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Transforming MAT, Part II: The Swiss Way

This is part two of a three-part piece. Part one can be found here.

There’s been a lot of talk about Portugal recently, and how, over the past thirty years, this little European country waged its own war on drugs – and won. 

NPR recently ran a story on how the country cut overdoses by eighty percent, and last month the New York Times compared Portugal’s and San Francisco’s responses to illicit drug use. Given that the Golden Gate City recently experienced its highest-ever number of overdose deaths and is struggling with rising rates of open-air drug use and crime, the Times’ comparison did not favor San Francisco.

In fact, none of America looks particularly good compared to the land of port wine and fado. After a heroin scare in the 1990s, Portugal spent the next few years building a vast network of public health services for its drug users, with everything from consumption rooms to methadone clinics to easy access to healthcare. It also funded this system so that all these services, which target Portugal’s most vulnerable, are free. In comparison, America’s response to our current illicit drug scene – which is the deadliest and most disturbing it’s ever been – is pitiful. We offer insufficient treatment to struggling people (only about a quarter of the 48.7 million Americans with a substance use disorder received treatment in 2022), and when treatment is offered, it’s often exploitative, financially and socially – a tragedy we covered in Part I. We shouldn’t be surprised it doesn’t work. For these reasons and more, America had over 100,000 overdose deaths last year. Portugal had just 80

With America such an outlier in overdose deaths, we’ve started looking abroad for tips on how to better handle our crisis. Places like Portugal, with its comprehensive and effective treatment system, seem ideal. Despite the widespread praise for Portugal in the media, I began wondering what these systems looked like on the ground. How does an integrated treatment system actually work? What does it look like? Who participates in it? And who pays the bills? Most importantly, if a system like this works so well in places like Portugal (whose population is roughly equal to New Jersey’s), is it scalable to the entire United States?

I don’t know about Portugal, but last summer I spent a week in Switzerland touring treatment clinics in Zurich, Basel, and Bern. There I found another comprehensive, integrated, organized, and extremely effective system – like the Portuguese, the Swiss experience very few overdose deaths, clocking just 160 in 2022. The doctors and psychiatrists I met with in Switzerland were congenial to a random American writer asking for their time;I learned a lot about how the Swiss system was developed and how their coordinated treatment programs are operated with care. Although the Swiss system is unique to Switzerland’s individual history and drug scene, it is nonetheless as effective as Portugal’s, and it was developed with American assistance. As we reimagine MAT and treatment today, the Swiss might offer some valuable lessons on what is – and isn’t – possible here in the United States. 

So let’s explore it.

The Panic in Needle Park 

Let me tell you, Zurich is lovely. Landing there in early June, when everything was green and warm and the sunshine sparkled on that giant blue lake – it was like landing in a fairy tale. The whole city is orderly and beautiful. From its transportation to its architecture to its cute little lakeside ice cream vendors to its extensive social services, Zurich operates like a fine Swiss watch, with everything functioning just so. So it’s strange that, forty years ago, the triangular little park tucked behind the city’s railway station was the largest open-air drug market in Europe, with hundreds of people living, and dying, within its walls.

The open-air drug scene in Platzspitz (“Needle Park”), Zurich, Switzerland, in the late 1980s (From here)

Location of Platzspitz Park in Zurich

Platzspitz is a small park situated behind Zurich’s buzzing train station and the imposing Swiss National Museum. The park is tiny – little more than a small green with a gazebo, trees and walking trails – and it’s secluded, jutting out like a talon between the Limmat and Sihl rivers. It’s a quiet place, where families picnic and teens gather and tour groups reconvene before catching their next train. But by the mid-1980s, Platzspitz was a disaster. 

In 1975, in response to increasing heroin and cocaine traffic from Lebanese and Turkish drug cartels, the Swiss government passed a new federal law that increased punishment for drug use and possession. In an ironic twist for a nation officially recognized as neutral since 1815, Switzerland declared its own war on drugs, and rates of arrests began to rise. That did little to stop use or trafficking, however, and by 1980, more people were gathering in Platzspitz to buy and use, as the park became ground zero for Zurich’s burgeoning heroin scene. 

