Could the North American opioid crisis hit Switzerland?

DOI: https://doi.org/https://doi.org/10.57187/s4094

Introduction

For over 10 years now, North America has been experiencing a major crisis linked to opioid overconsumption¹. Could Switzerland incur the same fate?² This question is often raised both in the media³ and in scientific publications⁴. Is it a form of fear mongering? Are we at the mercy of the same trends, or do we benefit from protective factors unique to Switzerland or Europe?

Actually, asking the question this way can be misleading. What is really meant by “opioid crisis”? Are we referring to the flood of deaths from intoxication (so called “overdoses”)? Or are we more generally referring to excessive (and medically unjustified) consumption?⁵ Are we targeting the consumption of certain substances that are perceived as particularly dangerous, such as fentanyl?⁶ Are we attacking the practices of certain doctors and their (in)famous US “pill mills”?⁷ Are we criticizing the dubious commercial strategies⁸and misleading advertising⁹ of a few pharmaceutical companies? Or the lack of access to appropriate care for people with opioid-related addiction disorders?¹⁰

Obviously, this issue has several facets. Our article aims to address some of them.

Significant differences between Switzerland and the United States

To simplify our analysis, we will start with the six “easiest” arguments; that is, areas where Switzerland does rather well.

1. Once Switzerland overcame its heroin crisis of the 1990s, the number of fatal intoxications stayed relatively low and stable,¹¹ at around 140 deaths per year.¹² Such deaths usually occur when several psychoactive substances are mixed (e.g., alcohol, benzodiazepines, opioids).¹³ By themselves, opioids taken under medical supervision rarely lead to death; taken at the dose tolerated by the body, they do not present chronic toxicity ,¹⁴ unlike other psychoactive substances such as alcohol¹⁵ Apart from dependence (physical and psychological), the lasting side-effects of opioids are mainly digestive disorders, in particular constipation.¹⁶ In the United States of America (USA), on the other hand, deaths from “overdoses” have risen massively.¹⁷ As a reminder, there were over 100,000 such deaths in 2022, mostly among men with low levels of education. The first so-called (temporal) “wave” of deaths was explained by the sudden change in access rules: patients who had become addicted suddenly found it difficult to obtain opioid medicines from their doctors once the government decided to introduce various bans (e.g., maximum daily doses).¹⁸ With no other options, individuals turned to the black market.¹⁹ Products they found on the street or on the internet are, by definition, unregulated; they are labelled neither for quality nor for dosage. Consumers incur significant risk when ingesting these substances. Moreover, in the past few years, the US illegal market expanded considerably; worse, there was a major surge of dangerous products containing fentanyl or xylazine,²⁰ without consumers being able to identify them as such.²¹

The combination of these two factors (a sudden change in regulatory approach and a black market inundated with dangerous products) is, at least for the time being, of no concern in Switzerland.²² On the contrary, for over 20 years now, Switzerland has been implementing a balanced policy based on 4 complementary pillars (i.e., prevention, treatment, repression,²³ and harm reduction²⁴).

2. In Switzerland, treatment for opioid use disorders is both easily accessible and reimbursed.²⁵ According to estimates,²⁶ around 70-80% of eligible persons are undergoing treatment (opioid agonist treatment or “OAT”).²⁷ People dependent on “illegal” opioids can obtain methadone, buprenorphine, or sustained-release morphine from their general practitioners, from a pharmacy, or from a specialized centre.²⁸ Waiting times are not too long (a few days or weeks at most). Treatment is covered by mandatory insurance.²⁹ Health professionals and government authorities try not to stigmatize these treatments and the people to whom they are offered. Physicians have been taught about OAT at university, and continuous training is easily available.³⁰ Moreover, specialized support networks are available to healthcare professionals having further concerns or questions.

Conversely, in the USA, long-term treatment with OATs, although based on the strongest scientific evidence, remains very difficult to access, with a coverage rate of between 10 and 20%.³¹ Emphasis is still too often placed on withdrawal and abstinence programs, known to be not only largely ineffective, but also dangerous, given the risks of relapse and overdose.³² Physicians wanting to prescribe OATs have to overcome various administrative hurdles;³³ patients on treatment often incur high direct and indirect costs.³⁴ People who use drugs are highly stigmatized, especially if they are poor and/or belong to certain minority groups.³⁵

3. In Switzerland, public advertising of prescription drugs, including opioids, is prohibited.³⁶ Hence, people are unlikely to ask their doctors for a specific drug just because they may have seen an advertisement on TV or in a magazine.

In contrast, the USA is one of the few countries in the world to allow all pharmaceuticals, including opioids, to be widely advertised to the public.³⁷

4. Physicians in Switzerland are banned from receiving remuneration from pharmaceutical companies or from other third parties, in exchange for prescribing medicines.³⁸ Nor may they receive gifts from the pharmaceutical industry.³⁹ These rules have been in place for two decades; they are subject to monitoring and sanctions.⁴⁰

Admittedly, prescribing practices vary both between and within Swiss cantons, and some can be problematic. However, large-scale scandals remain very rare.⁴¹ With the exception of “propharmacy” (i.e., the right that doctors in certain Swiss-German cantons have to sell the drugs they prescribe to their patients), doctors have no financial incentive to select specific drugs. As a result, the “pill mill” phenomenon seen in the USA is unlikely to take root in Switzerland.⁴²

5. In Switzerland, the (relatively low) prices of drugs, including narcotics, are set by the State, and 60 tablets of oxycodone cost around 45 Swiss francs (public price⁴³), compared to up to USD 200 in the USA (without including the possible discount negotiated directly by each insurance plan⁴⁴). For pharmaceutical companies, the profit potential is therefore lower and more regulated in Switzerland. In any case, Switzerland is a tiny market compared to the 332 million inhabitants of the USA.

The difference is also notable in prices on the black market, where opioids are extremely profitable in the USA. An oxycodone tablet is charged between USD 5 (5 mg) and USD 40 (40 mg) per tablet.⁴⁵ By comparison, in Switzerland, oxycodone is largely absent from the black market, but sustained-release morphine usually is found at CHF 5 per 200 mg tablet.⁴⁶

6. The opioid crisis in the USA has highlighted the link between the prescription of opioid drugs by hospital emergency departments and the ensuing risk of addiction among adolescents and young adults. In other words, if hospitalized young people receive opioids during their hospital stay, they are more likely to become dependent on the drug and/or develop substance use disorders.⁴⁷

In Switzerland, this risk has been widely recognized. As a result, hospital doctors only parsimoniously prescribe opioid drugs to underage patients. They may even have acted too sparingly, leading to oligoanalgesia (inadequate pain management). The knowledge of the US opioid crisis has only reinforced Swiss pediatricians’ caution.⁴⁸

The delicate aspects

Let's now turn to three aspects that, we believe, are more complex and less supported by causality studies, leading us to only draw hypotheses.

The Swiss medico-social safety net

In Switzerland, health insurance is compulsory, and the federal government and cantons support low-income policyholders by contributing to their health insurance premiums. Thus, a person who is ill or has had an accident can access long-term medical care relatively easily and at a high, but still reasonable, cost (CHF 1,000 maximum per year; i.e. CHF 700 co-payment and CHF 300 deductible if the lowest option is chosen, plus the already-paid-for insurance premiums).⁴⁹ If the person is employed, she cannot be dismissed immediately on grounds of illness; her employer must continue to pay the salary for a minimum period of one month.⁵⁰ If the sick employee is protected by a collective agreement, or if loss-of-earnings insurance has been taken out, payment may be due for up to 2 years.⁵¹

Hence, the pressure to recover as quickly as possible to keep one's job does not hang over the person as it does in the USA. Of course, there are also groups in Switzerland for which such a threat exists (e.g., self-employed individuals, people without residence permits, or undeclared employees). However, the various social insurances and safety nets guarantee a minimum of financial security in the event of illness – much more so than in the USA. As a result, suppressing short-term pain with an opioid is less likely to be the only feasible solution to maintain one’s subsistence or income.

Support for young people

In Switzerland, the age group most represented among those receiving OAT in 2022 was 50–54 year-olds. People under 29 account for 5.2% of people in OAT treatment,⁵² and there are more people over 60 than under 30 receiving OAT.⁵³ Likewise, the group most affected by overdose deaths is those over 50.⁵⁴

In the USA, the comparison cannot be based on people undergoing treatment, as they are too few in number and hence not representative of the general population. Instead, then, statistical data on lethal intoxication can be used. Recently,⁵⁵ the age groups with the highest number of such deaths were 25-34 (20,279) and 35-44 (21,100) year-olds, while the 45-54 (15,599) and 55+ (16,894) age groups are less affected; 6,531 people aged 0-24 died of intoxication.⁵⁶ Among adolescents and young adults, prescription and non-prescription opioid use is higher in the USA⁵⁷ than in Switzerland.⁵⁸

Why do the age groups concerned differ between the two countries? Do young people in the USA and Switzerland have different attitudes toward risk?

