Can Tx Reduce Addiction

101 Miscellaneous Can treatment reduce national drug problems? Peter Reuter & Harold Pollack

HORIZONS REVIEW SERIES

doi:10.1111/j.1360-0443.2005.01313.x

How much can treatment reduce national drug problems? Peter Reuter1 & Harold Pollack2 School of Public Policy, University of Maryland and the RAND Corporation, CA, USA1 and School of Social Service Administration, University of Chicago, IL, USA2

ABSTRACT Aims Treatment of drug addiction has been the subject of substantial research and, in contrast to several other methods of reducing drug use, has been found to be both effective and cost-effective. This review considers what is known about how much a nation can reduce its drug problems through treatment alone and what is known at the aggregate level about the effectiveness of prevention and enforcement. Methods The literature on the effectiveness of treatment, prevention and enforcement are reviewed, and set in a policy analytical framework. Findings Many studies have found treatment to have large effects on individuals’ consumption and harms. However, there is an absence of evidence that even relatively well-funded treatment systems have much reduced the number of people in a nation who engage in problematic drug use. For prevention, the scientific literature shows useful and modest effects at the individual level but there is little support for substantial aggregate effects. For enforcement, research has failed almost uniformly to show that intensified policing or sanctions have reduced either drug prevalence or drug-related harm. Nor— outside the UK—is there more than a modest effort to improve the evidence base for making decisions about the appropriate level of enforcement of drug prohibitions. Conclusions Treatment can justify itself in terms of reductions in harms to individuals and communities. However, even treatment systems that offer generous access to good quality services will leave a nation with substantial drug problem. Finding effective complementary programs remains a major challenge. Keywords

Drug policy, enforcement, harm reduction, prevalance, prevention, treatment.

Correspondence to: Peter Reuter, School of Public Policy and Department of Criminology, University of Maryland, College Park, MD, USA. E-mail: [email protected] Submitted 27 February 2005; initial review completed 5 May 2005; final version accepted 25 July 2005

HORIZONS REVIEW SERIES INTRODUCTION The mantra of the drug treatment community is that ‘treatment works’. At least in the United States, that mantra is chanted in necessary defense of beleaguered programs that do not receive the public support, funding or policy attention that they deserve. Yet the treatment enterprise is inherently frail. For most patients, treatment is a difficult process that includes significant disappointments. It does not fully, or immediately, or comprehensively ‘work’ in the way patients, clinicians or society hope that it would. These frailties can distract from the great individual and social benefits treatment provides. Starting from the strong empirical research base that treatment does indeed bring major social as well as individual benefits, this essay addresses two broad questions. First, how much can treatment contribute to reduction of a nation’s drug problems? Secondly, what, beyond

treatment, are necessary and appropriate programmatic interventions? Our conclusions are readily summarized. The argument for treatment expansion is strong. However, treatment has key limitations in controlling a nation’s drug problems. No nation has succeeded in treating its way out of a major cocaine or heroin problem. Treatment can substantially reduce the health burden of drug abuse, related crime and the quantity of drugs consumed. It can make only relatively modest reductions in the number of men and women who misuse drugs, or who have ongoing abuse or dependence disorders. Even with a wellfunded treatment sector, a nation will still face chronic problems of disease, addiction, crime and disorder associated with illegal drugs. Advocates for primary prevention and criminal justice interventions—the two main alternatives—are handicapped by a dearth of empirical evidence to provide guidance as to how much such pro-

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction

Addiction, 101, 341–347

342

Peter Reuter & Harold Pollack

grams can contribute to reducing drug problems. The available evidence suggests that each can, on its own, make only a modest contribution, and it is not clear that there are synergies between them. On the other hand, improving the links between enforcement and treatment is essential for either intervention to achieve its stated goals.