Platzspitz was the perfect location for an open-air drug market. The park is in the center of Zurich, which is in the center of Switzerland, which is in the dead center of Western Europe. Zurich is also connected to the rest of the continent by the over 3,000 trains that zip in and out the city’s Hauptbahnhof every day. Hidden as it was behind the train station, where buyers were catered to by thriving drug cartels out of sight, Platzspitz soon became the gathering place for Switzerland’s growing legion of heroin users. By the early 1980s, Platzspitz was reborn as “Needle Park,” and home to dozens of people who lived on its grounds, along with the hundreds more who came to score every day. 

At first, Zurich didn’t seem bothered. The Swiss have a strong “out of sight, out of mind” mentality, and Needle Park was relatively quiet at first. Chaos was kept to a minimum because all drug sales and use were confined to the green, which was regularly patrolled by the cops. In 1986, police officials and Zurich’s socialist city council went even further, designating Platzspitz a “tolerated but supervised” zone for drug use. In other words, officials said, people could gather in Needle Park, as long as they stayed quiet and kept their drug use out of sight. 

But the situation quickly spiraled out of control. Within months, hundreds more people began gathering – and living – in Needle Park, and over 1,000 more people visited the park every day. Soon Platzspitz wasn’t just home to Switzerland’s heroin users; it was the epicenter of Europe’s burgeoning addiction crisis.

Chaos and destruction quickly followed. By the mid-1980s, the gardens were trampled, trash and waste covered the grounds, and open wounds covered users’ bodies. As women prostituted, improvised market stalls sold injection supplies, with a used syringe costing ten Swiss francs and a new one upwards of fifty. The scene was horrific, a police officer remembered, rancid with the diarrhea and vomit of people going through withdrawal. “People were laying around in their own blood and feces like battlefield casualties,” he said. “Those still on their feet simply stepped over them.” 

But Platzspitz was quickly becoming a public health disaster as well. By the mid-1980s, pushed by shared needles and unprotected sex, almost a third of the heroin users living in Needle Park were HIV-positive, along with almost a quarter of Swiss heroin users nationwide. And with a thousand people streaming into Platzspitz daily to score – and share needles and buy sex – the virus’s threat was only poised to grow. Zurich wasn’t just home to the continent’s largest open-air drug scene anymore. Now it was Europe’s leading source of HIV infection as well.

Something had to be done. In 1985, Drs. Peter Grob and André Seidenberg organized three hundred and fifty physicians to sign a declaration telling the Swiss federal government they intended to disobey the 1975 drug law, which also forbade providing drug users with clean syringes or methadone. The severity of the HIV epidemic was unprecedented, Seidenberg said – he was attending a patient’s funeral every week – and doctors believed that distributing clean needles in Needle Park was the most immediate way to stem the virus’s surging tide. “Doctors were powerful people back then,” Seidenberg remembered. “We had a lot of influence and sway. And we were broadcasting our message everywhere, in all the papers, on the radio, on TV.” The cantonal legislature of Zurich relented, and by late 1986, Seidenberg was operating a small system out of a parked bus, distributing clean needles and disposing of used syringes.

By 1988, this system had grown into ZIPP-Aids (Zurich Intervention Pilot Program-AIDS), a program Grob set up in the Platzspitz public toilet, which was manned twenty-four hours a day, 365 days a year. There, doctors, nurses and medical students distributed harm reduction supplies like alcohol pads, ointments, condoms, and clean needles (up to 10,000 a day), along with basic nutrition like water, tea and fruit. The small team also provided rudimentary medical care, vaccinated people against hepatitis B, offered HIV testing, and responded to over 6,700 overdoses.

But it wasn’t enough. As Platzspitz’s population grew, so did its problems. By 1990, violence and crime were surging in Zurich, and residents pinned the problem squarely on Needle Park. Neighbors complained that “junkies” stole everything from stereos to bikes to food, and their shoplifting forced local businesses to close. Parents felt unsafe walking children to school, and gunshots rang out from Platzspitz at night. The district parson even complained about “prostitutes and their clients copulating on the church steps during service.” This was a shock for quiet little Zurich, a city of such wealth and order that Germans joked its name meant “zu reich und zu ruhig,” too rich and too quiet. But now, in the heart of this lovely city, Zurich had the most horrifying drug scene in Europe, and residents were starting to lose their patience. 