American culture is known to value individual freedom, performance, competition,⁵⁹ and risk-taking, all of which can contribute to increase stress⁶⁰ as well as dangerous substance-related behaviour. In addition, young people in the USA frequently leave home at the age of 18,⁶¹ often to find work or to live on college campuses hundreds or thousands of kilometers from their place of origin.⁶² Parental or social control is then diminished,⁶³ and we know that parental control is associated with a reduced risk of, for example, alcohol consumption<.⁶⁴ On the other hand, in Switzerland, young people remain much closer to their original social circles,⁶⁵ even when they come of age, not least because of the country’s small size and linguistic diversity.⁶⁶

In Switzerland, the pressure to perform at the highest level in sports or academics exists, but is less intense than in the USA.⁶⁷ University entrance selection is less competitive in Switzerland than in the USA.⁶⁸

In addition, the Swiss context tolerates (although illegal), also in young people, the use of certain substances such as alcohol and cannabis. These psychoactive substances are less likely to cause lethal intoxication, although recent figures suggest an increase in the mixing of alcohol with calming drugs (anxiolytics).⁶⁹

Specific harm reduction measures, such as Swiss drug testing services, also have a protective effect.⁷⁰ The same applies to safe drug consumption rooms, which are equipped to react quickly and effectively to intoxication occurring within their structures.

Social inequalities

We hypothesize that, compared to the USA, individuals in Switzerland are less likely to “self-medicate” their pain with opioids. Opioid drugs are first and foremost remedies for pain (analgesic effect), even though they also have a calming effect (sedative and anxiolytic) and a much-discussed euphoric effect. Schematically speaking, a person who wants to “party” won't turn to oxycontin, but rather to ecstasy and cocaine;⁷¹ someone who wants to “have fun with friends” will try alcohol or cannabis; and one who wants to “study all night” will probably take stimulant substances such as methylphenidate (Ritalin^®).⁷³ However, those who suffer psychologically and/or physically may be tempted to take opioids,⁷⁴ even though the latter offer only partial and temporary relief.⁷⁵

There are many causes of physical and mental suffering, and inequalities (whether economic, educational, social, or sexual) are among them. Inequalities increase the risk of falling ill, for example, because of substandard housing, arduous working conditions, unhealthy diet, exposure to (legal) toxic substances (chemicals, tobacco, alcohol), or lack of knowledge of preventative measures.⁷⁶ These inequalities also limit access to healthcare and may even lead to poorer quality of care. This in turn increases morbidity and mortality and reduces healthy life expectancy.⁷⁷ Disadvantaged people are therefore more likely to suffer from pain⁷⁸ and their perceptions of pain are often more acute.⁷⁹

In the USA, inequalities are greater than in Switzerland,⁸⁰ and they affect a number of life experiences.⁸¹ It's a vicious circle, made all the more unfortunate by the fact that faith in the famous “American dream” has been lost.⁸² It is therefore not surprising that the American opioid crisis has been described as an “epidemic of despair”.⁸³ This brings to light the unending debate about the social determinants of physical and mental health.⁸⁴

Risk factors in Switzerland

Despite all the aforementioned, the situation in Switzerland is not perfect. Recent studies have shown an increase in overall opioid consumption.⁸⁵ Ruchat et al. wrote that “Switzerland is the world’s 7^th largest per capita consumer of opioids. Between 1985 and 2015, Swiss consumption of strong opioids rose from 18 to 421 mg/inhabitant/year”.⁸⁶ It is therefore important not to ignore possible challenges and problems. We analyse three potential risks below.

High level of suffering among young people

The statistics on youth mental health in Switzerland are worrying. According to a 2022 report, “hospitalizations for mental and behavioural disorders increased by 26% [between 2020 and 2021] among girls and young women aged 10 to 24, and by 6% among men of the same age. For the first time, mental disorders are the leading cause of hospitalization among 10- to 24-year-olds (19,532 cases), ahead of injuries (19,243 cases). Hospitalizations for suicide attempts rose by 26% for the same age group. Outpatient psychiatric services provided in hospitals rose by 19% among young people”,⁸⁷ and nearly 24% of young women say they are depressed.⁸⁸

These numbers are dramatically high, and reactions so far have not been adequate. We need to do more to prevent this high level of psychological pain. Otherwise, young people could turn, even more so, to the use of psychotropic drugs.

The tendency to turn to medicines for “answers”

To a certain extent, one can get used to pain or learn to manage it.⁸⁹ However, this is a process that is very much up to the individual; it takes time and it requires resources (internal and/or external).⁹⁰ More and more, people are looking for “quick fixes”, in the hope of being fully “up and running” again.

In this respect, the Swiss Federal Office of Statistics provides interesting numbers about how the Swiss population increasingly consults healthcare professionals: in 2002, 26.2% of the population aged 25-34 had not consulted a doctor at all (20.6% aged 55–64), whereas in 2017, the figure had fallen to 13.9% for 25-34 year-olds (8.9% for people aged between 55 and 64). The percentage of the population who consulted their doctor between 5 and 9 times in a year stood at 10.5% among young people (14.7% among 55–64 year-olds) in 2002, rising to 18% (and 25.3% respectively) in 2017.⁹¹

Painkillers often work, at least at the beginning. However, they can also foster the view that pain is unacceptable⁹² and that medication is all that’s needed to get rid of it.⁹³ This could explain why⁹⁴ pharmaceutical consumption is on the rise in Switzerland.⁹⁵

Pharmacological dependence is often the consequence of medium- to long-term opioid use. The public is not necessarily sufficiently aware of, nor sufficiently warned about, this reality. It’s probably not enough for the doctor to say “be careful; use for no more than two weeks” (e.g., tramadol). Rather, healthcare professionals should explain what will happen if one exceeds this limit. People in care are often not informed about the concepts of physical (pharmacological) dependence, psychological dependence, and addictive disorders; they know little of their causes and interactions.⁹⁶ Imparting such information takes significant time and is hard to achieve given the very busy schedules of physicians.⁹⁷

Pressure on healthcare costs

Not least because of the phenomenon described above, healthcare costs are rising.⁹⁸ Logically, this implies higher premiums for Swiss compulsory health insurance, since premiums are the main source of financing of our health care system.⁹⁹ Authorities are forced to react to this increase as it has become a major political issue for politicians and, of course, for the general population.¹⁰⁰

However, the measures implemented by public authorities¹⁰¹ have not always been tailored to the needs of the public. Moreover, their consequences are rarely assessed, whether a priori or a posteriori. Pressure on drug prices, for example, is contributing to growing shortages, including of medicines used for OAT.¹⁰² Another example is the limitation on basic medical consultations to 20 minutes.¹⁰³ If the doctor only has a window of 20 minutes available, he or she will be far more likely to prescribe a drug. Trying to convince a patient to do without a drug or trying to encourage the person to adopt a healthier lifestyle (more physical activity, better sleep, etc.), all take time.¹⁰⁴ Similarly, health insurance companies that limit their coverage of rehabilitation care and “integrative” approaches may steer patients towards pharmacological solutions just because the latter are less costly in the short term.

Our provisional conclusions

At present, Switzerland is not facing the same difficulties as the USA. We’re not experiencing a rise in lethal intoxications, a black market of fentanyl, or chaotic opioid prescriptions. But “resting on our laurels” would be unwise. Risk factors are present. What’s more, things can evolve rapidly, as shown by the sudden upsurge in crack cocaine use in cities such as Geneva and Lausanne. So, how should we react?

As with almost all problems, we need to be clear about what we want, which also means knowing what we are prepared to sacrifice (the famous “opportunity costs”), in order to anticipate future challenges.

The road will be long and full of pitfalls. Compromises will be inevitable. If we focus on fighting/countering the risk of abuse (black markets, dependence, “overdoses”), we inevitably run the risk of restricting access for people who suffer and do need these painkillers.¹⁰⁵ Conversely, if we facilitate access to these substances, we run the risk of some people developing physical dependence, or even addictive disorders. Furthermore, the shortages increasingly affecting the pharmaceutical industry also demonstrate that, even in Switzerland, the supply of opioids is not always guaranteed, and that public authorities and the industry must work together to ensure access.¹⁰⁶

To find the most optimal balance, reliable data to monitor developments are needed. How many people receive opioid prescriptions? What other treatments or therapies have been tried beforehand and for which medical conditions? How quickly were people able to access treatment? At what dosages were opioids prescribed? For how long? For what beneficial effects? How many people became physically dependent on the substance? How many suffer from dependence? What other adverse effects occurred? What is the number and profile of overdose victims? Unfortunately, we don’t really know the answers to these questions.

