by Johann Hari
“I was sick, I was dirty,” when he first came here, he says. “I was really quite a typical addict.” He couldn’t concentrate to watch a film for more than a few minutes; he couldn’t eat fruit or anything even vaguely greasy, because his digestive system was so curdled by the street contaminants. He had been shooting up for thirty-five years. “When you are using on the street, you feel death already hiding inside you. You can feel it and you can see it,” he says. “You have death inside yourself, and death is progressing.”
He tried methadone, but it did nothing for him. He still craved heroin all the time. He would wake each morning in a flop-sweat of panic, asking himself: How am I going to get the money I need to buy my smack today? He was trapped in the constant misery-go-round of get money, buy heroin, inject, get money, buy heroin, inject, all day, every day.
“It’s not just an addiction. It’s a job,” he says. He survived only by being involved in drug trafficking—he doesn’t want to give the details, except to say that he was a “middleman”—until one day, he heard about the prescription program established by Ruth Dreifuss.
This is the last option in the system for people who cannot be helped any other way. To be eligible, you need to meet three conditions: you have to be over eighteen, you have to have gone through at least two other treatment programs without success, and you have to hand in your driver’s license.
“It wasn’t easy to accept and see at first,” he says. “All addicts are in a total confusion.” Suddenly, his constant scrambling for his drugs was taken away, and he had a day ahead of him he had to fill. He tells me patients here “have to reinvent our lives. We have to reinvent the imagination.” The heroin program is built around helping the patients to slowly rebuild: to get therapy, to get a home, and to get a job. One of Jean’s fellow patients, for example, owns a gas station, while another works in a bank. He discovered that “once you have stability, the speed of events decreases, and you come back into a normal life, and you say—okay, what am I going to do now?”
It’s hard to do this, after being addicted for so long, but Jean says “the pain I have now isn’t the pain of a sickness. It’s the pain of being reborn.” For the first time in decades, “I feel well and happy, to have recovered things I had completely forgotten.” He has started to eat fruit and watch films and listen to music again. “You can come back,” he says, “to reality.”
Harry Anslinger believed he had spotted the crucial flaw in heroin prescription programs like this. Addicts’ bodies gradually develop a tolerance for their drug, so he said they would need higher and higher doses over time to achieve the same effect. “The addict is never satisfied62 with his dose; he always tries to get more,” he explained. He praised two of his officers who laid out what they called the First Law of Addiction: “A person in the condition of63 opiate addiction, with free access to opiates, will continue in that condition at an accelerated rate of consumption unless the course of addiction is deterred by some extraneous force.”
That observation seems to make sense. Yet at this clinic, they tell me, they have discovered something that contradicts it.
If you are an addict here and you want a higher dose of heroin, you can ask for it, and they’ll give it to you. So at first, most addicts demand more and more, just as Anslinger and his agents predicted. But within a few months, most addicts stop asking for more and choose, of their own free will, to stabilize their doses.64
After that, “most of them want to go always down,” explains the psychiatrist here, Dr. Rita Manghi. Jean, for example, started at the clinic taking heroin three times a day—80 mg in the morning, 60 mg in the afternoon, and 80 mg in the evening. Now, he takes only 30 mg in the morning and 40 mg in the evening, and he says, “I’m on the brink of saying to my doctor I don’t want any more.” He is a typical user here.
Suddenly, the slightly depressing debate at the start of the drug war between Harry Anslinger and Henry Smith Williams—prohibition forever versus prescription forever—seems bogus. But in this clinic, they have discovered that that isn’t the real choice. If you give hard-core addicts the option of a safe legal prescription and allow them to control the dose, the vast majority will stabilize and then slowly reduce their drug consumption over time. Prescription isn’t an alternative to stopping your drug use. It is—for many people—a path to it.65
“This program,” Jean says, “gives you the chance to recover the control you have lost,” step by step, day by day. A Portuguese psychiatrist who treats people here, Dr. Daniel Martin, tries to explain it to me by giving me a visual image.