TREATMENT’S ACCOMPLISHMENTS A large literature shows that treatment can reduce an individual patient’s drug use, that treatment is associated with improved health and employment outcomes and that treatment can reduce the risk of serious harms including overdose, crime and HIV infection (e.g. Metzger et al. 1993; National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction 1998; IOM 2000; Stewart et al. 2002). Documented gains appear most striking in the treatment of opiate use disorders. The benefits of treatment have many dimensions that affect both the individual and the wider community. Crime reduction provides the most conspicuous, sometimes the dominant, benefit in economic policy analyses of treatment interventions (Cartwright 1998; Flynn et al. 2003; Godfrey et al. 2004;). Much of the estimated benefit of substance abuse treatment arises from the minority of patients who (before treatment) commit serious offenses. The social benefits of crime reduction are much smaller for the median client, and are smaller for marijuana than for other substances which are more correlated with felony offending. Crime reduction provides important benefits for drugusers as well. Continued offending exposes users to the risk of incarceration and criminal victimization, as well as lost short-term and long-term opportunities for legitimate employment. Treatment for heroin and cocaine use reduces demand for these substances. Treatment may also bring significant supply side effects. Drug-users comprise a large share of all cocaine and heroin retailers. For example, Reuter, MacCoun & Murphy (1990) found that 71% of a sample of drug sellers active in Washington, DC in 1988, selling mainly cocaine and heroin, had consumed an illegal drug other than marijuana in the previous 3 months. In Britain, one-third of the National Treatment Outcome Research Study (NTORS) respondents reported that they had sold drugs in the 3 months prior to treatment (Gossop et al. 1999). In NTORS, the number of drug selling offenses after 1 year in treatment was only 13% of the entry level (Gossop et al. 2003). If broad treatment provision appreciably shrinks the pool of users willing to work in the drug trade, it is possible that treatment can have substantial favorable supply side effects, without the

large personal and social costs that come with incarcerating non-violent drug offenders. No study of this effect is available. Treatment reduces offending rates through several pathways. Treatment lessens the risk of intoxicationrelated crimes. Clients may have less urgent needs for money and drugs, and consequently less willingness to take immediate risks. Patients who seek to curb their drug use are motivated to distance themselves from the subculture of users and sellers. Treatment may also bring or reflect increased monitoring or an increase in the perceived penalties associated with drug-selling. Finally, by shrinking the market, treatment increases the probability that any individual dealer will be arrested, given a constant level of enforcement resources (Kleiman 1993); this may raise prices and induce greater caution by sellers.

THE LIMITS Having noted the breadth of benefits from treatment, it is time to note the corresponding limits. Most fundamentally, is it possible for a nation to treat its way out of a drug problem? Assume that a treatment system had the resources needed to provide adequate services for all who seek care and that no new users initiated. What would be left as a drug problem, and what could be done to deal with that residue? An informal scan (all that is possible at present) suggests that no democratic nation with a major opiate problem has managed to cut the number of regular users sharply within a decade, even when a large proportion of the eligible individuals are served by treatment services. Consider the Netherlands, committed to the provision of treatment for anyone in need. It provided treatment to an average of 15 000 heroin users annually throughout the 1990s, about 50% of the heroin-dependent population. Yet in 2001 the estimated number of heroin-dependent persons was 28–30 000—essentially unchanged from the 1993 estimate. This is not mere statistical artifact from the inclusion of some of those in treatment; many patients remain active heroin users (National Drug Monitor 2003). Similar statements may hold for Australia and Switzerland, two other countries committed to a generous supply of decent quality treatment services. Nor does this stability of numbers in the Netherlands represent the consequence of high initiation canceling out the effects of high treatment success. Data on treatment clients suggested that very few of those dependent on heroin in 1999 had started use during the preceding decade. In 1989 the median age of those in treatment in Amsterdam was 32; in 2002 the median age was 43. (National Drug Monitor 2003). Many other western nations also experienced an ageing of the heroindependent population during the 1990s.

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction

Addiction, 101, 341–347

Can treatment reduce national drug problems?