Solid data¹⁰⁷to guide our healthcare system in prescribing opioids, particularly for analgesia, are scarce.¹⁰⁸ Public authorities rely too much on health insurance companies to provide them with data, but their figures are not designed to answer the aforementioned questions. Ideally, we should set up cohort studies,¹⁰⁹ or at least facilitate the regular collection of data from primary care physicians. Unfortunately, Swiss expertise in this area remains limited. However, the rapid development of IT tools (including AI) suggests that there is a considerable potential to be explored.¹¹⁰

Endnotes

1. Official data: Centers for Disease Control and Prevention (CDC), Understanding the Epidemic, https://www.cdc.gov/opioids/basics/epidemic.html. Other data: State Health Access Data Assistance Center, The Opioid Epidemic in the United States, https://www.shadac.org/opioid-epidemic-united-states.
2. This question is of course being asked in many other countries, particularly in Europe: see Verhamme K.M., Bohnen A.M. (August 20, 2019), Are we facing an opioid crisis in Europe?, The Lancet Public Health, https://doi.org/10.1016/S2468-2667(19)30156-2.
3. Langer M.-A., Wie tote Tiere in den Büschen – Fentanyl zerstört die Seele San Franciscos, Neue Zürcher Zeitung (NZZ of August 1^st, 2023), https://www.nzz.ch/technologie/san-francisco-wie-fentanyl-die-seele-von-amerikas-linker-hochburg-zerstoert-ld.1744206?reduced=true; Ruth Baumann-Hölzle, Gefahr einer sich anbahnenden Opioid-Krise in der Schweiz, Dialog Ethik, July 4, 2023, https://www.dialog-ethik.ch/medien/alle-downloads/kommentare-zur-zeit/592-gefahr-einer-sich-anbahnenden-opioid-krise-in-der-schweiz-4-juli-2023/file; Jecker N., Basler Suchtexperte warnt vor einer Opioid-Krise in der Schweiz, Basler Zeitung (BaZ, June 23, 2023), https://www.bazonline.ch/basler-suchtexperte-warnt-vor-einer-opioid-krise-in-der-schweiz-705558246194; Gamp R., Boss C., “J’étais droguée aux opioïdes, c’est clair“, 24 Heures, April 27, 2023, https://www.24heures.ch/jetais-droguee-aux-opioides-cest-clair-435254057935; Nau J.-Y. (October 3rd, 2018), Prévenir la “crise des opioïdes» de ce côté-ci de l’Atlantique, Revue Médicale Suisse (RMS), https://doi.org/10.53738/REVMED.2018.14.621.1770. Moreover, the recent ban on opium poppy cultivation in Afghanistan has raised fears of a reduction in heroin supplies, which could encourage consumers to turn to other substances such as fentanyl: Lovett S., Newey S., Farmer B. How the Taliban launched the ‘most successful counter-narcotics effort in human history’, The Telegraph, https://www.telegraph.co.uk/global-health/terror-and-security/taliban-war-on-drugs-poppy-ban-opium-heroin-afghanistan/.
4. Humphreys K. et al., Responding to the opioid crisis in North America and beyond: recommendations of the Stanford-Lancet Commission, The Lancet, February 2^nd, 2022, https://doi.org/10.1016/S0140-6736(21)02252-2.
5. Current medical consensus advises against using opioids to treat chronic pain: Els C. et al., Opioïdes à forte dose pour la douleur chronique non cancéreuse: une synthèse des revues systématiques Cochrane, Cochrane Library, March 2023, https://doi.org/10.1002/14651858.CD012299.pub3; Busse J.W. et al., Opioids for Chronic Noncancer Pain – A Systematic Review and Meta-analysis, JAMA, December 2018, https://doi.org/10.1001/jama.2018.18472; National Institutes of Health, Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain, September 2014 https://prevention.nih.gov/sites/default/files/documents/programs/p2p/ODPPainPanelStatementFinal_10-02-14.pdf; Volkow N.D., McLellan A.T., Opioid Abuse in Chronic Pain--Misconceptions and Mitigation Strategies, The New England Journal of Medicine (NEJM), March 31, 2016, https://doi.org/10.1056/NEJMra1507771
6. On fentanyl in the USA: Netherland J., Vakharia S.P., Facts about Fentanyl, Drug Policy Alliance, March 2023, https://drugpolicy.org/wp-content/uploads/2023/05/2023.04.05_fentanyl_factsheet.pdf. On the perception of contamination in the US: Park J.N. et al, Fentanyl-contaminated drugs and non-fatal overdose among people who inject drugs in Baltimore, MD, Harm Reduction Journal, July 5, 2018, https://doi.org/10.1186/s12954-018-0240-z. On its role in the crisis: Kaye A., Vadivelu N., The Opioid Crises: a Comprehensive Overview, Current Pain and Headache Reports, February 23^rd, 2018, https://link.springer.com/article/10.1007/s11916-018-0670-z; Agniel D. et al., Association of Postsurgical Opioid Refills for Patients With Risk of Opioid Misuse and Chronic Opioid Use Among Family Members, JAMA Network Open, July 2022, https://doi.org/10.1001%2Fjamanetworkopen.2022.21316; Jones C.M.P. et al., Opioid analgesia for acute low back pain and neck pain (the OPAL trial): a randomized placebo.controlled trial, The Lancet, July 2023, https://doi.org/10.1016/S0140-6736(23)00404-X; Dowell D., Prescribing Opioids for Pain – The New CDC Clinical Practice Guideline, NEJM, November 2022, https://doi.org/10.1056/nejmp2211040.
7. A “pill mill” is a prescribing doctor or pharmacy that grossly mis-prescribes, dispenses or sells opioids to its customers. For two illustrations: Food and Drug Administration (FDA – June 27, 2022), Defendant Convicted of Operating Large-Scale Opioid “Pill Mill” in Queens, https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/press-releases/defendant-convicted-operating-large-scale-opioid-pill-mill-queens; Karimi F., These Florida brothers ran one of the largest opioid ‘pill mills‘ in US history. The FBI says itw as linked to thousands of deaths, CNN US, February 3^rd, 2023, https://edition.cnn.com/2023/02/03/us/american-pain-pill-mill-documentary-cec/index.html. See also the US Supreme Court decision published on July 1st, 2022: https://www.bmj.com/content/378/bmj.o1630.
8. On the practices of the companies involved: Keefe P.R. (April 13, 2021), Empire of Pain: The Secret History of the Sackler Dynasty, Hardcover; Junod V., Drugs, Pills and Lawsuits: the Opioid Debacle, In Empreinte d’une pionnière sur le droit pénal: Mélanges en l’honneur d’Ursula Cassani, Editors: Jeanneret, Yvan / Sträuli, Bernhard, pp. 167-181, Schulthess Editions romandes.
9. Kirubarajan A. et al, Systematic assessment of opioid adverstisements in general medical journals, The College of Family Physicians of Canada, March 2023, https://www.cfp.ca/content/69/3/192/tab-article-info.
10. On the obstacles to overcome in the USA: Au-Yeung C.M. et al, Increasing Access to Medications for Opioid Use Disorder: Policy Strategies During and After the COVID-19 Pandemic October 21^st, 2021, The Milbank Memorial Fund, https://www.milbank.org/publications/increasing-access-to-medications-for-opioid-use-disorder-policy-strategies-during-and-after-covid-19-pandemic/.
11. However, there is a striking lack of information on the profile of the deceased (their age, canton, substances involved, comorbidities, etc.).
12. This represents 1.75 deaths per 100,000 inhabitants (compared with 33 in the USA) (Federal Office of Public Health (FOPH – mai 2020), Fiche d’information – Décès liés à la consommation de drogue en Suisse, https://www.bag.admin.ch/dam/bag/fr/dokumente/npp/faktenblaetter/faktenblaetter-drogen/faktenblatt-drogentodesfaelle-2017.pdf.download.pdf/2020.05_Fiche%20d'information_D%C3%A9c%C3%A8s%20li%C3%A9s%20%C3%A0%20la%20consommation%20de%20drogue%20en%20Suisse.pdf). On non-fatal poisoning: Scholz I. et al., Emergency department presentations related to abuse of prescription and over-the-counter drugs in Switzerland: time trends, sex and age distributions, Swiss Medical Weekly of July 24, 2019 (SMW), https://doi.org/10.4414/smw.2019.20056; Liakoni E. et al., Characteristics of emergency department presentations requiring consultation of the national Poisons Information Centre, SMW, of December 17, 2019, https://doi.org/10.4414/smw.2019.20164. Figures for the European Union: EMCDDA, Frequently asked questions: drug overdose deaths in Europe, August 2023, https://www.emcdda.europa.eu/publications/topic-overviews/frequently-asked-questions-faq-drug-overdose-deaths-europe_en. Fentanyl-related deaths remain very rare in Switzerland.
13. FOPH, Fiche d’information – Décès liés à la consommation de drogue en Suisse, May 2020, p. 2, https://www.bag.admin.ch/dam/bag/fr/dokumente/npp/faktenblaetter/faktenblaetter-drogen/faktenblatt-drogentodesfaelle-2017.pdf.download.pdf/2020.05_Fiche%20d'information_D%C3%A9c%C3%A8s%20li%C3%A9s%20%C3%A0%20la%20consommation%20de%20drogue%20en%20Suisse.pdf; Infodrog, Consommation de médicaments et consommation mixte chez les jeunes. Analyse de la situation et des besoins, 2022, p. 6, https://www.infodrog.ch/files/content/ff-fr/Consommation_de_medicaments_et_mixte_chez_les_jeunes.pdf.
