Incidence of heroin use in Zurich, Switzerland: a treatment case register analysis.

BACKGROUND: Switzerland has been criticised for its liberal drug policy, which could attract new users and lengthen periods of heroin addiction. We sought to estimate incidence trends and prevalence of problem heroin use in Switzerland.
METHODS: We obtained information about first year of regular heroin use from the case register of substitution treatments in the canton of Zurich for 7256 patients (76% of those treated between 1991 and March, 2005). We estimated the proportion of heroin users not yet in substitution treatment programmes using the conditional lag-time distribution. Cessation rate was the proportion of individuals leaving substitution treatment programmes and not re-entering within the subsequent 10 years. Overall prevalence of problematic heroin use was modelled as a function of incidence and cessation rate.
FINDINGS: Every second person began their first substitution treatment within 2 years of starting to use heroin regularly. Incidence of heroin use rose steeply, starting with about 80 people in 1975, culminating in 1990 with 850 new users, and declining substantially to about 150 users in 2002. Two-thirds of those who had left substitution treatment programmes re-entered within the next 10 years. The population of problematic heroin users declined by 4% a year. The cessation rate in Switzerland was low, and therefore, the prevalence rate declined slowly. Our prevalence model accords with data generated by different approaches.
INTERPRETATION: The harm reduction policy of Switzerland and its emphasis on the medicalisation of the heroin problem seems to have contributed to the image of heroin as unattractive for young people. Our model could enable the study of incidence trends across different countries and thus urgently needed assessments of the effect of different drug policies.