We would welcome disproof of our rather pessimistic argument. Recent suggestive findings from France (Emmanuelli & Desenclos 2005) suggest that expansion of treatment and harm reduction services have reduced overdose mortality and HIV behavioral risks, and have also reduced heroin-related arrests. Such welcome results highlight the possibility that interventions can reduce social harm. Whether such interventions reduce the number of dependent heroin users is less clear. The overall pattern from wealthy democracies suggests reasons for doubt. Is this surprising? Treatment is generally acknowledged to be useful, frail and incomplete. Viewed at the population level, treatment is cost-effective and perhaps cost-saving. Viewed at the client level, treatment reduces but rarely fully halts problem alcohol use or the use of illicit drugs. Most clients are imperfectly adherent to ‘good’ programs. Many or most clients will continue their use at some level after treatment is completed. The NTORS study illustrated both the benefits and limitations of treatment intervention. Treatment induced large declines in heroin use and in the use of nonprescribed methadone and benzodiazepines. Rates of acquisitive crime and drug-selling also declined by large margins. Treatment was markedly less effective in other domains. Even 5 years later, most respondents continued to report some recent use of at least one target substance. Among methadone patients, 61% reported recent heroin use. Only 26% reported that they had not recently used any of the examined target drugs. Among residential treatment clients, 51% reported recent heroin use and only 38% reported no recent use of any target drug. Compared with results for opiates, treatment proved less effective in reducing crack cocaine use. Many clients left treatment within 3 months. Similar results are reported in the drug abuse treatment outcome studies (DATOS) (Hubbard et al. 2003). McLellan (2002) cites a chronic disease model to argue persuasively that post-treatment relapses are predictable. These relapses do not undermine the value of treatment but do indicate the limits. What else is necessary? It is reasonable, then, to project that a substantial drug problem would remain, even if the state were willing to provide high-quality treatment on request to any drug user. One way of framing this question is to ask how much treatment reduces life-time consumption by the average entering client, and how soon after becoming aggregate dependent users enter into treatment. To assert that dependent heroin use could be reduced by half within 5 years appears to us as optimistic.

343

PREVENTION Treatment, by definition, helps only those who are already experienced users. The most effective treatment policy will not do much to reduce the total number of users. Even the generous official definition of the treatment-eligible population in the United States accounts for less than 25% of those who used drugs in the last year (Boyum & Reuter 2005, pp. 62–65). Treatment offers only indirect support, through supply and epidemiological pathways, in reducing initiation. For primary prevention the research base is scientifically impressive (see review in Manski, Pepper & Petrie 2001) but programmatically barren. Surprisingly little is known about the effectiveness of prevention programs as implemented. There is no counterpart to the series of observational treatment studies in the United States (Drug Abuse Research Program (DARP)/Treatment Outcome Prospective Study (TOPS)/DATOS) or NTORS in the United Kingdom. Research has been dominated by school-based programs, which are studied more readily than those in less controlled settings. The gap between best-practice and typical interventions is large; many school-based prevention interventions are poorly implemented. (Gottfredson & Gottfredson 2002). Schools that serve high-risk children face challenges that are likely to diminish further the quality of implementation (Gottfredson 2001). It has also been suggested (e.g. Manski, Pepper & Petrie 2001) that school prevention may be less a specific program than the creation of an atmosphere and expectations. The other frailty of the prevention literature is that many of the best studies measure short-term outcomes for programs implemented in 5th to 8th grades (typically ages 10–14 years) and are focused on marijuana, the illegal drug first used by youth. Less is known about the effects of prevention on use of cocaine, heroin or methamphetamine. There is only a presumption, eminently questionable, that the reductions in marijuana use will generate comparable reductions in use of these more damaging drugs. Caulkins et al. (1999) find that even full implementation of the most promising school-based prevention program would reduce future cocaine consumption in the United States only by 2–11%. Given the limitations and constrained supply of treatment services, it is striking that the prevention literature places such emphasis on primary prevention, with less systematic discussion of secondary and tertiary prevention for both in-treatment and out-of-treatment drug users. Treatment providers and researchers have noted the chronic, relapsing nature of substance use disorders. For this reason, harm reduction—by which we mean interventions to help people to more safely consume drugs if and when they continue to use—becomes an integral