Most addicts here, he says, come with an empty glass inside them;66 when they take heroin, the glass becomes full, but only for a few hours, and then it drains down to nothing again. The purpose of this program is to gradually build a life for the addict so they can put something else into that empty glass: a social network, a job, some daily pleasures. If you can do that, it will mean that even as the heroin drains, you are not left totally empty. Over time, as your life has more in it, the glass will contain more and more, so it will take less and less heroin to fill it up. And in the end, there may be enough within you that you feel full without any heroin at all.
Users can stay on this program for as long as they want, but the average patient will come here for three years, and at the end of that time, only 15 percent67 are still using every day.
Before, being a heroin addict was violent and thrilling—you were chasing and charging around. In Switzerland today, it is rather dull. It involves sitting in clinics, and being offered cups of tea. The subculture is gone.
After the clinics opened, the people of Switzerland started to notice something. The parks and railway stations that were filled with addicts emptied. Today, children play there once again. The streets became safer. The people on heroin prescriptions carry out 55 percent fewer vehicle thefts and 80 percent68 fewer muggings and burglaries. This fall in crime was “almost immediate,”69 the most detailed academic study found. The HIV epidemic among drug users stopped. In 1985, some 68 percent of new HIV infections in Switzerland were caused by injection drug use, but by 2009, it was down to approximately 5 percent.70
The number of addicts dying every year fell dramatically,71 the proportion with permanent jobs tripled, and every single one had a home.72 A third of all73 addicts who had been on welfare came off it altogether. And just as in Liverpool, the pyramid selling by addicts crumbled to sand: people on the heroin prescription program for a sustained period were 94.7 percent74 less likely to sell drugs than before their treatment. Jean tells me the drug dealers he used to work for are “completely against this program. They can control people in weak states and make money from them. If I was still in the criminal milieu, they could make me a killer, I would do anything.” As he said this, I thought of Chino and Rosalio. “But now? No. I am lost for them.”
The program costs thirty-five Swiss francs75 per patient per day, but it spares the taxpayer from having to spend forty-four francs a day76 arresting, trying, and convicting the drug user. So when people ask “Why should I pay for this?” the pragmatic Swiss answer is: This doesn’t cost you money. It saves you money.
But I was still wondering all the time—how did Ruth manage to sell these policies in such a conservative country? My Swiss relatives are often way to the right of the Tea Party—and they are regarded as moderates. This isn’t like people opting for drug reform in San Francisco—it’s like people opting for drug reform in Lubbock, Texas.
I knew she couldn’t have gone over the people’s heads, because Switzerland has a system of deep democracy. If you are a Swiss citizen and you don’t like a law passed by the parliament, all you have to do is gather fifty thousand signatures,77 and you will trigger a national referendum on whether it should be struck down entirely. In the late 1990s, a conservative group triggered a national referendum on heroin prescription, and there was a rowdy national debate—or as rowdy as Switzerland ever gets.
Ruth and the ma
ny people who agreed with her introduced something to the drug debate that nobody had ever tried anywhere else in the world. Ever since Anslinger, the drug warriors had presented themselves as the forces of order ranged against the chaos that would inevitably be brought by any relaxation in the drug laws. But, in a political jujitsu move, Ruth reversed that argument. Swiss citizens could see now that U.S.-style drug crackdowns had brought chaos to their streets—and after the government provided a legal route to heroin, the chaos vanished. So they argued that the drug war means disorder, while ending the drug war means slowly restoring order.
This argument won. In 1997, some 70 percent of Swiss electors voted to keep the reforms. In 2008, the conservative forces regrouped and called another referendum. The campaign supported by Ruth ran posters of a young mother with her baby, saying: “I want to keep our public parks free of syringes.” Another poster showed a couple in their fifties saying: “Thanks to treatment, our son could quit drugs.” This time, 68 percent78 backed the policy. These campaigns showed,79 in embryo, the case that, I believe, could end prohibition around the world.80
They did it to protect and defend not the addicts, but themselves. This is, it occurs to me, a crucial lesson for drug reformers. Those of us who believe in ending the drug war already pretty much have the liberals and leftists on our side. It’s the moderates and the conservatives we need to win over—and the way to do it may be heard in a distant yodel from the mountaintops of Switzerland.
