per cent drop. When the 1992 figure for all of Switzerland was 419 dropping to 181 in 1999 and then rising to 205 in the year 2000, why would the statistics be different for the City of Zurich? Maybe I am misinterpreting the information.
Mr. Dulex: It may be a bit uncertain to make a judgment based on these figures considering how small the figures are for Zurich. I cannot give you any more specific explanations but considering the decrease from 116 in 1991 to 82 in 1992, I can only point out that we did close the Needle Park scene in February 1992 and that there was a period of some months of activity after that.
The Chairman: Judging from the number of heroin seizures in your Canton of Zurich, the presence of heroin is enormous. That may explain the difference.
It was very interesting to have this dialogue with you and to learn from your experience. Once again we thank you for accepting our invitation and travelling to see us.
Our last witness this afternoon is Dr. Ambrose Uchtenhagen who is a professor with the Addictions Research Institute.
Dr. Uchtenhagen, you heard my preliminary remarks to the other witnesses. We try to fit the presentation and the questions in a period of one hour and thirty minutes. If we have any additional questions at the end, I shall put them to you in writing. Our questions and your answers will be entered on the committee's Internet site.
[English]
Dr. Ambros Uchtenhagen, Retired Professor, Addiction Research Institute: In 1970, in the framework of psychiatric university services, I set up the first specialized services for drug addicts in our country. For many years I chaired the cantonal drug committee as well as a European research network, financed by the European Commission, called ``Evaluation of Action Against Drug Abuse in Europe.'' Since my retirement as director of Psychiatric University Hospital, I have been president of this addiction research institute, which is a foundation attached to the university. I receive no subsidies, and I live exclusively on research contracts. I am absolutely free to decide which projects I want to tackle.
I have been asked to present to you a summary of the project which has made discussion of Swiss treatment an international topic again. I am referring, of course, to heroin-assisted treatment for refractory heroin addicts, a project that started in 1994, after several years of preparation time. I want to concentrate on the main facts and not give you too many figures. However, I am prepared to answer all your questions.
I will speak briefly about the heroin epidemic that started in about 1971 with an estimated number of 0.5 per cent of the total population. As your chairman has already remarked, there is an elevated prevalence of heroin dependence in our country. That is perfectly in line with a high addiction liability in terms of other substances in our population such as alcohol, tobacco and prescription medications.
Care for addicts was traditionally in the hands of non-governmental organizations, but since the arrival of the heroin epidemic, public agencies and private doctors have engaged in that care as well, in the following sequence. First were the detox-type, or American-type, therapeutic communities. Since 1975, following a major revision of our narcotics laws, there has been methadone maintenance. Since 1988, there have been harm reduction measures and, as you already have heard, repression. Finally, there was the closure of open drug scenes, and, as one of the main elements of the new national policy, heroin-assisted treatment.
You can see that the priority of the response at the outset was along the lines of educating people to live a drug-free life, but then came the evidence that not everyone is able to do so. The sequence in the years following 1975 is along the lines of caring for those who are unable to lead drug-free lives.
Addicts for whom other treatments have repeatedly failed are the main recruiting target population of heroin- assisted treatment. An objective of the program was to avoid premature dropping out of treatment programs. It would not make sense to invite addicts into a new therapeutic program only to have them repeat prior behaviour, that is, dropping out of treatment before it can have an effect.
Other objectives are to reduce illegal and not prescribed substance use in those who participate in the program; improvement of health status and of social integration; and, especially, reduction of drug-related and other delinquency. We wanted to compare heroin prescription with morphine and methadone prescription on the basis of specific international experience, of which you have knowledge, so we felt obliged to compare this approach with morphine and methadone treatments, because morphine and methadone treatments would have caused less controversy than prescribing heroin.
Another objective is the referral to regular treatment programs after stabilization, so that people can find their way through the ordinary therapeutic system.
The design for the main study — the prospective longitudinal cohort study and observational study — was to document and see what happens to people who engage in such a program. Such studies concerned the comparison to intravenous morphine or intravenous methadone via so-called randomized controlled or double-blind sub-studies. The entry criteria for those who wanted to participate in the program were restrictive. It was not a low-threshold program: minimal age, minimal duration of dependence on heroin, documented health and/or social deficits. No one consuming heroin without problems or without failed previous treatments should be accepted into the program. No one should be accepted as a first treatment in this program.