14. Addiction Suisse, Opioïdes: conséquences (consulted on April 6, 2024), https://www.addictionsuisse.ch/faits-et-chiffres/opioides/opioides-consequences/; Oelhaf R.C., Del Pozo E., Azadfard M., Opioid Toxicity, StatPearls, July 2023, https://www.ncbi.nlm.nih.gov/books/NBK431077/; Els C. et al., Adverse events associated with medium- and long-term use of opioids for chronic non-cancer pain: an overview of Cochrane Reviews, Cochrane Library, October 2017, https://doi.org/10.1002%2F14651858.CD012509.pub2.
15. In Switzerland, around 1,600 people die each year from alcohol-related causes. See Service du médecin cantonal, Addictions: Chiffres et statistiques, État de Fribourg, February 2024, https://www.fr.ch/sante/addictions-et-dependances/que-fait-le-canton-de-fribourg-en-matiere-daddictions/addictions-chiffres-et-statistiques. On side effects: Hôpitaux Universitaires Genève, Les effets indésirables de la morphine, December 2023, https://www.hug.ch/reseau-douleur/quels-sont-effets-secondaires-morphine; Benyamin R. et al., Opioid Complications and Side Effects, Pain Physician Journal (PPJ), March/April 2008, https://www.painphysicianjournal.com/linkout?issn=1533-3159&vol=11&page=S105. More generaly: Oelhaf R.C., Del Pozo E., Azadfard M., cited above.
16. Observatoire français des drogues et des tendances addictives, Méthadone et troubles de la sexualité mécanismes et prise en charge, July 2008, http://mediatheque.lecrips.net/docs/PDF_GED/S60081.pdf.
17. Global Commission On Drug Policy (GCD), The Opioid Crisis In North America, October 2017, http://www.globalcommissionondrugs.org/position-papers/opioid-crisis-north-america-position-paper; GCD, The World Drug Perception Problem – Countering Prejudices About People Who Use Drugs, 2017 Report, http://www.globalcommissionondrugs.org/wp-content/uploads/2018/01/GCDP-Report-2017_Perceptions-ENGLISH.pdf. Les personnes les plus touchées sont des hommes non mariés: Brown P. T., Opioids and the Unattached Male, City Journal, January 2022, https://www.city-journal.org/article/opioids-and-the-unattached-male.
18. Schatman M.E., Webster L.R., The health insurance industry: perpetuating the opioid crisis through policies of cost-containment and profitability, March 18, 2015, https://doi.org/10.2147/JPR.S83368.
19. Scholten W., Henningfield J.E., Negative outcomes of unbalanced opioid policy supported by clinicians, politicians, and the media, Journal of Pain & Palliative Care Pharmacotherapy, February 2016 https://doi.org/10.3109/15360288.2015.1136368.
20. See FDA warnings: FDA alerts health care professionals of risks to patients exposed to xylazine in illicit drugs, August 11, 2022, https://www.fda.gov/drugs/drug-safety-and-availability/fda-alerts-health-care-professionals-risks-patients-exposed-xylazine-illicit-drugs; NIH warnings: National Institute on Drug Abuse (consulted on April 6, 2024), Xylazine, https://nida.nih.gov/research-topics/xylazine; DEA warnings: U.S. Department of Justice – Drug Enforcement Administration (October 2022), The Growing Threat of Xylazine and its Mixture with Illicit Drugs, https://www.dea.gov/sites/default/files/2022-12/The%20Growing%20Threat%20of%20Xylazine%20and%20its%20Mixture%20with%20Illicit%20Drugs.pdf; and CDC warnings: Centers for Disease Control and Prevention (September 17, 2021), Morbidity and Mortality Weekly Report (MMWR), https://www.cdc.gov/mmwr/volumes/70/wr/mm7037a5.htm; Gupta R., Holtgrave D.R., Ashburn M.A., Xylazine – Medical and Public Health Imperatives, NEJM, April 26, 2023 https://doi.org/10.1056/nejmp2303120.
21. Unlike in Switzerland, North American consumers can rarely rely on drug testing services to check the contents of their products, as this practice is prohibited in most states. See Dance Safe, Promoting Health & Safety, https://dancesafe.org/; Dance Safe, State-by-state Legal Guide to Drug Checking Tools, https://drugcheckinglaws.wordpress.com/#guide. However, test strips to detect fentanyl have been made available.
22. Our interviews with Drug Checking services have revealed that fentanyl is virtually absent from Switzerland: Infodrog (2023), Fentanyl, Informations pour les professionnel-le-s des addictions – Fiche d’information, https://www.infodrog.ch/files/content/factsheets/2023-08_infodrog_fiche-d-information_fentanyl_fr.pdf. However, new threats can emerge quickly, as evidenced by the emergence of crack cocaine in Geneva: Anthonioz N.E., Zobel F. (2023), La problémetique du crack à Genève: situation et réponses, Addiction Suisse, https://www.addictionsuisse.ch/publication/la-problematique-du-crack-a-geneve/.
23. Swiss politics is therefore remarkably stable, albeit with changes being made in small steps.
24. In the USA, many risk reduction measures are still illegal in the States: Corey S. et al, Repealing State Drug-Paraphernalia Laws – The Need for Federal Leadership, NEJM, October 8, 2022, https://doi.org/10.1056/nejmp2207866.
25. See point 8 of Appendix 1 of the OPAS («Ordonnance du DFI sur les prestations dans l’assurance obligatoire des soins en as de maladie” – Status as of January 1^st, 2024): https://www.bag.admin.ch/dam/bag/fr/dokumente/kuv-leistungen/leistungen-und-tarife/aerztliche-leistungen/Anhang1-KLV/gesamtliste_klv_anh1_010723.pdf.download.pdf/liste_generale_opas_ann1_010723.pdf.
26. Switzerland lacks a recent study assessing heroin use over the last 30 days and the percentage of users suffering from opiate dependence (as defined by ICD-10).
27. The coverage rate is over 50% in the European Union, with major differences between countries (coverage rates vary between 10 and 90%): European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (2023), Opioid agonist treatment – the current situation in Europe (European Drug Report 2023), https://www.emcdda.europa.eu/publications/european-drug-report/2023/opioid-agonist-treatment_en; Simon O. et al, Morderniser les conditions-cadres des traitements médicamenteux du syndrome de dépendance aux opioïdes, RMS, June 6, 2018, https://doi.org/10.53738/REVMED.2018.14.610.1169.
28. Addiction Suisse (2021), Statistique nationale des traitements par agonistes opioïdes de substitution, https://www.addictionsuisse.ch/wp-content/uploads/2023/01/statistique-nationale-des-traitements-par-agonistes-opioides-de-substitution-resultats-2021.pdf.
29. However, the insured are required to pay an insurance excess and a co-payment.
30. Schmitt-Koopmann C. et al., Cantonal Opioid Agonist Treatment Authorization Systems – a mixed-method qualitative investigation, SMW of March 9, 2024, https://serval.unil.ch/fr/notice/serval:BIB_797E760DC0D2. See e.g.: Direction générale de la santé du canton de Vaud, Directives du Médecin cantonal concernant la prescription, la dispensation et l’administration des médicaments soumis à la législation sur les stupéfiants destinés à la prise en charge de personnes présentant un syndrome de dépendance, (status as of November 10, 2021), section 4, https://www.vd.ch/fileadmin/user_upload/organisation/dsas/DGS/fichiers_pdf/Directives_MC_prescription-TAO_09.12.2021.pdf.
31. Donald N., As drug deaths soar, experts urge expanded access to methadone, March 5, 2023, https://norcross.house.gov/2023/3/as-drug-deaths-soar-experts-urge-expanded-access-to-methadone; Englander H., Davis C.S., Hospital Standards of Care for People with Substance Use Disorder, NEJM, August 20, 2022, https://doi.org/10.1056/nejmp2204687.
32. Relapses and overdoses are caused by using of substitutes without medical supervision: Strang J. et al., Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study, British Medical Journal (BMJ), May 3^rd, 2003, https://doi.org/10.1136/bmj.326.7396.959; Ledberg A., Reitan T., Increased risk of death immediately after discharge from compulsory care for substance abuse, Drug and Alcohol Dependence, May 10, 2022, https://doi.org/10.1016/j.drugalcdep.2022.109492.
33. Gupta R. et al., Transforming Management of Opioid Use Disorder with Universal Treatment, NEJM, (September 21^st, 2022, https://doi.org/10.1056/nejmp2210121.
34. Leech A.A. et al., Buprenorphine Out-of-Pocket Costs and Discontinuation in Privately Insured Adults With Opioid Use Disorder, JAMA Internal Medicine, https://doi.org/10.1001/jamainternmed.2023.2826; Eisenberg M.D., Barry C.L., High-Deductible Health Plans’ Impact on Mental Health and Substance Use Disorder Treatments-Balancing Cost and Care, JAMA Psychiatry, August 9, 2023, https://doi.org/10.1001/jamapsychiatry.2023.2625.