One day, Ruth went as president to a heroin clinic in Bern to talk to the addicts there, and among them was one young man—well-dressed and handsome—whom she tried to strike up a conversation with, but he seemed shy, and would barely say a word to her. To her surprise, as she was leaving, he handed her a note, and said she should wait until she was back in her office before reading it.
“Six months ago81 I was in the streets,” he said. “I hated myself, I had lost all respect for myself. I was dirty, I slept outside in the streets and the parks, and [then] I was accepted in the clinic . . . and now I am coming three times a day to receive my heroin. I regained respect.” And then he explained that he had been reluctant to talk to her because now he worked for her, in the department she runs.
“When you read such a letter,” she says, “you can continue for many years on that.”
It’s hard, I say to Ruth in her apartment in Geneva one afternoon, to imagine an American president or British prime minister doing what she has done: sitting with addicts, learning their stories, and urging people to help them. “They should,” she says. “You have to learn and to see with their own eyes.” If she was stuck in an elevator with Barack Obama and David Cameron, she would tell them: “You are responsible for all of your citizens, and being responsible means protecting them and giving them the means to protect themselves. There is no group that you can abandon.”
Yet the same forces that had pressured Britain into locking down John Marks tried to intimidate the Swiss. The International Narcotics Control Board declared: “Anyone who plays82 with fire loses control over it,” and said Switzerland was “send[ing] a disastrous signal to countries in which the drugs were produced.” But Ruth Dreifuss was not going to be intimidated by anyone. When the U.S. drug czar, General Barry McCaffrey, visited Europe, he went to the Netherlands and held a press conference at which—like a colonial governor addressing the natives—he berated the Dutch government for their wickedness. He was scheduled to come to Switzerland shortly after. “It was terrible what he said in the Netherlands [about] the cannabis shops,” Ruth says.
So she called him and explained: “There will be no83 press conference in Switzerland. We do not accept [for] you to interfere in our political debate.”
Once she left office, Ruth came together with other former heads of state—including President Fernando Henrique Cardoso of Brazil—to set up an organization called the Global Commission on Drug Policy, demanding an end to the global drug war. When I spoke to her, she had recently been to Mexico, Ghana, Budapest, Vilnius, and Italy. Everywhere she goes, she says, she can see that “doubts are rising,” and people are eager to hear about the rational alternatives.
It’s even harder to imagine, I tell her, a former U.S. president or British prime minister living a minute’s walk from a heroin clinic.
“As far as possible, we always wanted to have these places in the center of the city,” she says, smoking a cigarette and flicking the ash. “For many reasons. I mean, these people have to come regularly. We can’t send them I-don’t-know-where. When they have a job it’s important they can come during the lunch break or so. It’s practical.”
And she looks out the window, in the direction of the heroin clinic.
After I returned from Switzerland, I enthusiastically jabbered to several Americans about these results and said they should be tried back in the Land of the Free—and they often came back with a response that threw me.
But we already prescribe powerful opiates, they said. We prescribe Oxycontin and Vicodin and other painkillers—and, far from having the effect you are describing, it has caused a disaster. Look, they said, at the headlines any day of the week. More people are becoming addicted every year to prescription drugs that they were given at first for pain relief. More people are overdosing. More people are becoming criminals. More people are transferring to even harder drugs, like heroin. You want more of that?
This narrative was everywhere—including in liberal outlets normally receptive to drug policy reform, like Rolling Stone. The conclusion seemed obvious: for some reason, in this country, prescription doesn’t reduce problems—it metastasizes them.
This seemed to blast a hole in the case for providing legal access to the most potent drugs in the United States, and I was sent into a spiral of confusion. I looked over the evidence, and these critics seemed to be right. Oxycontin and Vicodin addictions are indeed spreading in the United States, and they are causing more criminality and overdose. The cause, everyone seems to agree, is that doctors have prescribed the drugs too freely.