Data sources used in the study were self-report data from the participants, laboratory data, including urine analysis and staff observations, and police data to corroborate the self-report data of the participants.
Following are the main results of the randomized and double-blind sub-studies. Methadone and morphine, when offered intravenously, have a low acceptance in randomized samples. Retention in those two arms, methadone and morphine intravenously applied, is lower, with higher drop-out rates compared to heroin intravenously applied, as well as in the double-blind condition where patients did not know what they were receiving. Morphine still resulted in a much higher drop-out rate, mainly due to differences in side effects.
With respect to compliance with the rules of the program, in the methadone and morphine groups, we had higher rates of illegal heroin and cocaine consumption as compared to the heroin group.
We had to carefully document the side effects of diamorphine, which is the pharmaceutical term for heroin, in heroin-assisted treatment because one of the primary objectives of treatment is not to do harm to your patients. We had to document side effects because the side effects of illegal street heroin are not comparable to those of pharmaceutical heroin. Allergic reactions following injection were the main side effects, especially when applied intravenously. Patients also have the same allergic reactions, but less frequently, after intramuscular injection, which is for patients whose veins are so destroyed that they can no longer inject into their veins. Intoxication following injection is the second side effect, but I may mention that not a single case of fatal overdose has resulted from prescribed heroin among the thousands of patients who have followed this program so far.
The third main side effect is epileptic seizures following injection, which are mainly due to a temporary deficit of oxygen saturation in the brain. Adequately instructing the patients not to lie down or sleep after injection can minimize this side effect.
What are the main findings of the cohort study and not of these mainly pharmaceutical studies? We did not know beforehand whether the whole program would be politically and financially feasible. Only part of the budget came from central government. It is quite important to note that funding had to be found from cantonal or municipal authorities and, in the course of the program, voluntary contributions from health insurance were available.
The safety of patients — as mentioned, no one died from an overdose — and the safety of the staff, that is, protecting staff from aggressive activities was feasible, as was the safety of the environment. The environment in the program was safer as compared to the environment of the injection rooms where a certain amount of purchasing of new drugs would take place.
As to the highly significant reduction in substance use, illegal heroin use dropped significantly. Of course, that is not surprising since the person is being given heroin. The same was true of cocaine use, which was the main reason we stopped the preliminary study with cocaine prescription, which was part of the overall study. We did not see any reduction in the use of cannabis in these patients, but that was of no importance to the health and the social outcome.
Significant improvements in mental health status, a reduction in depressive and paranoid episodes and a reduction in suicide attempts, which are frequent in this population, as well as physical health improvements could be seen. With respect to social integration, there was a significant reduction of delinquency, based on the self-report and police data, and from the central register for court cases.
Crime has been reduced in the participants, particularly crimes that are typical of drug abusers, but also other types of crime.
The majority of those who left the program in the first three years of the study switched to regular follow-up treatment, drug-free treatment or methadone treatment. One of the main questions for the follow-up study was whether they had a better result this time than before coming to heroin-assisted treatment. The follow-up study could assert that improvements are stable at follow-up, including the discharged patients.
As to mortality rates, one of the main issues was to protect people from premature death. In the second year of the study, 1995, we had an elevated rate of mortality, which was mainly due to a high prevalence of HIV infections, AIDS cases and a high incidence of hepatitis in this population. In the following years, the rate of mortality went down, until last year. We are now studying what that elevated death rate means. These are deaths during treatment or within 30 days of leaving the program. The death rate in the overall cohort after a person has left the program for longer than 30 days is different. It is more elevated.
The next item deals with stability of change after discharge and it is a short overview of the relapse rates of those who left the program. Daily cocaine use was found in about 12 per cent at follow-up in those who could be contacted. That represented the great majority of the probands. You can see quite a difference among relapse figures for those who were still in treatment, those who had follow-up treatment and those who had no follow-up treatment. The lower relapse rate in those with follow-up treatment is due not only to a will to be treated and to shake the habit, but also to the influence of the treatment chosen.