35. Hoffman J., Addition Treatment Medicine Is Vastly Underprescribed, Especially by Race, Study Finds, The New York Times (NYT) of May 10, 2023, https://www.nytimes.com/2023/05/10/health/addiction-treatment-buprenorphine-suboxone.html.
36. Art. 32 al. 1 lit. a, b and d LPTh; Art. 10 and 23 OPuM; Art. 17 and 22.b LStup; Art. 56 OCStup. The same applies in the European Union, see Art. 88.1 of the Directive 2001/83/EC of the European Parliament and of the Council of 6 November 2001 on the Community code relating to medicinal products for human use, https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:02001L0083-20220101.
37. FDA (consulted on April 6, 2024), Prescription Drug Advertising – Questions and Answers: Does Federal law ban ads for drugs that have serious risks?, https://www.fda.gov/drugs/prescription-drug-advertising/prescription-drug-advertising-questions-and-answers#law.
38. Art. 55 LPTh; OITPTh; Art. 56 LAMal; Art. 76a-76c OAMal.
39. See the precise rules of the Ordinance on Integrity and Transparency in the Field of Therapeutic Products of 10 April 2019 (OITPTh; RS 812.214.31).
40. They were introduced with the Federal Law on Medicinal Products and Medical Devices (LPTh) and its Art. 33 came into force on January 1st, 2022.
41. Humbert C., Dérapages en série: une pharmacie fermée, 20 minutes of June 21^st, 2023https://www.20min.ch/fr/story/derapages-en-serie-une-pharmacie-fermee-170442712412; 20 minutes of September 1^st, 2021, L’anesthésiste se servait sur son lieu de travail, https://www.20min.ch/fr/story/lanesthesiste-se-servait-sur-son-lieu-de-travail-432540573814.
42. It is true that doctors who provide regular consultations for their addicted patients can increase their turnover. However, the insurance companies compare the average turnover per patient of each doctor with his group, check the figures and demand reimbursement of any excess. Insurers may also refuse to reimburse off-label prescriptions, because the dosage or duration exceeds what is permitted in the FOPH’s List of Specialities (LS) or by Swissmedic’s marketing authorization (MA).
43. We have used here on the LS price of Oxycodon Naloxon Spirig HC tablets 10/5 mg, 60 tablets, retail price. Th French price is much lower, around 10 euros.
44. Price per unit of an oxycodone oral tablet (10 mg): $2.66 – $4.37 (extended release): Drugs.com (consulted on April 6, 2024), Oxycoodone Prices, Coupons and Patient Assistance Programs, https://www.drugs.com/price-guide/oxycodone.
45. Ohio Recovery Center (consulted on April 6, 2024), Oxycodone Street Value, Prices & Prescription Costs, https://www.recoveryohio.org/oxycodone/street-prices/.
46. Information provided by clinicians in the field; Infodrog (2022), Consommation de médicaments et consommation mixte chez les jeunes – Analyse de la situation et des besoins, p. 4, https://www.infodrog.ch/files/content/ff-fr/Consommation_de_medicaments_et_mixte_chez_les_jeunes.pdf. According to the FOPH’s list of specialties, the factory price for a box if CHF 20.28, while the retail price if CHF 39.70.
47. The causal link has not been demonstrated, only an association. As a result, strategic measures and recommendations for good practice have been – and are still being – developed: Ruskin D., Rasul R., McCann-Pineo M., Predictors of Emergency Department Opioid Use Among Adolescents and Young Adults, Pediatric Emergency Care (PEC), August 2022, https://doi.org/10.1097%2FPEC.0000000000002777; Chang C.D. et al., Emergency department strategies to combat the opioid crisis in children and adolescents, Journal of the American College of Emergency Physicians Open, February 20, 2021, https://doi.org/10.1002/emp2.12512.
48. Van Winkle P.J. et al., Opioid prescribing patterns in emergency departments and future opioid use in adolescent patients, The American journal of Emergency Medicine (AJEM), November 18, 2019, https://doi.org/10.1016/j.ajem.2019.10.020.
49. The deductible varies from CHF 300 to CHF 2,500 and the total co-payment of 10% may not exceed CHF 700 (Art. 64 LAMal; 93 et 103 OAMal). Certain treatments, in particular dental treatment, are not covered, but prescriptions for drugs included in the List of specialities (LS) are almost always covered. On the renunciation of care or rationing of care, see: Observatoire de la santé, Renoncement à des prestations médicales et dentaires nécessaires pour des raisons financières, MonAM, https://ind.obsan.admin.ch/fr/indicator/monam/renoncement-a-des-prestations-medicales-et-dentaires-necessaires-pour-des-raisons-financieres-age-16. See also: Groupe de travail «Rationnement», Le rationnement au sein du système de santé suisse: analyse et recommandation, Académie Suisse des Sciences Médicales (ASSM), July 2007, https://www.samw.ch/dam/jcr:d1a90c1d-12d2-4c34-a4c6-535e3a70fde2/feuille_de_route_assm_rationnement_sante_suisse.pdf.
50. Art. 335c, 336c et 324a Swiss Code of Obligations (CO). For more detailed and nuanced explanations, see: Dupont A.-S. (2019), La compensation financière de l’incapacité de travail, Revue de droit suisse, p. 37, https://libra.unine.ch/server/api/core/bitstreams/ee1533f2-c3d0-49f4-bded-e30536c2a5fd/content.
51. Art. 336c CO.
52. Site official de la statistique nationale des traitements par agonistes opioïdes (consulted on April 7, 2024), Statistiques annuelles (2022), tao-oat.ch, https://www.substitution.ch/fr/statistiques_annuelles.html&year=2022&canton=ch.
53. Id. See also Fachverband Sucht/GREA, Recommandations pour l’accompagnement des personnes âgées souffrant d’une addiction – Guide déontologique à l’intention des médecins d’établissements médico-sociaux et des médecins de famille, December 2022, p. 14, https://www.grea.ch/sites/default/files/guide_deontologique_fs_web.pdf.
54. MonAM (consulted on April 6, 2024), Décès dus à la drogue, https://ind.obsan.admin.ch/fr/indicator/monam/deces-dus-a-la-drogue.
55. The first wave of deaths affected older people. See the graphs by age group on the Kaiser Family Foundation (KFF), Opioid Overdose Deaths by Age Group, https://www.kff.org/other/state-indicator/opioid-overdose-deaths-by-age-group/?dataView=1&currentTimeframe=12&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. These were the people who received medical prescriptions. In subsequent waves, the age groups concerned were broadened: Manchikanti L. et al., Fourth Wave of Opioid (Illicit Drug) Overdose Deaths and Diminishing Access to Prescription Opioids and Interventional Techniques: Cause and Effect, PPJ, March/April 2022, https://www.painphysicianjournal.com/current/pdf?article=NzQxOQ%3D%3D&journal=142.
56. KFF (consulted on April 6, 2024), Opioid Overdose Deaths by Age Group, https://www.kff.org/other/state-indicator/opioid-overdose-deaths-by-age-group/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
57. Hudgins J.D. et al. (November 2019), Prescription opioid use and misuse among adolescents and young adults in the United States: A national survey study, Plos Medicine, https://doi.org/10.1371%2Fjournal.pmed.1002922; Mieach R.A. et al., National Survey Results on Drug Use, 1975-2022: Secondary School Students, Monitoring the Future, June 2023, https://monitoringthefuture.org/wp-content/uploads/2022/12/mtf2022.pdf.
58. Infodrog (2022), Consommation de médicaments et consommation mixte chez les jeunes – Analyse de la situation et des besoins, https://www.infodrog.ch/files/content/ff-fr/Consommation_de_medicaments_et_mixte_chez_les_jeunes.pdf.
59. Moeller J. et al., High school students’ feelings: Discoveries from a large national survey and an experience sampling study, Learning and Instruction, January 7, 2020, https://doi.org/10.1016/j.learninstruc.2019.101301.
60. 70% of teenagers say that anxiety and depression is a major problem in their age group and 26% say it is a minor problem; only 4% say it is not a problem. For drug addiction, the figures are 51%, 35% and 13% respectively: Horowitz J.M., Graf N., Most U.S. Teens See Anxiety and Depression as a Major Problem Among Their Peers, Pew Research Center, February 20, 2019, https://www.pewresearch.org/social-trends/2019/02/20/most-u-s-teens-see-anxiety-and-depression-as-a-major-problem-among-their-peers/.
61. See Reher D.S. (2004), Family Ties in Western Europe, p. 45.
