Scottish Drugs Forum Glasgow 30th June 2005 Residential Drug Services – Where do they fit on the treatment map? The situation in Switzerland Nicolas Heller Gilgamesch House Basle, CH Tel:

ComparisonSwitzerlandScotland Area: 15,940 sq mi 78,782 sq mi Area: 15,940 sq mi 78,782 sq mi Population: 7,450,867 5,054,800 Population: 7,450,867 5,054,800 IDU: 30,000 50,000 IDU: 30,000 50,000 (15-49 years old) 0,9% ?%

Language(s) German60% German60% French30% French30% Italian10% Italian10% Romansh Romansh

Political divisions  26 cantons (responsible for health services)  2,904 communes  26 “different” drug policies

Switzerland's drug policy 1980s: 1980s: HIV-AIDS epidemic HIV-AIDS epidemic “Open drug scenes” “Open drug scenes” Miserable state of drug addicts becomes visible to everybody (public pressure to act) Miserable state of drug addicts becomes visible to everybody (public pressure to act)  Needle exchange programmes  Hepatitis vaccinations

New approach: Harm reduction 1990s: 1990s:  Fourfold approach (4 pillars): 1. Prevention 2. Law enforcement 3. Treatment 4. Harm reduction  300 projects/programs supported by 6,5 millions Pounds/year

Heroin assisted treatment HAT  Severely dependent heroin addicts, who had failed at other treatment programmes, “treatment non-responders” Restricted clinical trials Restricted clinical trials Strict scientific evaluation Strict scientific evaluation Begin 1994 – End 1996

Evaluation report (1997) Increase of physical and/or psychic health Increase of physical and/or psychic health Increase of quality of life (housing, work etc.) Increase of quality of life (housing, work etc.) Decrease of illegal use of heroin/cocaine Decrease of illegal use of heroin/cocaine Decrease of prostitution and criminality Decrease of prostitution and criminality Economy benefits Economy benefits  Since 1999 HAT recognized type of therapy

Treatment  Objectives: Breaking drug addicts of their habit Breaking drug addicts of their habit Social reintegration Social reintegration Better physical an mental health Better physical an mental health : - 1,280medically prescribed heroin - 14,588medically prescribed methadone (1979: 728) - 486medically prescribed buprenorphin - 51medically prescribed morphin

Residential drug services 1999:100 institutions – 1,750 spaces 1999:100 institutions – 1,750 spaces  Thunderclouds: - Lower demand - Standard Quality Management System - 80% occupancy at least claimed  2005: 80 institutions – 1,000 spaces

Costs Residential rehabilitation: Residential rehabilitation: 150 Pounds/day Social welfare Residential detoxification: Residential detoxification: 300 Pounds/day Health insurance Methadone programmes: Methadone programmes: 20 Pounds/day Health insurance Heroin assisted treatment: Heroin assisted treatment: 20 Pounds/day Health insurance o Welfare outpatients: + 40 Pounds/day + 40 Pounds/day

Drug-abstinence  Methadone programme (2 years): 42,4%  Abstinence based therapy (1 year): 50%

Traditional residential services Aims: Aims: withdrawal / abstinence / reintegrationwithdrawal / abstinence / reintegration Duration: Duration: short / medium / longshort / medium / long Interventions: Interventions: clinical detoxification / psychosocial support / counselling / group therapy / employability trainingclinical detoxification / psychosocial support / counselling / group therapy / employability training

Main treatment goal  Empowering to lead a life 1. as independent as possible 2. as satisfying as possible for themselvesfor themselves and their social environmentand their social environment

Combination of residential and substitution benefits 2 residential rehabilitation services specialized for addicts in methadone programme and/or heroin assisted therapy: 2 residential rehabilitation services specialized for addicts in methadone programme and/or heroin assisted therapy: 1. House Gilgamesch, Basle (since 1995) 7-12 beds 2. Saurenhorn Community, Berne (since 1998) 10 beds

Challenges  Concomitant cocaine and crack cocaine consumption Resulting relapses for substituted patients Resulting relapses for substituted patients  Psychiatric co-morbidity Flexible, made-to-measure setting Flexible, made-to-measure setting Training for the staff Training for the staff

Thank you