The figures are the same for cocaine users who returned to delinquency. There were low relapse rates especially in those who went for follow-up treatment but the figures were a bit higher for those who had no follow-up treatment. Overall, returning to the old habit of delinquent behaviour was pretty low, at 11 per cent. ``Same contact'' means having mainly contact with other active drug users. The relapse rates for that group were in a similar range.
Being Swiss, we also wanted to know how good was the benefit of the resources put into this program. As you can see in the slide, the costs were roughly 50 Swiss francs per patient day in the program, and the calculated benefit, mainly due to the reduction of delinquency, was about 95 Swiss francs per patient day. We could document quite an important gain from the program. Everyone knows that not all the money came the same budgets, but the overall effect was quite obvious.
I now switch to the present state of this treatment. After having evaluated the first three years, the government took the decision to continue, based on the results I just showed you. As you heard earlier this morning, the government decree, which was accepted by the parliament and by a national referendum, ends the legislation in 2004, at which time it must be replaced by new legislation. At present, however, it can continue with 22 authorized clinics around the country prescribing intravenous heroin to patient loads of more than 1,100 patients by now — that was the exact figure from last year — with the highest mean age in all treatment programs in our country, with a mean duration of being on the program of 3.6 years, and with a proportion of male and female participants that resembles the same proportion we have in other treatment programs. Entries during last year were 282. New patient exits were less, which means that more patients tend to stay in the program now.
The present research program monitors who is coming into the program, the characteristics of the patient, the patient's history, the type of problem, who is leaving the program and what kind of services the patient needs during the program.
The clinical monitor is a special monitor that looks at the side effects, including the desired anti-effects, of the program and at a special study on psychiatric co-morbidity. The rate of psychiatric patients among these heroin addicts is elevated. This is what we call ``co-morbidity.'' They are a special burden on staff working in these programs. Therefore, we had to set up a special study on what their specific needs are and how best we could help those patients.
In January of this year, diamorphine was registered as a drug for maintenance treatment of heroin addicts under the name of Diaphine. Switzerland is the first country in Europe that has introduced this. Some countries already have diamorphine registered as a drug for therapeutic purposes, but not for the maintenance treatment of heroin addicts. It is used as an analgesic.
The present conditions for heroin-assisted treatment are that it be used only in authorized clinics; that there will be no private doctors; and that there will be the political will to stick to this policy in the future.
The restrictive entry criteria have already been mentioned. There is, particularly, the stipulation that there must have been multiple previous treatments. Individual permission to enter the program is required from two authorities and those are the federal and the cantonal authorities.
A comprehensive diagnostic therapeutic program does not just involve prescribing heroin, it is a therapeutic program that is prepared to look at all the problems — that is, physical, medical, psychiatric and social problems — the person may be experiencing.
Supervised injections and the no-take-home policy are in sharp contrast to the British practice.
Duration of treatment is not limited, and that is based on the evidence that any administrative limitation of the duration of treatment is counter-productive, leading to relapse. The time for how long patients need methadone or other substitution programs is to be defined individually. Participation in the therapeutic and research program is mandatory. If you have a driver's licence, you must not use it for the time you are on the program. You are not allowed to drive a car or a motorbike while on the program. That stipulation is based on good intention: You should not drive under the influence of injected drugs.
We have just finished a second six-year follow-up study. The data from that study has not yet been published. All entries — that is, the complete cohort until March 1995 — are involved in this follow-up from eight clinics and 366 patients. During this time, 43 have met their deaths. Follow-up was made with face-to-face interviews by independent interviewers rather than by staff from the clinics. The attrition rate was 25 per cent, which means that for face-to-face interviews we could contact 75 per cent of all participants, including those who had left the program, which is pretty high and representative. Participation in follow-up treatment was not quite half of this cohort.
Referral to drug-free residential treatment was 24 per cent of those who had left the program, and to methadone maintenance 22 per cent of those who had left the program. This means that total referrals to other treatment was a bit lower than in the beginning, at almost 50 per cent.