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction

Addiction, 101, 341–347

344

Peter Reuter & Harold Pollack

part of any prevention program. If treatment clients are imperfectly adherent, if many or most will experience episodes of post-treatment relapse, then the proper boundary between treatment and prevention services and between treatment and harm reduction becomes more permeable than either treatment professionals or harm reduction advocates often assume. Although abstinence is the right ultimate goal, treatment providers face a key challenge to provide appropriate services to clients at varying stages of recovery, within a life-cycle of episodic or recurring drug use. At the same time, harm reduction interventions merit careful inclusion within a continuum of care, so that clients of syringe exchange or other services are brought into contact with more intensive interventions which address a broad range of individual and social risk. A remarkable study by Strang et al. (2003) underscores the need for secondary and tertiary prevention in treatment services. Detoxification is a precursor to treatment. It is not, by itself, an accepted modality of care. However, detoxification creates particular risks by lowering drug tolerances. Examining the experiences of 137 opiate clients receiving detoxification and subsequent inpatient services, Strang et al. classified 37 clients as having ‘lost tolerance’ after completing detoxification and subsequent in-patient services. Among the remaining clients who failed to complete the program, 43 were classified as ‘still tolerant’ because they failed to detoxify; while 57 were classified as ‘reduced tolerance’ because they failed to complete in-patient treatment. Treatment completers experienced markedly higher mortality rates than were observed in the other two groups. Within 4 months, three of the 37 ‘lost tolerance’ clients had died from overdose. None of the ‘still tolerant’ or ‘reduced tolerance’ clients experienced a fatal overdose over the same period. Our point is not to disparage treatment interventions, but to note that clients encounter predictable threats to well-being at different points in their drug-using careers. The above findings highlight the importance of prevention education, currently provided in many programs, to warn clients about post-treatment overdose risks. Clients also require services such as hepatitis B vaccination and basic medical services that are sometimes, but not always, provided within treatment settings. (IOM 2000)

ENFORCEMENT Even compared to treatment and prevention, enforcement is a heterogeneous category of interventions, ranging from efforts to eradicate poppy-growing in Afghanistan to street sweeps against buyers outside the Frankfurt train station. Two general characteristics of these interventions are (1) a near-total absence of impact or outcome evaluation and (2) a near-total absence of public and policymaker demands that such evaluations be performed.

There is, at present, no empirical basis for estimating how much any of these enforcement efforts contribute to reductions in drug use and related problems, let alone a basis to evaluate the broad costs and benefits of competing enforcement approaches for society. Research gaps reflect methodological problems (for example, the absence of small area drug indicators to match with enforcement intensity measures) and the view that drug enforcement is a moral obligation, for which the term ‘crusade’ is not too strong in the United States. Prevention and treatment have been studied more carefully, in part because policymakers and clinicians have demanded that these evaluations be performed to justify program funding. In the absence of similar demands, we have no comparable body of evaluation research pertaining to law enforcement interventions. The case for enforcement aimed at higher levels of the drug trade is narrow. Interdiction and source country controls aim to raise prices, reduce availability, signal social disapproval and (perhaps) reduce the political influence of drug suppliers in source countries. Yet the impact of these policies remains hard to measure credibly. Only one study has found that interdiction raised prices and treatment admissions (Crane Rivolo & Comfort 1997), but it has been critiqued extensively for methodological flaws by the National Research Council (Manski, Pepper & Thomas 1999). Other simulation studies have found that interdiction, at least in the United States, is unlikely to raise drug prices or to notably restrict drug availability (e.g. Caulkins, Crawford & Reuter 1993). Current research does not imply that interdiction should be eliminated. Smuggling cocaine and heroin is expensive. It costs approximately $15 000 to move 1 kg of cocaine from Bogota to Miami; Federal Express would charge less than $100 to move (much more reliably) 1 kg of legitimate white powder between the same cities. The combination of illegality and some enforcement seems to generate somewhat higher prices and thus somewhat lower drug use. Illegality surely deters some potential users, in part because of availability effects (MacCoun & Reuter 2001). Yet because of gaps in the available research, there is no empirical basis for assessing whether current interdiction efforts, at the margin, should be increased or reduced. Because US interdiction strategies appear somewhat unsuccessful in raising drug prices, the available research does not provide much guidance about what would actually happen if supply-side enforcement policies achieved greater market effects. Recent intriguing data suggest that some interdiction-like activity may have been responsible for a sharp decline in Australia’s heroin availability starting at the end of 2000 (Degenhart et al. 2005). Analysis of this Australian experience may provide useful insights for policymakers in other industrial democracies.