62. Hatflied J. (May 3, 2023), Young adults in the U.S. are less likely than those in most of Europe to live in their parents’ home, Pew Research Center, https://www.pewresearch.org/short-reads/2023/05/03/in-the-u-s-and-abroad-more-young-adults-are-living-with-their-parents/. The same article provides a graph showing the number of young people living with their families in Europe and in the USA. There are only 4 European countries where young people stay with their families more than in the USA: Germany, Finland, Denmark and Sweden. The average age at which people leave home is 26.4 in Europe, compared with 24-25 in Switzerland and ___ in the USA: Eurostat (August 18, 2022), Archive:Age of young people leaving their parental household, https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Age_of_young_people_leaving_their_parental_household&oldid=572375#Gender_differences. Furthermore, in Switzerland, it is young people in training who remain at home, whereas in the USA, the reverse is true: Tribune de Genève of December 26, 2016, Les jeunes tardent à quitter le nid familial, https://www.tdg.ch/les-jeunes-tardent-a-quitter-le-nid-familial-340512642047. For a breakdown by US state: Suneson G. (2019), Do you still live with your parents ? Odds are you’re from the Northeast, USA Today Money, https://eu.usatoday.com/story/money/2019/07/02/living-at-home-states-where-millenials-stay-with-parents/39627465/. The figure varies greatly from one state to another: Ethier M. (August 20, 2021), On The Move: New Study Shows More Students Leaving Home For College, Poest & Quants for Undergrads, https://poetsandquantsforundergrads.com/news/on-the-move-new-study-shows-more-students-leaving-home-for-college/.
63. On the role of the community in preventing the non-medical use of narcotics: Collins D. et al., Non-Medical Use of Prescription Drugs among Youth in an Appalachian Population: Prevalence, Predictors, and Implications for Prevention, Journal of Drug Education, October 11, 2011, https://doi.org/10.2190/DE.41.3.e.
64. Ranker L.R., Lipson S.K., Prevalence of heavy episodic drinking and alcohol use disorder diagnosis among US college students: Results from the national Healthy Minds Study, Addictive Behaviors, December 2022, https://doi.org/10.1016/j.addbeh.2022.107452.
65. Overall, less than 2% of the population moves outside Switzerland each year, and less than 2% move outside their own canton: Federal Statistical Office (FSO) (consulted on April 7, 2024), Home moves, https://www.bfs.admin.ch/bfs/en/home/statistics/construction-housing/dwellings/home-moves.html. In the USA, the figure is 2.3%: Decker B. (consulted on April 7, 2024), State-to-State Migration Trends in the United States, The Texas A&M University System, https://www.tamus.edu/data-science/2023/02/15/state-to-state-migration-trends-in-the-united-states/; Mariotti T., Moving Statistices: Industry Trends & Data (2024); Ruby Home – Luxury Real Estate, https://www.rubyhome.com/blog/moving-stats/.
66. Linguistic differences between the German- and French- speaking regions of Switzerland result in a low rate of migration between these two regions.
67. Horowitz J.M., Graf N., Most U.S. Teens See Anxiety and Depression as a Major Problem Among Their Peers, Pew Research Center, February 20, 2019, https://www.pewresearch.org/social-trends/2019/02/20/most-u-s-teens-see-anxiety-and-depression-as-a-major-problem-among-their-peers/.
68. Dehon C., Jacobs D., Vermandele C., Ranking universities, 2009, https://library.oapen.org/bitstream/handle/20.500.12657/37384/9782800414416.pdf#page=107; Pro Juventute, Étude sur le stress de pro juventute: environ un tiers des enfants et des jeunes en Suisse sont stressés – conclusions pour les jeunes, les parents et les écoles, July 2021, https://www.projuventute.ch/sites/default/files/2021-08/%C3%89tude-sur-le-stress.pdf.
69. Infodrog, Cannabis, cocaïne, ecstasy & Cie. – Actualités du monde des substances psychoactives, 2022 https://www.infodrog.ch/files/content/nightlife/fr/2022_Cannabis_cocaine_ecstasy_Cie_2021_v02.pdf; Infodrog, Consommation de médicaments et consommation mixte chez les jeunes – Analyse de la situation et des besoins, 2022, p. 3, https://www.infodrog.ch/files/content/ff-fr/Consommation_de_medicaments_et_mixte_chez_les_jeunes.pdf.
70. Armengaud J.-B. et al., Drogues: mineur-e-s et réduction des risques ?, RMS of June 7, 2023, https://doi.org/10.53738/REVMED.2023.19.830.1127.
71. Palamar J.J., Diffusion of Ecstasy in the Electronic Dance Music Scene, Substance Use & Misuse, July 2020, https://www.tandfonline.com/doi/full/10.1080/10826084.2020.1799231. However, festive opioid use does exist: Palamar J.J., Le A., Cleland C.M., Nonmedical opioid use among electronic dance music party attendees in New York City, Drug and Alcohol Dependence, March 27, 2018, https://doi.org/10.1016/j.drugalcdep.2018.03.001.
72. Egan K.L. et al., More than just alcohol: Marijuana and illicit drug use at parties attended by 15-20 year olds, Substance Use & Misuse, November 2018, https://doi.org/10.1080/10826084.2018.1517798.
73. Lucke J.C. et al. (2011), Academic doping or Viagra for the brain?, EMBO Reports, https://www.embopress.org/doi/epdf/10.1038/embor.2011.15.
74. Terry-McElrath Y.M., O’Malley P.M., Johnston L.D., Reasons for Drug Use among American Youth by Consumption Level, Gender, and Race/Ethnicity: 1976-2005, Journal of Drug Issues, 2009, https://doi.org/10.1177/002204260903900310; Farrugia P.L. et al., Childhood trauma among individuals with co-morbid substance use and post traumatic stress disorder, Mental Health and Substance Use, November 2011, https://doi.org/10.1080/17523281.2011.598462; Szalavitz M. (April 24, 2023), This Is What Neuroscientists and Philosophers Understand About Addiction, NYT, https://www.nytimes.com/2023/04/24/opinion/addiction-free-will.html.
75. Busse J.W., Wang L., Kamaleldin M., Opioids for Chronic Noncancer Pain – A Systematic Review and Meta-amalysis, JAMA, December 18, 2018, https://doi.org/10.1001/jama.2018.18472; Infodrog (2022), Consommation de médicaments et consommation mixte chez les jeunes – Analyse de la situation et des besoins, p. 4, https://www.infodrog.ch/files/content/ff-fr/Consommation_de_medicaments_et_mixte_chez_les_jeunes.pdf.
76. Matthew P., Brodersen D.M., Income inequality and health outcomes in the United States: An empirical analysis, The Social Science Journal, December 2018, https://doi.org/10.1016/j.soscij.2018.05.001.
77. In the US: Atkins N., Mukhida K., The relationship between partients’ income and education and their access to pharmacological chronic pain management: A scoping review, Canadian Journal of Pain, 2022, https://doi.org/10.1080/24740527.2022.2104699. More generally: Brennan F., Lohman D., Gwyther L., Access to Pain Management as a Human Right, American Journal of Public Health (AJPH), December 2018, https://doi.org/10.2105/AJPH.2018.304743. English study: Jain S. et al., Inequalities and inequities in the types of chronic pain services available in areas of differing deprivation across England, Scandinavian Journal of Pain, (May 2, 2022, https://doi.org/10.1515/sjpain-2022-0015.
78. In general, pain, whether chronic or not, is a widespread symptom: Lomte T.S., What are the rates of chronic pain and high-impact chronic pain incidence and persistence in US adults?, News Medical & Life Sciences, May 19, 2023, https://www.news-medical.net/news/20230519/What-are-the-rates-of-chronic-pain-and-high-impact-chronic-pain-incidence-and-persistence-in-US-adults.aspx; Nahin R.L. et al., Estimated Rates of Incident and Persistent Chronic Pain Among US Adults, 2019-2020, JAMA Network Open, May 16, 2023, https://doi.org/10.1001/jamanetworkopen.2023.13563.
79. Dahlhamer J. et al., Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults – United States, 2016, MMWR Morb Mortal Wkly Rp, September 14, 2018, http://dx.doi.org/10.15585/mmwr.mm6736a2; Choi H.Y. et al., Social Disparities of Pain and Pain Intensity Among Women Diagnosed With Early Stage Breast Cancer, Frontiers in Oncology, February 8, 2022, https://doi.org/10.3389/fonc.2022.759272; Chou E.Y., Parmar B.L., Galinsky A.D., The Link Between Income Inequality and Physical Pain, Harvard Business Review, March 21^st, 2016, https://hbr.org/2016/03/the-link-between-income-inequality-and-physical-pain.
80. The exception is certain groups, mainly illegal migrants. In Switzerland, the Gini coefficient of inequality is 0.3 after social redistribution (equivalent disposable income): FSO, Redistribution des revenus par les transferts sociaux, https://www.bfs.admin.ch/bfs/fr/home/statistiques/situation-economique-sociale-population/bien-etre-pauvrete/inegalites-de-repartition-des-revenus/redistribution-revenus.html. In the USA, it is 0.41/47 of the raking; compared to 114 for Switzerland: Wisevoter (consulted on April 6, 2024), Gini Goefficient by Country, https://wisevoter.com/country-rankings/gini-coefficient-by-country/. On the concepts of social justice and equity in Europe, see the study by the European Social Survey: Main results of the 9^th edition of the European Social Survey, 2020.