“It couldn’t go on,” Seidenberg said. “To see that every day was awful. Parents were scared for their children, neighbors felt threatened. It was fundamentally disturbing for everybody.” But the services ZIPP-Aids put into place didn’t seem to be curbing the issue, either. Dr. Albert Weittstein, the city’s chief medical officer, said escalating heroin use had left Needle Park’s medical staff overwhelmed. Over 1,000 people now lived in the park, and over 1,500 visited to buy drugs daily. “We were having to resuscitate an average of twelve people a day, with peaks of forty one some days,” Weittstein said. “Our people were running around the park blowing oxygen into people’s lungs. We started with three doctors, but recently had to put in two more. It has become an impossible strain.” 

Weittstein recognized that harm reduction alone hadn’t solved Zurich’s drug crisis. “We hoped we could minimize the social costs by creating an open market where people could get help,” he said. “We failed.” 

But with chaos spiraling out of Platzspitz, law enforcement stepped in to fill the void. On the night of February 5, 1992, squads of riot police stormed Needle Park. With truncheons, shields and tear gas, cops drove the “children of Platzspitz” out of the park and placed a heavy gate across its entrance so they couldn’t come back. The action was hugely controversial. Demonstrators marched down the Bahnhofstrasse, the most elite street in Zurich, shouting “Polizischte! Mördr ond faschischte!” (Swiss German for “cops are murderers and fascists”), and one young man warned, “This is a crazy decision. We’ll be in the whole city now.” 

He was right. Within days, Needle Park had flooded all of Zurich, with users cooking heroin in the street and dealers soliciting customers on corners. Zurichers were horrified and demanded a more forceful response, so police once again pushed the scene away. By spring, thousands of users had found a new home, gathering in the overgrown fields near the abandoned Letten railway station, a half-mile up the Limmat river. 

The Letten drug scene (From here)

But neither switching locations – nor regular police raids – stopped Zurich’s heroin scene from growing. Instead, no longer constrained by the tight parameters of Platzspitz, Letten offered more room for the market to expand – and it did. “More and more people started arriving with each passing day,” said Alain, a former user, and regular raids didn’t dissuade the scene. “It was like interrupting a trail of ants.” But with more people, and more money, arriving every day, Letten was even more violent and dangerous than Platzspitz. “Platzspitz had an almost family-like atmosphere in the beginning,” Alain said. “Letten had none of that. It was all about business, pure and simple.”

With Zurich’s heroin problem entering crisis mode, Seidenberg knew that something had to be done – again. The small drug scene the city had tolerated in the mid-1980s had, by 1992, evolved into a dangerous and deadly public health crisis. Alongside rising heroin use, the city was experiencing escalating levels of violence, crime, and HIV infection, which meant Zurich’s drug problem threatened the lives of users and residents alike. If this threat was going to be effectively contained, Seidenberg argued, Zurich, and Switzerland as a whole, needed to respond quickly – and it had to try something new.

Seidenberg had spent the past few years working on a report with Dr. Robert Hämmig, a psychiatrist from Bern who specialized in addiction. Delivered to the federal Office of Public Health in 1990, “Perspectives for a New Drug Policy” outlined a different approach – one that threaded the needle between harm reduction and law enforcement. The doctors recognized that heroin users – and Swiss residents – needed more than just clean needles or arrests to feel safe. Instead, what Switzerland needed was a variety of coordinated programs to reduce the damage of the heroin scene. These included everything from healthcare and maintenance drugs and safe consumption sites for users, to social services, law enforcement and prevention for affected communities. It wouldn’t be a simple job, but the doctors hoped their plan – one that combined harm reduction and law enforcement with a medicalized system of legal opioid distribution – would reduce the chaos, disease and destruction of addiction, and allow for that famous sense of Swiss social order to return.