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction

Addiction, 101, 341–347

Can treatment reduce national drug problems?

Low-level enforcement has a broader set of mechanisms to address drug problems. In particular, a police focus on street distribution can make dealers more discreet and thus hinder new users finding suppliers. Even if street enforcement aimed at retailers and buyers has little ultimate effect on drug availability, the arrest process itself can further secondary and tertiary prevention by sweeping users into treatment. Kuebler et al. (2000) found that enforcement aimed at closing down open drug scenes in Zurich led to an increase in the demand for methadone maintenance treatment. If substantial relapse poses a high risk of arrest and thus return to treatment as an alternative to penal sanctions, criminally involved drug users are more likely to halt or reduce their substance use. Treatment may be frail, but it is likely to work more effectively if providers have many opportunities to treat the same person. Existing evidence suggests that treatment episodes motivated by criminal justice pressure are no less successful than those with other motivations (e.g. Gostin 1991). Drug courts are an interesting attempt to combine criminal justice and treatment resources for druginvolved offenders. Drug court participants appear to have better legal and drug-use outcomes than apparently comparable non-participants (Gottfredson, Najaka & Kearley 2003). In a similar fashion, Kleiman (2001) argues for ‘coerced abstinence’, in effect making the criminal justice system an explicit recruiter for treatment and other ways of reducing individual drug use. The few evaluations available on this regime are promising; reoffending and drug use rates are lower for those coerced than for those subject to standard pre-trial or probation conditions (Harrell, Cavanaugh & Roman 1998). Faced with such pressures and incentives, many of those who succeed do so without formal treatment. Both drug courts and ‘coerced abstinence’ interventions deploy frequent monitoring and chemical tests with the threat of graduated penal sanctions to deter re-initiating drug use and to reduce the probability of more serious offending and subsequent criminal sanctions. Other enforcement measures may also have promise. Stricter controls on precursor chemicals appear to have at least short-term effects on methamphetamine consumption (Cunningham & Liu 2003). Work-place testing is argued by some to have led to reductions in adult drug use, by threatening job loss (French et al. 2004). Evaluations of school testing programs provide hints that these, too, might reduce adolescent substance use.

CONCLUSION We cannot treat, prevent, deter or incarcerate ourselves out of ‘the drug problem’, although each measure is a valuable component of drug policy. For the foreseeable

345

future, under any feasible policy regime, intoxicating illegal substances will pose large concerns. Treatment is no total solution to a nation’s drug problem; neither is anything else. Millions of men and women in industrial democracies will continue to suffer the consequences of chronic use of intoxicating illegal substances. America’s inability to eliminate drug-related problems is no special failure of national policy. The United States has not fared much worse in reducing its dependent population when compared with treatment-focused peers. Its inability to contain social harms connected with drug use deserves greater condemnation, because these harms were often more avoidable. By 2001, 193 000 American injecting drug users had been diagnosed with AIDS. Injection drug use accounts for significant numbers of other secondary infections; 57% of all AIDS cases among women are now traceable to injection drug use (CDC 2003). Two decades of desultory policy responses account for a real, if never knowable fraction of these cases. The high homicide rate connected with existing drug markets should be counted another distinctive failure of American social policy. The social costs of substance use—and of efforts to deter and police such use—have been higher than in other industrial democracies. The problem is not that the United States has failed to achieve the impossible, but that it has failed to achieve things that could readily be achieved. HIV points to the set of interventions commonly denoted as harm reduction. Writing as Americans, we regard harm reduction as an approach, a set of guiding questions for assessing and designing interventions, rather than a category of programs itself. It is striking that harm reduction programs to date, powerful though they are, generally address only one slice of drug problems. Needle exchange, naloxone distribution, safer injecting rooms—these iconic programs of the harm reduction movement all focus on injection drug use. Few interventions have been offered or deployed to address harms associated with crack or methamphetamine use. Opportunities surely exist for harm reduction in these domains, but these opportunities remain mostly unexploited, unstudied and unproven. For interventions other than treatment, policymakers must rely on impression and image; the empirical base for policymaking is lacking. The National Academy of Sciences panel on drug policy (Manski, Pepper & Petrie 2001) lamented the US government’s failure to fund any significant quantity of research on the effectiveness of drug enforcement. The United Kingdom provides a rare exception to the data-free discourse regarding the effectiveness of enforcement interventions. The Home Office is funding an ambitious research agenda to assess what various kinds of enforcement can contribute to drug control.

