04.09.2017 The course is set for the new addiction strategy
Addiction policy. Since time immemorial, mankind has consumed psychoactive substances, and what a society considers to be an addiction is continually being renegotiated. Besides substances such as alcohol, tobacco, drugs and medication, there are also new substances such as neuroenhancers, whereas opiates (which had long been prominent in addiction services and policies) have recently become less prominent in Switzerland. In the 1980s and 1990s, answers had to be found to the plight of the open drug scenes. Nowadays, thanks to substituent treatment and harm reduction programmes, the heroin problem has somewhat faded into the background. The massive increase in opioid use in the United States, however, illustrates that ongoing monitoring of such developments remains vital. Besides the lingering problems that occur as a result of high-risk alcohol and tobacco consumption, this also means addressing newer manifestations of dependencies that are unrelated to substances. The National Strategy on Addiction which was launched this year takes on the entire spectrum of dependency and addiction, spanning all types of substances and other kinds of addiction. The strategy views addiction as a comprehensive phenomenon that is affected by interacting biological, psychological and socioeconomic aspects and is also dependent on current consumer trends and cultural behaviours. Together with the NCD Strategy, (1) it replaces the National Prevention Programmes on Alcohol and Tobacco as well as the Package of Drug-Related Measures from 2017 on.
A cool beer after work, a cigarette break, a chocolate bar in-between. Reading the news on your smartphone while on the go, jogging five times a week, spending an evening at the casino, toasting a happy occasion. Enjoyment, benefits, play, social rituals: for most people, potentially addictive behaviour is part of everyday life. Not all of us are equally successful at striking a balance between enjoyment and behaviour that is detrimental to health. High-risk behaviour that leads to dependency or addiction is not only detrimental to individuals and their environment but is also responsible for massive social costs.
The existing types of addiction and consumption patterns are subject to constant changes, and our society has to continually address the topic anew. Any sociopolitical debate must include measures that promote the development of proven approaches to addiction assistance, as well as considerations regarding effective statutory regulations for prevention. Such regulations must take account of societal changes and create the conditions for a modern addiction policy. With the conclusion, at the end of 2016, of the National Prevention Programmes on Alcohol and Tobacco and the Package of Drug-Related Measures, the Confederation, together with the previously involved stakeholders, has launched the present Strategy on Addiction. It aims to provide both a reference as well as an orientation framework and will use coordinated measures to tackle the challenges that have to be faced by a society defined by digitalisation and globalisation, with its "old" and "new" forms of addiction.
Guilt or co-responsibility?
Most people in Switzerland are not affected by addiction. They live abstemiously or take a conscientious approach to stimulants and substances. Those whose boundaries have shifted from enjoyment to use, through dependence to addiction, face serious problems: the damage can be devastating – physically, mentally, financially and socially. On a societal level, it is socioeconomic consequences such as the breakdown in work performance, weakened family structures and financial costs in the billions that result from individuals’ addictions. The fact that a society wishes and must become active is not solely out of sheer solidarity. The state’s duty of care towards its population is legally enshrined as well. Yet it is not this duty alone that prompts the state to act. One of the main objectives of state action should be to ensure a healthy population as the basis for societal stability and efficient social systems.
The question regarding reasonable use of a substance or behaviour invariably raises the question as to "responsibility" and who is deserving of assistance. In her interview, Julia Wolf (2) states that every individual has to take their share of responsibility for non-injurious consumption and for their own health. She calls for "co-responsibility" which individuals bear as part of society, just as society bears towards its members. For implementing the National Strategy on Addiction, for an addiction policy that considers the population as a whole and for concrete and targeted addiction assistance, this means continually finding the balance between "strengthening personal responsibility" and "providing the necessary low-threshold support".
Addiction assistance as an interaction between multifaceted expertise, many years of experience and innovation
The Confederation, cantons, cities, communes and private individuals have in the past years provided services for people suffering from dependency disorders. The landscape of addiction assistance is made up of a differentiated network of support services, which are as varied as the conditions themselves: inpatient, abstinence-oriented social therapies – in the middle of the city or in remote farming families; contact points and drop-in centres where severely dependent addicts can consume their substances in hygienic surroundings and suffer less harm; housing assistance; drug checks in party settings or in fixed locations; online addiction counselling which also reaches clients who can’t (yet) manage actually going to an outpatient advisory centre for a face-toface chat; self-help groups for those affected or their relatives; day clinics and outpatient clinics for addiction medicine; job integration services where addicts are given a daily structure or negotiate their first steps back into the regular labour market; heroin-assisted or other substitution treatments in case of opioid addiction; smoking cessation counselling; early intervention in schools; outpatient or inpatient withdrawal programmes; mobile outreach intervention groups in public places; emergency overnight accommodations – the spectrum is broad and provides a wealth of experience.