81. Argo N., Sheikh H., The Belonging Barometer – The State of Belonging in America, Over Zero, American Immigration Council, March 2016, https://www.americanimmigrationcouncil.org/sites/default/files/research/the_belonging_barometer_-_the_state_of_belonging_in_america.pdf; Chancel L., Rapport sur les inégalités mondiales 2022, World Inequality Lab, https://wir2022.wid.world/www-site/uploads/2021/12/Summary_WorldInequalityReport2022_French.pdf.
82. Case A., Deaton A., The Epidemic of Despair – Will America’s Mortality Crisis Spread to the Rest of the World?, USA Foreign Affairs, February 2020 https://www.foreignaffairs.com/articles/united-states/2020-02-03/epidemic-despair.
83. On the correlation between socio-economic status and fatal overdoses: Altekruse S.F. et al., Socioeconomic risk factors for fatal opioid overdoses in the United States: Findings from the Mortality Disparities in American Communities Study (MDAC), Plos One, January 17, 2020, https://doi.org/10.1371/journal.pone.0227966; Chapman A., The Opioid Crisis and Child Maltreatment Across Counties and Time in the United States, 2007-2017, The ANNALS of the American Academy of Political and Social Science, March 20, 2023, https://doi.org/10.1177/00027162221144172; Kurani S. et al., Place, poverty and prescriptions: a cross-sectional study using Area Deprivation Index to assess opioid use and drug-poisoning mortality in the USA from 2012 to 2017, BMJ Open, April 21^st, 2020, https://bmjopen.bmj.com/content/10/5/e035376.abstract; Chou E.Y., Parmar B.L., Galinsky A.D., Economic Insecurity Increases Physical Pain, Psychological Science, February 18, 2016, https://doi.org/10.1177/0956797615625640; Dorner T.E., Muckenhuber J., Stronegger W., The impact of socio-economic status on pain and the perception of disability due to pain, European Journal of Pain, January 9, 2012, http://dx.doi.org/10.1016/j.ejpain.2010.05.013; Rios R., Zautra A.J., Socioeconomic Disparities in Pain: The Role of Economic Hardship and Daily Financial Worry, Health Psychology, 2011, https://doi.org/10.1037/a0022025.
84. For Switzerland, see the FOPH summary: FOPH (2018), Health equity – Facts and figures for Switzerland, Brochure: Health equity – Facts and figures for Switzerland (PDF, 472 kB, 16.01.2018). For the USA, see Whitman A. et al., Addressing Social Determinants of Health: Examples of Successful Evidence-Based Strategies and Current Federal Efforts, Office of the Assistant Secretary for Planning and Evaluation, April 1^st, 2022, https://aspe.hhs.gov/reports/sdoh-evidence-review.
85. Ruchat D. et al., Consommation d’opioïdes entre 1985 et 2015: chiffres suisses et mise en perspective internationale, RMS of June 20, 2018, http://dx.doi.org/10.53738/REVMED.2018.14.612.1262; Hooijman M.F. et al., Opioid sales and opioid-related poisonings in Switzerland: A descriptive population-based time-series analysis, The Lancet, June 2022, https://doi.org/10.1016/j.lanepe.2022.100437; Müller D. et al., Increased Use and Large Variation in Strong Opioids and Metamizole (Dipyrone) for Minor and Major Musculoskeletal Injuries Between 2008 and 2018: An Analysis of a Representative Sample of Swiss Workers, Journal of Occupational Rehabilitation, April 2023, https://doi.org/10.1007/s10926-023-10115-5; Wertli M.M. et al., Analyse der Entwicklung der Verschreibungspraxis von Schmerz- und Schlafmedikamenten zwischen 2013 und 2018 in der Schweiz, FOPH, 2020, https://www.bag.admin.ch/dam/bag/de/dokumente/npp/forschungsberichte/forschungsberichte-medikamentenmissbrauch/verschreibungspraxis-schmerz-und-schlafmedikamente.pdf.download.pdf/Schlussbericht_Pain-medication-use.pdf. Non-oncological pain is also on the increase: FOPH, Fiche d’information – Évolution de la prescription d’analgésiques et de somnifères en Suisse, February 2021, https://www.bag.admin.ch/dam/bag/fr/dokumente/npp/faktenblaetter/faktenblaetter-medikamente/faktenblatt-entwicklung-verschreibung-schmerz-und-schlafmedikamente.pdf.download.pdf/210118_Faktenblatt_EntwicklungVerschreibungspraxis_Medikamente_FRA.pdf.
86. Ruchat D. et al. cited above.
87. FSO, Traitements pour troubles psychiques chez les jeunes en 2020 et 2021, Troubles mentaux: hausse sans précédent des hospitalisations pour les jeunes femmes de 10 à 24 ans, December 12, 2022, https://www.bfs.admin.ch/asset/fr/23772012; Peter C., Tuch A., Schuler D. (March 2023), Psychische Gesundheit – Erhebung Herbst 2022, Wie geht es der Bevölkerung in der Schweiz ? Sucht sie sich bei psychischen Problemen Hilfe?, Observatoire suisse de la santé, https://www.obsan.admin.ch/fr/publications/2023-psychische-gesundheit-erhebung-herbst-2022; see also the interview of Adrian Ritter: Günes N., Pauli D. (August 2^nd, 2023), Trop de pression sur les jeunes?, Bulletin des Médecins Suisses, https://doi.org/10.4414/bms.2023.22005.
88. Barrense-Dias Y., Chok L., Surís J.-C. (2021), A picture of the mental health of adolescents in Switzerland and Liechtenstein, Unisanté – Centre universitaire de médecine générale et santé publique Groupe de recherche sur la santé des adolescents – GRSA, https://serval.unil.ch/resource/serval:BIB_04ED542FD91C.P004/REF; Tuchschmid B., La santé mentale des jeunes Suisses inquiète les spécialistes, Blick of September 15, 2022, https://www.blick.ch/fr/news/suisse/depression-suicide-anxiete-la-sante-mentale-des-jeunes-suisses-inquiete-les-specialistes-id17879398.html. In the US, we observe a similar phenomenom: Ghorayshi A., Rabin R.C., Teen GirlsReport Record Levels of Sadness, C.D.C. Finds, NYT of February 13, 2023, https://www.nytimes.com/2023/02/13/health/teen-girls-sadness-suicide-violence.html.
89. Smit T. et al., Chronic pain acceptance: Relations to opioid misuse and pain management motives among individuals with chronic low back pain, Addictive Behaviors, September 19, 2022https://doi.org/10.1016/j.addbeh.2022.107495; Stanic J. et al., Applications de la méditation de pleine conscience dans différents secteurs de médecine somatique, Un outil de gestion de la douleur physique et morale, RMS of June 21, 2023, https://doi.org/10.53738/revmed.2023.19.832.1228.
90. On the subject of pain neuroscience education, see for example: Malfiet A. et al, Effect of Pain Neuroscience Education Combined With Cognition-Targeted Motor Control Training on Chronic Spinal Pain: A Randomized Clinical Trial, JAMA Neurology, July 2018, https://doi.org/10.1001/jamaneurol.2018.0492; Çinar H.G., Yilmaz D., Akin E., Pain acceptance levels of patients with chronic pain, Medicine, April 2020, http://dx.doi.org/10.1097/MD.0000000000019851; McCracken L.M., Learning to live with the pain: acceptance of pain predicts adjustment in persons with chronic pain, Pain, January 1998, https://doi.org/10.1016/s0304-3959(97)00146-2; Gauthier L.R. et al., Acceptance of pain: A study in patients with advanced cancer, Pain, May 2009, https://doi.org/10.1016/j.pain.2009.02.009; Kranz D., Bollinger A., Nilges P., Chronic pain acceptance and effective well-being: A coping perspective, European Journal of Pain, January 13, 2012, https://doi.org/10.1016/j.ejpain.2010.03.010; Mason V.L., Mathias B., Skevington S., Accepting Low Back Pain: Is It Related to a Good Quality of Life?, The Clinical Journal of Pain, January 2008, https://doi.org/10.1097/ajp.0b013e318156d94f.
91. FSO, Consultations chez un médecin par sexe, âge, niveau de formation, région linguistique, press release of October 30, 2018, https://www.bfs.admin.ch/bfs/fr/home/statistiques/sante/systeme-sante/cabinets-medicaux.assetdetail.6466031.html.
92. Allaz A.-F., Leutke S.M., Cedraschi C., Douleurs chroniques en contexte: du côté du social, RMS, of June 21, 2023, https://doi.org/10.53738/revmed.2023.19.832.1220.
93. Tomczak-Plewka A., Pourquoi le mieux peut être contreproductif, Bulletin des Médecins Suisses (BMS) of November 22, 2022, https://doi.org/10.4414/bms.2022.21298; van Loenen T. et al., Propensity to seek healthcare in different healthcare systems: analysis of patient data in 34 countries, BMC Health Services Research, October 9, 2015, https://doi.org/10.1186%2Fs12913-015-1119-2.
94. Survey of Swiss people on their knowledge of mental health: Promotion Santé Suisse, La Suisse sait-elle ce qu’elle peut faire pour sa santé psychique ? Résultats d’une enquête représentative sur les compétences en matière de santé psychique en Suisse, June 2021, https://promotionsante.ch/sites/default/files/2022-11/Feuille_d_information_060_PSCH_2021-06_-_Competences_en_matiere_de_sante_psychique_en_Suisse.pdf.