First, to control the threat of HIV, the doctors wanted to open comprehensive clinics that would bring opioid use under the umbrella of medical care. Seidenberg was inspired by programs he saw in the United States – he worked closely with Dr. Robert Newman on the report, who operated the Beth Israel methadone program in New York – as well as heroin maintenance programs he visited in Rotterdam and Liverpool. Seidenberg believed maintenance was key; opioid addiction was a chronic disease, he said, and users needed access to legal drugs, possibly for life. “You can’t take away the heroin, drive the dealers out, and force users into withdrawal,” he said. “That’s no way to restore public order, either.” But if Switzerland allowed users to access a safe supply of regulated drugs like methadone and heroin – distributed by doctors, in a controlled environment – that would not only reduce the threat of AIDS, Seidenberg argued, but it would also decrease the social disorder of chaotic addiction, by bringing drug use under medical care. 

Second, the doctors recommended more social services to decrease the visibility of remaining illicit use. Seidenberg recommended increasing harm reduction services like needle exchanges and opening supervised consumption sites, which kept drug use out of the public eye. He also recommended strong social supports, like hiring social workers to mitigate problems between drug users and their larger communities, and ensuring that areas around clinics and consumption sites were safe. 

Finally, the doctors recommended a stronger role for law enforcement. Non-medicalized drug use would not be legalized under this system, and anyone operating outside the new rules would still be subject to punishment and arrest. This appealed to Switzerland’s conservative majority. Most of the country’s heroin use was quarantined to the German-speaking areas in the north, and many in the more-conservative French- and Italian-speaking cantons were unconcerned about the drug problem and suspicious of legal opioids and liberalized policy. “This was an intensely polarized discussion in the beginning,” Seidenberg said. “There’s a component of Switzerland that’s very right-wing.” (He’s not wrong. The country struggles with integrating immigrants, experiences periodic nationalist revivals, and didn’t allow women to vote in federal elections until 1971 – and in one canton, women had to wait until 1990.) The strong emphasis on continued law enforcement made the doctors’ plan – an unprecedented attempt to legalize addictive drugs – palatable to Switzerland’s arch-conservatives.

This plan – which integrated medicine, harm reduction, and the police – was Seidenberg’s attempt at a third way which recognized, and accommodated, the hard truths surrounding addiction. Seidenberg knew that illicit drug use would never go away, and that even in tiny, bucolic Switzerland, a drug scene had always and would always exist. But if illicit drug use could be brought under control, and operated within an agreed-upon set of social boundaries, he believed both the country’s users and non-users could live with it again. The Swiss have a strong sense of social cohesion, Seidenberg said, and believe that “any society refusing to integrate its marginalized members is a looming danger to itself.” The doctors’ new approach – allowing drug use to happen if everyone played by the rules – represented the “practical, liberal, humane side of Switzerland,” Seidenberg said. It was a reflection the Swiss liked to see.

And it worked. Desperate to control the spiraling heroin crisis, in 1991 the Swiss Federal Council scrapped its 1975 drug law and adopted a new “four-pillar approach,” which emphasized law enforcement alongside prevention, therapy, and harm reduction. A year later, in 1992, federal officials passed another law that provided the legal framework for the prescription of maintenance narcotics, including heroin and methadone. Seidenberg immediately set up the first low-threshold methadone clinic in Zurich, called ARUD (Arbeitsgemeinshaft für Risikoarmen Umgang mit Drogen). And when Platzspitz was closed on February 5 of that year, ARUD’s doors were open on February 10.

“It was chaotic in the beginning,” Seidenberg said. “But we slowly found our way.” 

The Swiss Way

“We were careful in the early days,” Seidenberg said. “At first, patients had to come every day for their methadone. But we soon recognized that many could come weekly and live their normal lives.” 

As the first comprehensive treatment clinic in Switzerland, ARUD set the pattern for how the country approached addiction. Seidenberg worked with fourteen other general practitioners, including infectious disease experts and a gynecologist, who immediately provided patients with methadone maintenance. Once patients were stabilized, the doctors began treating their other medical needs as well. In less than a year, ARUD was treating over 500 people, all of whom volunteered for treatment, and low-threshold methadone was transforming Zurich’s heroin-using population. “When patients stabilized, their health improved and they survived,” Seidenberg said. “It was an amazing transformation.”

By 1995, ARUD brought in psychiatric services, too. “Heroin is a great anti-anxiety drug,” said psychiatrist Dr. Thilo Beck, who started at ARUD in 1997. “But when a client becomes stabilized on methadone, all their other problems – like anxiety, depression, bipolar disorder and schizophrenia – come out. Those need to be treated, too.” By the mid-‘90s, ARUD was offering comprehensive medical and behavioral health services, and its in-house pharmacy was dispensing psychiatric medications alongside methadone.

