Triple Epidemic: the Swiss way Switzerland suffered from a heroin epidemic that had its peak around

1990 and went together with a HIV epidemic among IVDUs. To tackle this situation a national 4 pillar drug policy was used that added to the traditional approach harm reduction. This included needle exchange and safe injecting facilities and an expansion of substitution treatments, incl. heroin assisted treatment. This newly introduced treatment mode caused some international uproar despite its tradition (UK, US). All these measures are based on human rights. This multimodal approach resulted in Switzerland in a reduction of the overdose death rates, reduced incidence of new HIV infections among drug users and a reduced incidence of new heroin addicts. Today drug users have easy access to substitution treatment, which either are provided by GPs or specialized treatment centres. Specialized treatment centres are basically psychiatric institutions that are able to provide an integrated service for addiction and psychiatric disorders at the same time. As substitution medications are methadone, buprenorphine, diacetyl-morphine (heroin) and in the near future morphine available. This variety is necessary to tailor best the treatment to the needs of the patients in the daily practice. Alternatives to methadone are necessary in patients with long QTc, especially if they need neuroleptics for psychiatric conditions. Principally all treatments are also available in prisons. However, in the present situation new problems arise from the fact that actual heroin users are an aging population that suffer from a whole range of physical disorders incl. chronic Hep C infections and severe osteoporosis. For this reason most specialized treatment centres include nowadays general medical services.

Robert Haemmig MD Medical director addiction services of University Psychiatric Services Berne President of Swiss Society of Addiction Medicine

5 CME questions: 1. Harm reduction is based on modern bioethics False or True? 2. The 4 pillar drug policy of Switzerland was able to stem against the heroin and HIV epidemic. False or True? 3. Prisoners have not the right to get the same services as outside the walls. False or True? 4. Prescribed heroin injections for addicts were never available in the US so far. False or True? 5. Methadone can be dangerous in patients with long QTc, especially when they need neuroleptics. Alternatives for them can be buprenorphine or morphine. False or True?