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction

Addiction, 101, 341–347

346

Peter Reuter & Harold Pollack

Before this research is completed, we conjecture that enforcement would be most valuable and effective when authorities work closely with treatment providers to reduce substance use among criminal offenders. We also conjecture that treatment itself proves most effective when it expresses the value of abstinence as an ultimate goal, while paying great attention to secondary and tertiary prevention for clients likely to continue some drug use. We are confident that both use reduction and harm reduction will remain essential pillars of sound drug control policy. Use reduction—in the form of primary prevention, enforcement, and treatment—is essential because continued drug abuse and dependence cast so many dark shadows on the user and on others that can never be mitigated fully by available interventions. Harm reduction remains essential because, despite our best use-reduction efforts, drug misuse will remain prevalent and socially costly. Defining acceptable and attainable base rates of drug use disorders remain important subjects for another essay. Acknowledgements We thank Keith Humphreys for suggesting the topic. Helpful comments were received from Stan McCracken, Mike Trace and three anonymous reviewers. References Boyum, D. & Reuter, P. (2005) An Analytic Assessment of US Drug Policy. Washington, DC: AEI Press. Cartwright, W. S. (1998) Cost–benefit and cost-effectiveness analysis of drug abuse treatment services. Evaluation Review, 22, 609–636. Caulkins, J., Crawford, G. & Reuter, P. (1993) Simulation of adaptive response: a model of interdictor–smuggler interactions. Computer and Mathematical Modelling, 17, 37–52. Caulkins, J., Rydell, C. P., Everingham, S., Chiesa, J. & Bushway, S. (1999) An Ounce of Prevention, A Pound of Uncertainty. Santa Monica, CA: RAND Corporation. Centers for Disease Control and Prevention (CDC) (2003) HIV diagnoses among injection-drug users in states with HIV surveillance—25 states, 1994–2000. Mortality & Morbidity Weekly Report, 52, 634–636. Crane, B. D., Rivolo, A. R. & Comfort, G. C. (1997) An Empirical Examination of Counterdrug Program Effectiveness. IDA Paper P3219. Alexandria: Institute for Defense Analysis. Cunningham, J. & Liu, L.-M. (2003) Impacts of federal ephedrine and pseudoephedrine regulations on methamphetamine related hospital admissions. Addiction, 98, 1229–1237. Degenhart, L., Reuter, P., Collins, L. & W. Hall (2005) Evaluating factors responsible for Australia’s heroin shortage. Addiction, 100, 459–469. Emmanuelli, J. & Desenclos, J-C. (2005) Harm reduction interventions, behaviours and associated health outcomes in France, 1996–2003. Addiction, 100, 1690–1700. Flynn, P. M., Porto, J. V., Rounds-Bryant, J. L. & Kristiansen, P. L. (2003) Costs and benefits of methadone treatment in DATOS—Part 1. Discharged versus continuing patients. Journal of Maintenance in the Addictions, 2, 129–149.