What were the findings regarding daily illegal drug use by patients who are still on the program and by those who have left the program, who we refer to here as ex-patients? We checked the consumption of heroin, cocaine, tranquilizers, benzodiazepines and cannabis. What do we see here? Looking at the red bars, it indicates heroin use. ``T0'' is daily heroin use when entering the program, of those who are still on the program. ``T6'' is daily heroin use at follow-up, six years later, of those who are still on the program. It is absolutely minimal. Also the ``A6,'' which means those who had left the program, have seen an enormous reduction in daily heroin use. At entry, it is the same as those who are still on the program, and at follow-up about 20 per cent of those who left the program returned to daily heroin use.
Looking at cocaine figures, which are the yellow bars, you also can see highly significant reduction in those who are still on the program, but also in those who are out of the program. There is no reduction in cannabis, the grey bars, but also significant reduction in benzodiazepine use, that is, non-prescribed tranquilizers. This is an interesting finding, and the interpretation of this finding probably is that the good psychiatric care people get results in less need for non- prescribed tranquilizers. You probably know the so-called self-medication hypothesis — that people take drugs for improving their own state of mind in a kind of self-medication; and if they get proper treatment and proper medication, they need fewer drugs.
Regarding social status of patients, you may see again that homelessness has practically disappeared in those who left the program. You can also see that illegal income — these are the red bars — has highly significant reductions in those who left the program, A0 to A6, but that unemployment did not change much. This is mainly due to the difficulties in the labour market to reinstate patients even when they are ex-drug users. Some have found a job and others have lost their jobs, so this is not a very good result. ``Court cases'' means new court cases pending, and there also you can see a tremendous reduction in new court cases in these patients.
What are the conclusions? Treatment-resistant heroin addicts can be reached and sufficiently retained in this type of treatment. Use of illegal and non-prescribed substances can be significantly reduced. Safe and stable dosages are feasible. I did not show you the figures on that, but one of the anxieties was that once you prescribe heroin people will need more and more, which is not the case. On the contrary, the average dosage slows down during participation in the program.
Side effects can be well-controlled by adjusting the dosage and by adequate care measures. Motivation to engage in drug-free treatment increased during treatment. There was not a decrease in motivation to get off drugs. The result was to the contrary. Health and social improvements are stable over time, and have been documented for six years.
What are the consequences of these findings? Heroin-assisted treatment will continue with restrictive indication as a kind of last resort. Suppose that the referendum results in a positive verdict. It will be available in authorized clinics only, which means that the authorization can be taken away if the rules are not followed by the clinics. Treatments other than heroin-assisted treatment will be optimized, and important steps in that direction have been taken. Heroin- assisted treatment should not replace any other treatment, but other treatments are qualitatively supported and staffs are supported to be even better than up to now.
There will be a coordinated monitoring of all treatment in a national statistic of addictions, and this will be the basis of continued comparative evaluation of outcome, including cost-effectiveness analysis. I have talked about the consequences in our country. I may mention that since we made our first study similar projects have seen the light in other countries. The Netherlands started a heroin co-prescription project, as they call it, in 1998, and the results will be published when they have been presented to parliament in March this year. Germany is implementing heroin-assisted treatment this year on a large scale in eight cities. Belgium has prepared a project that has not yet found approval of the government. France is looking into authorizing a heroin prescription project that already has been designed. Canada is engaging in the NAOMI, the North American Opiate Maintenance Initiative. Spain has formulated two projects that are waiting for government approval. It is interesting to see that other countries with a heavy heroin problem are looking at the same type of additional treatment options for those who have not profited from other treatment. That is a main feature of all these projects as far as they are documented.
The WHO, as you know, has made an expert report on the Swiss experience, confirming their findings but advocating additional research efforts, which are needed. These recommendations have been taken into consideration in the Dutch and German projects. Finally, the UN organization in Vienna has been very concerned about our efforts, but they always gave the green light to continue what we had proposed to them.
The Chairman: Just to follow up on your last remark, what is the reaction in Vienna to the findings of the two analyses you made?