How could it be, I asked myself, that opiate prescription worked so well in Switzerland but was proving to be a disaster in the United States? Is this just a deep cultural difference? Or is there a flaw in the Swiss model that I’m not seeing?
It was only when I discussed this with Meghan Ralston, an expert on prescription drugs with the Drug Policy Alliance, with Professor Bruce Alexander back in Vancouver, and with Dr. Hal Vorse, a medical doctor who treats prescription drug addicts in Oklahoma City, that I began to understand what was really happening. Between them, these three experts raised three different questions that forced me to see the prescription drug crisis in a radically different light.
The first question that made me think again is: When do the worst problems associated with Oxycontin and Vicodin, the ones you see on the news, start? When do the addicts start to hold up pharmacies to get their next batch, or prostitute themselves, or start overdosing on a massive scale? Meghan Ralston, one of the leading experts on this crisis, explained to me: They don’t begin when the drugs are prescribed. They begin when the prescriptions are cut off.
The United States, she explained, doesn’t have a Swiss-style policy of prescribing Oxycontin or Vicodin or other opiates to addicts. In fact, it has the precisely opposite policy. If I am an American who has developed an Oxycontin addiction, as soon as my doctor realizes I’m an addict, she has to cut me off. She is allowed to prescribe to treat only my physical pain—not my addiction. Indeed, if she prescribes just to meet my addiction, she will face being stripped of her license and up to twenty-five years in jail84 as a common drug dealer—just like Henry Smith Williams’s brother at the birth of the drug war.
That’s when, in desperation, I might hold up a pharmacy85 with a gun, or go and buy unlabeled pills from street dealers. Most of the problems attributed to prescription drugs in the United States, Meghan Ralston says, begin here, when the legal, regulated route to the drug is terminated. Nobody, she explai
ned to me, swallows 80 mg of Oxycontin prescribed by their doctor and goes out to commit a crime, or dies of an overdose. No: it’s when the doctor realizes the patient is an addict and cuts them off that all the trouble begins.
This is so different from how the prescription drug crisis has been almost universally reported that it took some time for me to absorb it. It was only when I began to think about it in relation to the last time drugs were sold freely in the United States—before 1914—that I started to understand.
Remember the transformation Henry Smith Williams lived through. Before the ban, almost all opiate users would buy a mild form of the drug at their corner store for a small price. A few did become addicts, and that meant their lives were depleted, in the same way that an alcoholic’s life is depleted today. Nobody should dismiss this effect: it is real human suffering. But virtually none of them committed crimes to get their drug, or became wildly out of control, or lost their jobs. Then the legal routes to the drug were cut off—and all the problems we associate with drug addiction began: criminality, prostitution, violence.
The same pattern is playing out today with prescription drugs. If I am a young man with a legal Oxycontin prescription that I am using compulsively to deal with my psychological pain, my life will be depleted, and sluggish, and incomplete. If I am cut off from that prescription—if my own personal 1914 hits me—my life will become disastrous, and I will start acting in all the chaotic ways associated with the prescription drug crisis today. It is when the legal routes are cut off that the worst begins. So, Meghan says, the prescription drug crisis doesn’t discredit legalization—it shows the need for it.
But what does “legalization” mean when it comes to prescription drugs? Some people would argue that they should be openly sold, like alcohol—but I think Switzerland’s heroin experiment shows a better path forward: you could expand the criteria for prescription. If you can prescribe opiates for back pain, why can’t you prescribe them for psychological pain? Imagine if a woman addicted to Oxy in Oklahoma City wasn’t abruptly told to stop using, with directions to the nearest Narcotics Anonymous group and a brisk “Good luck.” Imagine if, instead, she was told exactly what the patients in Geneva are told: you will be given a safe, legal dose for as long as you need it, and while you receive it, we will give you support and care to help you to rebuild your life, get secure housing, and keep your job.