Once patients’ medical and psychiatric conditions were treated, a growing number of clinical social workers began attending to their other needs. Social workers helped patients navigate Swiss bureaucracy, from paying their taxes, to getting an ID, to signing up for health insurance, to finding housing or employment. Meanwhile, therapists worked on patients’ psychological and social needs, and community centers gave patients a safe space to gather, to take cooking classes or do art projects and play games. None of the counseling or therapy was mandatory, Seidenberg said, but as patients were stabilized on medications, ARUD staff found social services were in demand, and a vital component of reintegrating patients into Swiss society. 

For those who still weren’t willing to fully medicalize their drug use, cities across Switzerland also opened consumption rooms, more commonly referred to as K&As, for Kotackt und Anlaufstellan, or “contact and connection.” These are perhaps the most surprising part of the Swiss system. Participants have to show a Swiss ID to enter, but once they’re within the K&A’s tall walls, “approved” dealers – ones with a good product, who treat customers fairly and don’t cause violence or problems – are allowed to sell small amounts of drugs (under 100 grams) to buyers, who are then allowed to consume these drugs under supervision, indoors. Most K&As also have bathrooms, a small cafe, and regular hours with physicians and social workers, who can connect users to clinics when they’re ready. Social workers also mitigate problems between the K&A and its community, while city workers ensure any discarded paraphernalia is contained. K&As are available in every Swiss city, Beck said, because they’re “necessary. Drug use will never disappear, and people need a place to go.” But K&As are also a critical opportunity to access the “illest people in Switzerland, in the location where they already are.” “You have to start at the K&A,” Beck said. “It’s where the beginnings of social reintegration take place.”

Finally, by 1993, ARUD and clinics in seventeen other cities began federally-authorized trials for heroin-assisted treatment (HAT). The highly-structured and heavily-evaluated program lasted for three years, from 1993 to 1996, and allowed over 1,000 patients to receive daily supplies of Swiss-made heroin, to be injected, under supervision, up to five times daily in clinics that had received federal approval. ARUD was one of the first places to offer this treatment, and Seidenberg tracked the experiment closely. It worked. By 1998, 1,035 legal heroin users nationwide had been stabilized on up to 600 mg of the drug daily, and retention in treatment was almost ninety percent. But HAT was not an easy program. Patients had to attend the clinic every day, clean up after themselves (usually by disposing properly of their syringe and bleaching their injection site), and could not use the drug in a public or illegal way. Swiss heroin was also far from a commercial venture. Poppies grown in the South Pacific were transported to a pharmaceutical manufacturer in Thun, where the heroin – which was only allowed to be distributed and used in federally-approved clinics – was delivered in the same armored cars used to deliver $60,000 watches and priceless art to the Basel Messe. 

Meanwhile, with opioid use thoroughly medicalized, city officials relied on law enforcement to clean up any remaining problems with illicit use. Police continued to patrol Letten, arresting open-air users and dealers. Those who weren’t residents of Zurich were forced back to their home country or canton, and dealers were arrested or deported. Slowly, the scene in Letten – once thousands of people strong – dwindled to a few dozen, and then none. By 1995, over 150 low-threshold clinics were treating thousands of patients nationwide, and, alongside a strong police presence and comprehensive social services, the drug scene was effectively eradicated there. “On the morning Letten was closed” in 1995, said Andres Oehler, a Zurich information officer, “there was not a single dealer or ‘junkie’ in sight.” 

Best of all, no new generation of Swiss drug users embraced heroin. Ric Curtis, an anthropologist at the John Jay College of Criminal Justice, calls it the “smarter younger brother effect”: when one generation sees the devastation wrought by drug use on older family members, they usually avoid that drug. (We saw the same phenomenon with crack cocaine here in the United States.) The heroin problem had been so uniquely disturbing for the Swiss, and Seidenberg and Hämmig’s plan had so effectively contained it, that there was almost no black market for young people to experiment with by the mid-’90s – and they didn’t want to, anyway. 