95. As regards the use of painkillers in the last 7 days, see the figures and how they have changed: among young people aged 15-34, the figure has risen from 12% in 1992 to 22%: FSO (February 28, 2019), Enquête suisse sur la santé 2017: tableaux standard – Une personne sur deux en Suisse prend des médicaments chaque semaine, https://www.bfs.admin.ch/asset/fr/7486440. The quantities of psychotropic drugs purchased did not change significantly between 2017 and 2020; they remained stable for antidepressants, increased (slightly) for antipsychotics and ADHD drugs, and decreased for anxiolytics/sedatives. An increase in these quantities is more likely to be observed amoung younger people (antidepressants, antipsychotics, anxiolytics/sedatives): Observatoire suisse de la santé , Les médicaments psychotropes en Suisse – Quantités, coûts, acheteurs et prescripteurs, March 17, 2022, https://www.bfs.admin.ch/bfs/fr/home/statistiques/catalogues-banques-donnees/publications.assetdetail.21844497.html; FOPH, Fiche d’information – Évolution de la prescription d’analgésiques et de somnifères en Suisse, February 2021, https://www.bag.admin.ch/dam/bag/fr/dokumente/npp/faktenblaetter/faktenblaetter-medikamente/faktenblatt-entwicklung-verschreibung-schmerz-und-schlafmedikamente.pdf.download.pdf/210118_Faktenblatt_EntwicklungVerschreibungspraxis_Medikamente_FRA.pdf; FOPH (February 2019), Fiche d’information – Consommation simultanée de médicaments et d’alcool chez les personnes âgées, https://www.bag.admin.ch/dam/bag/fr/dokumente/npp/faktenblaetter/faktenblaetter-alkohol/faktenblatt-arzneimittel-und-alkohol.pdf.download.pdf/2019.02_Fiche%20d'information_Consommation%20simultan%C3%A9e%20de%20m%C3%A9dicaments%20et%20d%E2%80%99alc.pdf; Ecoplan (August 15, 2019), Auslegeordnung zum problematischen Gebrauch psychoaktiver Medikamente, https://www.bag.admin.ch/dam/bag/de/dokumente/npp/forschungsberichte/forschungsberichte-medikamentenmissbrauch/auslegeordnung-psychoaktive-medikamente.pdf.download.pdf/190815_Medikamente_Schlussbericht.pdf.
96. On the lack of studies on this subject: Bonnie R.J., Ford M.A., Philips J.K., Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use, The National Academies Press, July 13, 2017, https://www.ncbi.nlm.nih.gov/books/NBK458653/. On draft guidelines to improve communication between healthcare professionals and patients: Dowell D., Haegerich T.M., Chou R., CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016, JAMA, February 26, 2019, https://doi.org/10.1001/jama.2016.1464.
97. On patients’ understanding of instructions given by doctors: Graham S., Brookey J. (2008), Do Patients Understand?, The Permanente Journal, https://doi.org/10.7812/TPP/07-144; Gotlieb R. et al. (November 30, 2022), Accuracy in Patient Understanding of Common Medical Phrases, JAMA Network Open, https://doi.org/10.1001/jamanetworkopen.2022.42972; Olson D.P., Windish D.M. (August 9, 2010), Communication Discrepancies Between Physicians and Hospitalized Patients, JAMA Internal Medicine, https://doi.org/10.1001/archinternmed.2010.239; Bickel N.B. (November 30, 2018), Most patients are not 100 percent honest when talking to their doctors, Michigan News – University of Michigan, https://news.umich.edu/most-patients-are-not-100-percent-honest-when-talking-to-their-doctors/. A more optimistic Swiss study: Chen Y.-Y. et al. (2014), To evaluate the effectiveness of health care ethics consultation based on the goals of health care ethics consultation: a prospective cohort study with randomization, BMC Medical Ethics, https://doi.org/10.1186/1472-6939-15-1; FOPH (October 2018), Communication in the healthcare sector, Spectra 122, https://www.spectra-online.ch/admin/data/files/issue/pdf_en/88/spectra_122_oct_en_weg.pdf.pdf?lm=1540210982; Loayza N. (2012), Adherence to antidepressant treatment: What the doctor think and what the patient says, Université de Lausanne – Faculté de biologie et de médecine, https://serval.unil.ch/resource/serval:BIB_A90CB85C25BB.P001/REF.
98. Helsana (2022), Helsana-Report: Drug Report 2022, Costs at an all-time high, https://reports.helsana.ch/en/drugs2022/.
99. Histoire de la Sécurité Sociale en Suisse, Evolution des coûts et financement de l’assurance-maladie, December 2015, https://www.histoiredelasecuritesociale.ch/chiffres/evolution-des-couts-et-financement-de-lassurance-maladie.
100. Le Temps of September 27, 2022, La combinaison de l’inflation et de la hausse de prime fait craindre une précarisation, https://www.letemps.ch/suisse/combinaison-linflation-hausse-prime-craindre-une-precarisation.
101. For upcoming measures, see CuraFutura’s summary: Cura Futura (August 29, 2023), Communiqué de presse, https://curafutura.ch/app/uploads/230829_MM_Jahresmediengespraech_FR.pdf.
102. Junod V. et al., Ruptures d’Approvisionnement de Médicaments sous Contrôle – Peut mieux faire?, Life Science Recht, April 2021, https://lsr.recht.ch/de/artikel/04lsr0421auf/ruptures-dapprovisionnement-de-medicaments-sous-controle.
103. FOPH , Antworten auf häufig gestellte Fragen zu den Anpassungen der Tarifstruktur TARMED per 1. Januar 2018, July 5, 2019 p. 1, https://www.bag.admin.ch/dam/bag/de/dokumente/kuv-leistungen/tarifstruktur-tarmed/faq-anpassungen-tarmed-01-01-2018.pdf.download.pdf/FAQ%20TARMED.pdf.
104. Babaiantz C. et al., L’impact des limites de temps de consultation sur l’empathie du médecin dans la prise en charge du patient, Unisanté, July 2023, https://www.unisante.ch/sites/default/files/upload/imco/imco2023-gr30-abstract-poster.pdf.
105. World Health Organization (WHO), Left behind in pain: Extent and causes of global variations in access to morphine for medical use and actions to improve safe access, June 2023, p. 15, https://www.who.int/publications-detail-redirect/9789240075269. Access to opiates is difficult in most countries of the world: Duthey B., Scholten W., Adequacy of opioid analgesic consumption at country, global, and regional levels in 2010, its relationship with development level, and changes compared with 2006, Journal of Pain and Symptom Management, July 17, 2013, https://doi.org/10.1016/j.jpainsymman.2013.03.015.
106. Swiss Federal Council (April 6, 2023), Transfert des tâches de la task force Pénurie de médicaments aux structures en place, https://www.admin.ch/gov/fr/accueil/documentation/communiques.msg-id-94170.html.
107. Prescriptions for painkillers vary widely between cantons: Wertli M.M. et al., Changes over time in prescription practices of pain medications in Switzerland between 2006 and 2013: an analysis of insurance claims, BMC Health Services Research, February 2017, https://doi.org/10.1186/s12913-017-2086-6.
108. Existing recommendations: Nicollier L. et al. (September 21, 2022), Prescription des opioïdes en médecine générale pour les douleurs chroniques non cancéreuses, RMS, https://doi.org/10.53738/REVMED.2022.18.796.1761; Organisation de soutien «smarter medicine – Choosing Wisely Switzerland» (February 11, 2020), smarter medicine: liste Top-5 pour le traitement des rhumatismes, Bulletin des Médecins Suisses, https://doi.org/10.4414/bms.2020.18609; Rodieux F. et al. (June 20, 2018), Prescription des opioïdes chez les patients vulnérables: les enfants et les personnes âgées. Recommandations pratiques, RMS, https://doi.org/10.53738/REVMED.2018.14.612.1268; Ruchat D., et al., Consommation d’opioïdes entre 1985 et 2015: chiffres suisses et mise en perspective internationale, RMS of June 20, 2018, https://doi.org/10.53738/REVMED.2018.14.612.1262.
109. See motion 19.4069 entitled “Swiss cohort study on the health of children and adolescents” of September 19, 2019, which the Federal Council proposed to reject, but which the National Council accepted in 2021. However, as far as we know, no progress has yet been made and the Council of States has not taken a decision. See however: FOPH, Phase pilote de l’étude suisse sur la santé – Résultats de la biosurveillance humaine (Human biomonitoring HBM), August 2023, https://www.bag.admin.ch/dam/bag/fr/dokumente/chem/chemikalien-alltag/pilotphase-der-schweizer-gesundheitsstudie.pdf.download.pdf/BAG-Kurzbericht-Analytik-SHeS-pilot-FR-V4.0.pdf.
110. Davenport T., Kalakota R., The potential for articial intelligence in healthcare, Future Healthcare Journal, June 2019, https://doi.org/10.7861/futurehosp.6-2-94; Ho C.W.L., Ali J., Caals K., Ensuring trustworthy use of artificial intelligence and big data analytics in health insurance, Bulletin World Health Organization, April 2020, https://doi.org/10.2471%2FBLT.19.234732; Ali O. et al., A systematic literature review of artificial intelligence in the healthcare sector: Benefits, challenges, methodologies, and functionalities, Journal of Innovation & Knowledge, January 2023, http://dx.doi.org/10.1016/j.jik.2023.100333.