Dr. Uchtenhagen: They did not make many comments on the results. Their main concern is — and I can well understand this — that such a project may be run well in a well-organized country, but it may show very different results in a less well-organized country, where diversion into the black market, for instance, or unreliability of data are more common. That is the main concern.
The Chairman: They already have that concern with other drugs, so it is not new.
[Translation]
The Chairman: How is the heroin supplied to the clinics? Through diamorphine?
[English]
Dr. Uchtenhagen: First, it was a state secret. I can tell you, we imported it from France; when it became public knowledge that we had it from France, the French government put a stop to it.
The Chairman: I know it was here in Canada; it was one of the big concerns they had with the NAOMI project.
Dr. Uchtenhagen: Now we produce it in our country. Other countries that are now engaging in similar projects have applied to get it from the Swiss source.
[Translation]
The Chairman: Why was cocaine withdrawn from your project at the very outset?
[English]
Dr. Uchtenhagen: Our government said that, once we engage in such a difficult exercise, we want to profit in every way we can, eventually including cocaine prescription. We did so, prescribing non-tobacco cocaine cigarettes. We did so for about three months for a limited number of heavy cocaine users.
We evaluated the findings, and found that some of those patients could cope perfectly well with the cocaine cigarettes without reverting to injecting cocaine. This was the positive part of it. The negative part was that others, when they had cocaine cigarettes, felt a stronger urge to have a strong dose of coke intravenously, and their consumption rose higher than before. It was a mixed bag of results, which made us very cautious.
The second reason we were very cautious is that the effects of cocaine are so different from the effects of heroin. With cocaine, you may introduce a paranoid psychosis, even in a person who never had psychosis before, which is not the case for heroin. Being doctors, we are very reluctant to introduce psychosis in one of our patients. However, the main reason we discontinued this line was the finding that cocaine use in those who did not receive cocaine was also diminishing. As you have seen, the figures for daily cocaine use were reduced consistently and highly significantly, so why prescribe cocaine in a project where cocaine use is going down. These are the main reasons they discontinued the project.
This did not affect us as researchers, but politicians in our country were very happy that cocaine prescription was discontinued because prescribing cocaine would have caused even more controversy than prescribing heroin.
[Translation]
The Chairman: As you explained, there are 22 clinics operating in your country. That means the treatment is not being offered to all the Swiss citizens in need of it. Could you give us some idea of the importance of public opinion?
The results of a recent referendum indicate that a majority of the Swiss population supports this type of treatment. Can you tell me how the situation has evolved and how you perceive it?
[English]
Dr. Uchtenhagen: I cannot say what people think, but I am disposed to think that seeing the effects of the project — not only the scientific results, but the disappearance of drug scenes in the cities — has had a major influence in this shift of public opinion. One of the advantages of the repeated referenda was the very intensive public debate on the issue. Every fact and all the figures that were handed out were debated, so the preconceived opinions about heroin changed significantly.
People, in a majority, are convinced that heroin can be prescribed without killing the patient or causing major disadvantages for the patient, even though heroin is the killer drug on the streets. This discrepancy, I think, is now understood by our population.
We also were concerned about the image of heroin in the perception of young people. We were extremely concerned that changing the perception of heroin from a killer street drug to a prescribed medication could give young people the notion that heroin is not really harmful and that they could experiment with it. We found that the image of heroin has never been so low than at the end of this heroin trial, and especially the image of the heroin user. It is quite understandable that the career of a person who has to come forward three or four times a day for supervised injection is not attractive to young people.
We also found that the decision to experiment with illegal drugs is not dictated by the legal status of the drug but by the perceived risks and danger. There, the differences between heroin on the one hand and cannabis on the other hand could not be greater.
Senator Christensen: Therefore, it seems that the higher the risk, the more popular the drug was.
Dr. Uchtenhagen: When the risk was higher, there was less intention to ever take it in your hands.
[Translation]
The Chairman: Could you describe to us a day in the life of a patient at one of your clinics?
[English]
Dr. Uchtenhagen: When he awakes in the morning, he feels the urge for the next injection.
The Chairman: Where is he living? I have seen on the chart that he is not homeless. He is living somewhere.