A primary objective of the National Strategy on Addiction is to further develop tried and tested approaches to addiction assistance. With constantly changing framework conditions, innovation is called for, as is the courage to challenge structures that were appropriate in the early days of addiction assistance and update them according to present-day possibilities and requirements. A central objective is the mainstreaming of addiction-specific knowledge in primary care. Besides primary medical care providers such as hospitals and general practises, this also includes other social support service structures. Whether it’s in social services, regional employment centres, the Spitex home-care service and homes for the elderly or in schools and vocational training institutions: knowledge in dealing with addiction-prone or dependent persons is needed wherever we deal with people and their fates as well as their normal everyday lives. Addiction is a transversal issue, and addiction assistance will be successful if cooperation between different systems is actively sought and lived, and synergies are taken advantage of. The interprofessional cooperation of the various specialists is of great importance in that respect.
Shifting focus to vulnerable target groups and those in particular need of protection
Persons in vulnerable situations require particular attention. They are often people who are already marginalised due to other circumstances or have less access to information and support services. This may include people with mental illness, traumatised migrants, but also children and adolescents from families with low socioeconomic status or people in prison. It is important to create low-threshold access to assistance that is tailored to the different types of need. Especially in times of limited finances, it is important to focus the scarce resources on the situations of greatest urgency.
Special attention should be paid to children and adolescents. Even with younger schoolchildren, promotion of self-efficacy and social competences can help prevent addiction. Comprehensive measures to strengthen resources are supplemented by specific measures aimed at responsible use of addictive substances, and are deployed for the purpose of early detection and intervention where problems might occur or are already appearing. Such educational approaches are supplemented by youth protection provisions. Here too, the National Strategy on Addiction is deployed and supports stakeholders in implementing legal provisions using appropriate instruments and scientific principles.
Curiosity and the testing of boundaries are inherent to adolescence. Important tasks in adolescent development include evaluating risks and dealing with temptations. Prevention should begin where it enables young persons to inform themselves and make conscious decisions. Here, adaptation of time-tested awareness-raising and information materials to new channels and the use of new technologies is a key starting point for the further development of addiction assistance and prevention.
National Strategy on Addiction (2017–2024)
This strategy does not reinvent the wheel. It is based on the time-tested and successful four-pillar addiction policy and leaves room for further development. It serves simultaneously as a reference and an orientation framework for addiction assistance stakeholders and focuses on coordinating and using synergies. Services are no longer just oriented to individual substances or behaviours but take an all-round approach to considering people in their addiction, across the various stages of their lives, possible crisis situations and the associated increased risk of succumbing to addiction. The proven four-pillar system is supplemented by four control-oriented action areas that describe cross-sectoral tasks and are used for control and coordination purposes.
- Health promotion, prevention and early detection
- Treatment and counselling
- Harm reduction and minimisation of risk as well as
- Regulation and enforcement
Focus on behavioural addictions
Behavioural addictions or dependencies unrelated to substances are given increased consideration in the National Strategy on Addiction. This broad spectrum of problematic behaviour requires expertise as well as knowledge sharing among addiction assistance institutions and multipliers. The problematic use of the Internet and its detrimental effect on the development of children and adolescents is one example: the manifestation spectrum is vast and ranges from cyberbullying to online gaming to excessive consumption of pornography. Other areas include muscle dysmorphia, abuse of anabolic steroids as well as body image and eating disorders. Gambling addiction in physical or online casinos that can leave sufferers with lifelong financial debts has long been acknowledged as an addiction issue and is being addressed through various programmes. Our interview partner Renanto Poespodihardjo (3) would also like to see an increased focus on shopping addiction, which is hardly perceived as a problem by the public. Overall, far more education and information is necessary on the part of the federal government in the area of behavioural addictions.
Additional tasks of the federal government include coordination, research, examples of best practice and international exchange
Another important feature of the strategy are the coordination by the federal government and the provision of evidence- based material, examples of best practice that cantons, cities, communes and NGOs can use for their own purposes. Not everyone has to develop their own concepts, and not all cantons and stakeholders face the same challenges. They are thus called upon to reflect jointly on who should provide which services where and how they can establish and coordinate joint projects.
However, National health policy cannot tackle the problems and concerns of population health on its own. Inclusion of other policy areas with the goal of a comprehensive health policy continues to be indispensable. In addiction policy, the judiciary and the police are already important partners when it comes to regulation and enforcement. Furthermore, most developments in the area of addiction do not stop at national borders. Exchange of experience with partner countries and cooperation in developing and implementing international addiction-related agreements continue to remain important.
(1) NCD = non-communicable diseases
Markus Jann, Head of Political Foundation and Enforcement Section, email@example.com
Mirjam Weber, Project Manager, National Strategy on Addiction, firstname.lastname@example.org