By 1995, the “children of Platzspitz” were a unique and isolated population, the result of the unique and isolated Swiss heroin crisis, which lasted for just twenty years. They were also a testament to Seidenberg and Hämmig’s success. By following the doctors’ “third way,” Switzerland took a new direction in its war on drugs, and it was reaping enormous rewards. By treating addiction as a legitimate disease and medicalizing opioid use, the Swiss waged peace with drugs – and successfully contained the threats of violence, open-air drug markets, and HIV.

It was a system that played to Switzerland’s strengths: neutrality, practicality, and “out of sight, out of mind.” When the social contract was fulfilled and users and non-users alike operated by certain rules – just like how the trains were expected to run on time, and grocery stores were closed on Sundays for a day of rest – Switzerland found it could tolerate opioid use just fine. As Monika Stocker, director of Zurich’s Social Affairs Department, summed it up in 1995, “What counts for me is that what you don’t see is okay.” 

The American Prospect

Thirty years later, the Swiss system has only evolved and grown. 

ARUD remains the country’s trailblazer, and the largest treatment program in Switzerland. 150 staff now run four outpatient clinics that treat over 4,000 “clients” a year (most clinics I visited used the term client, not patient). To accommodate its growing clientele, in 2017 ARUD moved to a newer, larger space in the heart of Zurich, just a few blocks from Platzspitz – and in true Zurich fashion, into the former headquarters of a bank that got caught money laundering and had to close. But because so few Swiss use heroin after the “children of Platzspitz” were medicalized, ARUD’s staff now focuses on a lengthy menu of other behavioral addictions and substance use disorders instead. Only about 1,500 of ARUD’s 4,000 clients are on maintenance medications, while the rest are being treated for problems with everything from cocaine to prescription drugs to alcohol to sex. ARUD is a “clinic for everyone,” a young client told me. “If you have a problem, this is where you go.”

For the few thousand Swiss nationwide on maintenance, they have an assortment of options to choose from. As more medications have become available, clinics have embraced nearly all forms of opioid agonist treatment. Every clinic offers methadone, buprenorphine, and long-acting oral morphine. (They still need special federal approval to dispense heroin.) I even found one clinic in Basel that still offered LAAM. The majority of patients, over fifty percent, use long-acting morphine, while the remaining forty percent are on methadone, eight percent are on buprenorphine, and two percent are on heroin. But patients are allowed to switch at any time and move freely between which form of medicine they’d like. The stark division between medications in the United States is “inconceivable” in Switzerland, Seidenberg said. “It’s pointless. I don’t understand why you do it.” 

The Swiss also make these medications easily available. Low-threshold access remains the national standard, and most maintenance patients live in cities, where they can walk or take the bus to their clinics, which usually have on-site pharmacies. For rural patients who live in the mountains, private physicians prescribe their medications, which can be picked up weekly or monthly from local pharmacies. Distribution of the drugs is also liberalized, with very few patients having to come to the clinic every day. Even HAT patients – roughly 1,500 people nationwide – can get up to a week’s worth of take-home doses of Swiss-made heroin, picking up a collection of filled syringes from their pharmacy or clinic. (Though the doctors I spoke with noted that if said heroin becomes available on the street, patients’ rights to take-homes will be reduced.)

Treatment, in all its many manifestations, has also become a recognized and legitimate form of reimbursed healthcare. In 1996, just a year after Letten closed, the Swiss federal government began requiring mandatory health insurance for everyone living within its borders, and since then nearly one hundred percent of Swiss citizens have been covered. Private, nonprofit companies offer this insurance, which the Swiss purchase according to their needs, and for clients who can’t afford basic insurance, federal and cantonal support cover any payment gaps. Some clinical services, like medical treatment and psychiatric care, are reimbursed more substantially than others, like meetings with social workers or therapeutic counseling. But by combining general practitioners, psychiatrists, psychologists and social workers in each clinic, programs are able to function sustainably, without having to charge most clients any fees. 