Dr. Uchtenhagen: He lives alone, somewhere, and some have returned to their families. In the course of the program, reconciliation with the family of origin is often the case. However, at such an age, many choose to live on their own. It is a fascinating experience to see how many of these patients find an apartment for themselves. It was our feeling that they would be ``non-acceptable'' in a normal, multi-family house. On the contrary, many owners of houses are happy to rent apartments to these people because the rent is guaranteed by the social agency responsible for the patient. Therefore, this is not really a problem.
Those who cannot live on their own live in numbers in protected apartments. That means that they are regularly visited by a social worker. The city rents the apartment, puts up the patients and visits them regularly — two or three times per week. The settings are quite different, but there is practically no homelessness, although we do have homeless people.
[Translation]
The Chairman: So the person's private life takes place in a relatively stable environment and he shows up at your clinic?
[English]
Dr. Uchtenhagen: Yes. It is part of integration.
[Translation]
The Chairman: And how does the day unfold? Is there more than one injection during the course of a day? You told us that they can receive between three and four injections a day. Can you describe to us your patient's daily routine?
[English]
Dr. Uchtenhagen: When they enter the program, they have to adjust to the rules of the program and they must learn a great deal. They attend three or four times each day, and they may even stay for hours in the program, talk with a social worker and learn about the program. The first thing to tackle is finding the adequate daily dosage for the individual. This dosage determination is between the individual and his or her doctor. We carefully step up the dosage day by day so that intoxication is avoided.
Once this is settled, other matters can be tended to, such as the individual's physical health. Many areas of the individual's health may need medical or psychiatric attention. Also, stabilizing the living conditions is a primary concern, because once someone lives on the streets, it is difficult to stabilize anything else, including health. Therefore, putting the person up somewhere in a well-organized surrounding is of primary importance.
Once the individual's daily dosage is stabilized and he has a place to live, then other concerns arise. For instance, the individual's days are now empty. Previously, the individual was busy looking for his drugs or busy in small-scale trafficking. Now, there is no need to do that. Thus, he has a boring existence. Many in the first phase become depressed, but it is a different kind of depression. They do not know what to do with themselves. So, they have to take some lessons on how to reorganize their lives. Going to a daily job, to school or to any kind of program and making contact with other groups of people in treatment or outside of treatment is one of the main activities that must be resolved.
Once a job has been found or the individual has returned to school or is engaged in another daily program, he or she prefers to reduce from three or four injections per day to one or two injections per day, combining injectable heroin with oral methadone. With one heroin injection in the morning and an adequate dosage of oral methadone, the person can cover his need for opiates for 24 hours. Thus, he is free to organize his day. The majority on the program are choosing this kind of arrangement.
[Translation]
The Chairman: That is quite impressive. You mentioned that the way in which heroin is perceived by the population has evolved. Heroin was perceived less as a killer and more as a drug that could be obtained by prescription. Were you afraid that there would be an increase in heroin consumption on the black market?
[English]
Dr. Uchtenhagen: There are two questions in that. If we had some concern about prescribed heroin being on the black market —
The Chairman: No, no.
Dr. Uchtenhagen: We did not know, and we could not know beforehand. We simply took care that no prescribed heroin should ever come to the black market. I believe that, according to police information, this is correct.
The Chairman: Do you want that?
Dr. Uchtenhagen: Yes, due to the severe visual control of the injections. It is not possible to take heroin out of the clinics. We had two break-ins at the clinics with the intention to get to the heroin, but they did not succeed.
The other question was whether in general heroin consumption would increase. As I mentioned, heroin still has the image of a highly risky drug. This has not changed. In fact, we observe in all the surveys that have been done and that have been quoted before that heroin consumption did not increase. What we could see is a certain change in mode of application. Injection rates regarding heroin have gone down, not as in the Netherlands where you find only a 10 to 20 per cent rate of injections nowadays, but it still went down from almost 100 per cent to around 80 per cent. Some 20 per cent do not inject. This pertains mainly to the very young who start smoking from tin foil. There are some studies that show that for economic reasons, later on, a small percentage of those people switch to injection use. You need much more heroin for inhaling than you do for injecting. It is a money issue. However, it pertains to only a small proportion of the population. Some continue to inhale, which has created a situation for the clinics.