French, M., Roebuck, M. & Kebreau, A. (2004) To test or not to test: do workplace drug testing programs discourage employee drug use? Social Science Research, 33, 45–63. Godfrey, C., Stewart, D. & Gossop, M. (2004) Economic analysis of costs and consequences of the treatment of drug misuse: 2year outcome data from the National Treatment Outcome Research Study (NTORS). Addiction, 99, 697–707. Gossop, M., Marsden, J. & Stewart, D. (1999) NTORS at One Year. London: Department of Health. Available at: http:// www.dh.gov.uk/assetRoot/04/07/67/46/04076746.pdf. Gossop, M., Marsden, J., Stewart, D. & Kidd, T. (2003) The National Treatment Outcome Research Study (NTORS): 4–5 year follow-up results. Addiction, 98, 291–303. Gostin, L. O. (1991) Compulsory treatment for drug dependent persons: justifications for a public health approach to drug dependency. The Millbank Quarterly, 69, 561–593. Gottfredson, D. C. (2001) Schools and Delinquency. New York: Cambridge University Press. Gottfredson, D. C. & Gottfredson, G. D. (2002) Quality of school-based prevention programs: results from a national survey. Journal of Research in Crime and Delinquency, 39, 3– 35. Gottfredson, D., Nakaja, S. & Kearly, B. (2003) Effectiveness of drug treatment courts: evidence from a randomized trial. Criminology and Public Policy, 2, 171–196. Harrell, A., Cavanugh, S. & J. Roman (1998) Findings from the Evaluation of the D.C. Superior Court Drug Intervention Program. Washington, DC: Urban Institute. Hubbard, R., Craddock, S. & Anderson, J. (2003) Overview of 5year followup outcomes in the drug abuse treatment outcome studies (DATOS). Journal of Substance Abuse Treatment, 25, 125–134. Institute of Medicine (IOM) (2000) No Time to Lose: Making the Most of HIV Prevention. Washington, DC: National Academy Press. Kleiman, M. (1993) Against Excess. Drug Policy for Results. New York: Basic Books. Kleiman, M. (2001) Controlling drug use and crime with testing, sanctions and treatment. In: Heymann, P. & Brownsberger, W., eds. Drug Addiction and Drug Policy: the Struggle to Control Dependence, pp. 168–192. Cambridge: Harvard University Press. Kuebler, D., Hausser, D. & Gervasoni, J.-P. (2000) The characteristics of ‘new users’ of cocaine and heroin unknown to treatment agencies: results from the Swiss Hidden Population Study. Addiction, 95, 1561. MacCoun, R. & P. Reuter (2001) Drug War Heresies: Learning from Other Vices, Times and Places. Cambridge: Cambridge University Press. Manski, C., Pepper, J. & Petrie, C., eds. (2001) Informing America’s Drug Policy on Illegal Drugs. Washington, DC: National Academy Press. Manski, C., Pepper, J. & Thomas, Y., eds (1999) Assessment of Two Cost-Effectiveness Studies on Cocaine Control Policy. Washington, DC: National Academy Press. McLellan, A. T. (2002) Have we evaluated addiction treatment correctly? Implications from a chronic disease perspective. Addiction, 97, 249–253. Metzger, D., Woody, G., McLellan, A., O’Brien, C., Druley, P., Navaline, H. et al. (1993) Human immunodeficiency virus seroconversion among intravenous drug users in- and out-oftreatment: an 18-month prospective follow-up. Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 6, 1049–1056.

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction

Addiction, 101, 341–347

Can treatment reduce national drug problems?

National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction (1998) Effective medical treatment of opiate addiction. JAMA, 280, 1936–1943. National Drug Monitor (2003) Drug Situation in the Netherlands. National Report. Lisbon: European Monitoring Center on Drugs and Drug Abuse. Reuter, P., MacCoun, R. & Murphy, P. Money from Crime: a Study of the Economics of Drug Dealing in Washington, DC. Santa Monica, CA: RAND Corporation.

347

Stewart, D., Gossop, M. & Marsden, J. (2002) Reductions in nonfatal overdose after drug misuse treatment: results from the National Treatment Outcome Research Study (NTORS). Journal of Substance Abuse Treatment, 22, 1–9. Strang, J., McCambridge, J., Best, D., Beswick, T., Bearn, J., Rees, S. et al. (2003) Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study. BMJ, 326, 959–960.

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction

Addiction, 101, 341–347