The Swiss system, liberal and conservative at the same time, is based on several key ideas: that, in order to prevent another Platzspitz or Letten, clients and residents alike deserve flexibility, access, and respect. Surprising as it is to come from a country that only allowed women to vote fifty years ago, the Swiss system also shows visible signs of success, especially compared to America. For years, the leading cause of death for young Americans (aged 20 to 24) has been unintentional drug overdose, and in places like Ohio, the average age of a casualty from a fatal opioid poisoning is just over 40. Compare this to Switzerland, where the “children of Platzspitz” are now well into their fifties and sixties and are battling the ailments of old age. ARUD’s doctors now focus on treating clients’ heart and lung diseases alongside their opioid dependencies (over a quarter of the Swiss population smokes cigarettes), and many clinics I visited were in the process of moving to single-story locations or buildings with elevators, to help clients with age-related mobility issues. 

The Swiss system isn’t perfect, of course, and there have been some complaints. Like any business, clinics can be shaky financially, and every place I visited had an office full of people busy filling out insurance paperwork. Some have also argued that Switzerland’s system overmedicalized opioid use, making heroin the equivalent of a daily vitamin. And despite the breadth of social services offered, the Swiss system still hasn’t fully eradicated illicit use. Especially on warm summer nights, after the consumption rooms have closed, open air drug scenes periodically appear in cities like Basel – which usually lead to angry public meetings and demands for more police. The country, like the rest of Europe, is also struggling with rising problems with cocaine, where historically high levels of trafficking and use are wreaking havoc with public health.

Despite lingering problems and the shifting drug scene, however, the Swiss are still at peace with their system, because it’s worked so well for so long. With opioid use effectively medicalized (and with services in place to keep Swiss citizens employed, fed, and housed), there are no Kensingtons in Switzerland, no Portlands or Tenderloins – all those troubled American neighborhoods that have prompted so many recent stories in the New York Times and NPR. With the Swiss system proving so effective, the political polarization that surrounded the issue thirty years ago is also gone, even if the country’s base conservatism is not. With drug use effectively “out of sight, out of mind,” Seidenberg said, “even the right wing wouldn’t want to get rid of this.”

When I asked Seidenberg what advice he had for the United States on how we could better tackle our opioid crisis, he was verklempt. “I don’t understand what you’re doing over there,” he said. “I honestly don’t.” But he also offered some useful advice. “The key to solving the problem of opioid addiction and restoring social order and public health is transforming your view of drug use, and drug users, as a whole,” he said. “You can’t fight it or eradicate it or profit off it. You have to integrate it.”

So why haven’t we? 

When I got back from Switzerland singing the praises of their coordinated treatment system, I was told one thing over and over: “That could never happen here.” 

I was told that America was too racist to effectively treat drug users. Or we were too puritanical, or profiteering, or cheap. It didn’t matter how well the system in Switzerland worked. Over here, on the other side of the Atlantic, the colleagues and experts I talked to told me America was too fundamentally broken to bring our number of annual overdoses down. 

But is that true? It struck me as an odd omission, especially since the Swiss learned their system from us. Seidenberg was mentored in methadone maintenance – an American invention – by an American doctor, and now the country uses buprenorphine, another American drug. It’s also an odd omission given that we’ve already offered users almost every other form of treatment available, from equine therapy to stripmall Suboxone. So why hasn’t anyone offered comprehensive treatment to the estimated 7 million Americans currently struggling with OUD, with connected services like the Swiss? Clearly it isn’t impossible – Switzerland and Portugal are knocking it out of the park. What’s possible there that people find so impossible here?

More importantly, it’s time to ask how our failures have held us back. The difference between America’s heavily corporate, private system and Switzerland’s comprehensive care is the difference between 100,000 and 160 overdose deaths a year. There are countless horrors associated with our current drug scene – from the flesh wounds of xylazine to the violence of Mexican drug cartels – but the most heartbreaking proof of our failures, and the most visible sign of Swiss success, is in our graveyards. If that’s not enough to demand change, what is?

I’ll explore all this in Part III of the series, coming soon. But I’m not writing an obituary for America’s broken treatment system just yet. Instead, a colleague will offer a vision for a different plan, an alternative akin to Switzerland’s neutral third way, and one achievable even within our country’s labyrinthine drug policies and laws. With overdoses poised to remain high for years – and over 40% of Americans already reporting they know someone who died from an OD – this could be a way forward for the United States that, after decades of chaos and destruction, could model the success of the Swiss. 

Stay tuned!


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