What is an adequate response to someone who is heavily addicted to heroin and who has tried other treatments that have failed and who has never injected? If he has never injected before, we cannot offer him injectable heroin in the clinic. We now offer, with good acceptance rates, slow release heroin tablets to these people. They are quite happy. Thus far, we have good retention in those persons. However, this has been a short experience. In contrast to the Dutch, we do not offer inhalable heroin.
Senator Christensen: Did you say that there are six clinics in this particular study?
Dr. Uchtenhagen: In the follow-up study, we considered patients from eight clinics. This refers to the first eight clinics that were started in the early phase. There are now 22.
Senator Christensen: Where are those eight clinics situated? Are they all in the same area or are they in different parts of the country?
Dr. Uchtenhagen: The majority of the clinics are situated in the German-speaking part of the country. The eight clinics to which I refer are in different places in the German-speaking part of the country.
Senator Christensen: How do people get into those programs? What is the process for being accepted into the program?
Dr. Uchtenhagen: Practically everyone nowadays knows about the clinics. If an individual feels the need, or if he or she has contact with a social service that has the information, the individual knows where to apply. A person applies directly to the clinic. The clinic is obliged to take a full history, including, of course, the history of drug taking, the history of former treatments, and so on, determining whether the individual fulfils the entry criteria. If so, they hand over this information to the federal office of public health and to the highest medical officer in the respective canton. The medical officer determines whether the individual in question is already on a methadone program, in which case the patient has to decide if he wants to stay on the methadone program or if he wants to go to the heroin clinic. He cannot do both at the same time.
Senator Christensen: You were also saying that the average duration is 3.6 years. What happens when an individual drops out? What follow-up is there? Does he or she go back to the street?
Dr. Uchtenhagen: The clinics are obliged to propose to everyone leaving the program what else they can do in terms of follow-up treatment. This can be accepted or refused; however, it is the obligation of staff at the clinic to do so. As you have seen, about half of those who leave the program go to follow-up treatment. Some go back to the streets, while others stop the habit completely — which means that the heroin-prescription program was the last therapeutic effort needed to result in a drug-free life. Some are dead.
[Translation]
The Chairman: The issue of cannabis is currently the focus of our committee's work. Your presentation shows that cannabis use by patients in clinics has not changed over the past six years. You also stated in your presentation that cannabis was of very little importance in your patients' history of drug use.
Mr. Uchtenhagen: No.
The Chairman: No; can you comment on that please?
[English]
Dr. Uchtenhagen: No, I mentioned that the consumption of cannabis has no major impact on the results of participating in the heroin program. That is another issue. Of course, they have in their previous history been engaged in cannabis use, as most of the people we contact who have a heroin problem have also had a cannabis problem, as Mr. Dulex already explained. On the other hand, this is why we have no evidence for the stepping-stone hypothesis. The large majority of those who have engaged in cannabis use have never touched heroin. That is the other side of the coin.
[Translation]
The Chairman: The theory that cannabis is the start of a long path of drug use has never been proven in evidence our committee has heard from witnesses nor in the serious studies that we have consulted. I wanted to confirm our committee's finding with your work.
Mr. Uchtenhagen, we are pleased that you accepted our invitation, and I thank you for the interest you have shown in our work. If, in the coming weeks, you feel it is appropriate to send us additional information, please do not hesitate to share it with us.
Before we adjourn, I would like to remind all of those who are interested in the work of this committee that they can find more information on illegal drugs by consulting our Web site at the following address: www.parl.gc.ca.
There you will find the briefs submitted by all of our witnesses, as well as there biographical data and any supplementary documentations submitted by the witnesses. There are also more than 150 links related to illegal drugs. E-mail messages may also be sent to us through this Web site.
On behalf of the Special Senate Committee on Illegal Drugs, I would like to thank you for the interest that you have shown in this important study.
We shall now adjourn until the next sitting of the Special Senate Committee on Illegal Drugs that will take place on March 11, 2002. At that time, we will be hearing from various national non-governmental organizations in Canada.
The committee adjourned.