Addiction: 101 341-347 (March 2006)
How Much Can Treatment Reduce National Drug Problems?
Peter Reuter
School of Public Policy, University of Maryland and the RAND Corporation
preuter@umd.edu
Harold Pollack
School of Social Service Administration, University of Chicago
haroldp@uchicago.edu
We thank Keith Humphreys for suggesting the topic. Helpful comments were received from
Stan McCracken, Mike Trace and three anonymous reviewers.
July 2005
1
ABSTRACT
How Much Can Treatment Reduce National Drug Problems?
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 costeffective. 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 effectives of treatment, prevention and enforcement are
reviewed, and set in a policy analytic 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
almost uniformly failed to show that intensified policing or sanctions have reduced either drug
prevalence or drug-related harm. Nor--outside of the U.K.--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.
.
2
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 the 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? Second, 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 well-funded
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 programs 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. National
Consensus Development Panel on Effective Medical Treatment of Opiate Addiction, 1998; IOM,
3
2000; Stewart et al. 2002; Metzger et al., 1993.]. 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 drug-users 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 and Murphy (1990) found that 71 percent
of a sample of drug sellers active in Washington, DC in 1988, mostly selling cocaine and heroin,
had consumed an illegal drug other than marijuana in the previous three months. One-third of
NTORS respondents reported that they had sold drugs in the three months prior to treatment
(Gossop et al., 1999). In NTORS, the number of drug selling offenses after one 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 nonviolent drug offenders. No study of this effect is available.
Treatment reduces offending rates through several pathways. Treatment lessens the risk
of intoxication-related 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.
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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 presently) 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 share of the eligibles 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 2830,000--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 aging of
the heroin dependent population during the 1990s.
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.
5
The NTORS study illustrated both the benefits and limitations of treatment intervention.
Treatment induced large declines in heroin use and in the use of non-prescribed methadone and
benzodiazepines. Rates of acquisitive crime and drug-selling also declined by large margins.
Treatment was markedly less effective in other domains. Even five years later, most
respondents continued to report some recent use of at least one target substance. Among
methadone patients, 61 percent reported recent heroin use. Only 26 percent reported that they
had not recently used any of the examined target drugs. Among residential treatment clients, 51
percent reported recent heroin use, and only 38 percent 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 three months. Similar results are reported in 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 for all drug users. One way of
framing this question is to ask how much treatment reduces lifetime consumption by the average
entering client, and how soon after becoming dependent users enter into treatment. To assert that
dependent heroin use could be reduced by half within five years strikes us as optimistic.
.
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 percent of those who used drugs in the last year (Boyum and Reuter, 2005; pp.62-65)
It offers only indirect support, through supply and epidemiologic pathways, in reducing initiation.
For primary prevention the research base is scientifically impressive (see review in
Manski, Pepper and Petrie, 2001) but programmatically barren. We know surprisingly little
about the effectiveness of prevention programs as implemented. There is no counterpart to the
6
series of observational treatment studies in the U.S. (DARP/TOPS/ DATOS) or NTORS in the
UK. Research has been dominated by school-based programs, which are more readily-studied
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 and
Gottfredson, 2002). Schools that serve high-risk children face challenges that are likely to
further diminish the quality of implementation (Gottfredson, 2001).
It has also been suggested
(e.g. Manski, Pepper and 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) 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 only reduce future cocaine
consumption in the United States by 2-11 percent.
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 part of any
prevention program. If treatment clients are imperfectly adherent, if many or most will
experience episodes of post-treatment relapse, the proper boundary between treatment and
prevention services, 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 lifecycle 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.
7
A remarkable study by Strang and colleagues (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, detox creates particular risks by lowering drug
tolerances. Examining the experiences of 137 opiate clients receiving detox and subsequent
inpatient services, Strang et al. classified 37 clients as having "lost tolerance" after completing
detox and subsequent inpatient services. Among the remaining clients who failed to complete the
program, 43 were classified as "still-tolerant" because they failed to detox; while 57 were
classified as "reduced tolerance" because they failed to complete inpatient treatment. Treatment
completers experienced markedly higher mortality rates than were observed in the other two
groups. Within four months, 3 out 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 characteristic 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, 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
8
more carefully studied, in part because policymakers and clinicians have demanded that these
evaluations be done to justify program funding. Absent 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 credibly measure. Only one study finds that interdiction raised
prices and treatment admissions (Crane, Rivolo and Comfort, 1997) but it has been extensively
critiqued for methodological flaws by the National Research Council (Manski, Pepper and
Thomas, 2000). Other simulation studies have found that interdiction, at least in the U. S., is
unlikely to notably raise drug prices or to notably restrict drug availability (e.g. Caulkins,
Crawford and 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 one kilogram of
cocaine from Bogota to Miami; Federal Express would charge less than $100 to move (much
more reliably) a kilogram 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 and 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 U.S. interdiction strategies appear rather unsuccessful in raising drug prices, the
available research does not provide much guidance about what would actually happen if supplyside 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 (Degenhardt, Reuter, Collins and Hall, 2005).
Analysis of this Australian experience may provide useful insights for policymakers in other
industrial democracies.
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.
9
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 high risk of arrest and thus return to treatment as an alternative to penal
sanctions, criminally-involved drug users are more likely halt or reduce their substance use.
Treatment may be frail, but it is likely to work better 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 effort to combine criminal justice and treatment resources
for drug-involved offenders. Drug court participants appear to have better legal and drug-use
outcomes than apparently comparable non-participants (Gottfredson, Najaka and Kearley, 2003).
In 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 show substantial promise; re-offending
and drug use rates are lower for those coerced than for those subject to standard pre-trial or
probation conditions. (Harrell, Cavanaugh and Roman, 1998) Faced with such pressures and
incentives, many of 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 and Liu, 2003). Workplace 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 can’t treat, prevent, deter, or incarcerate ourselves out of “the drug problem,” though
each measure is a valuable component of drug policy. For the foreseeable 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
10
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 U.S. has not done much worse in reducing its dependent population, when compared
with treatment-focused peers. Its inability to contain social harms connected with drug use is
more worthy of condemnation, because these harms were often more avoidable. By 2001,
193,000 American IDU had been diagnosed with AIDS. Injection drug use accounts for
significant numbers of other secondary infections. 57 percent of all AIDS cases among women
are now traceable to injection drug use (MMWR 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 U.S. has failed to do the
impossible, but that it has failed to do things that could readily be done.
HIV points to the set of interventions commonly denoted 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 then treatment, policymakers must rely on impression and image;
the empirical base for policymaking is often lacking. The National Academy of Sciences panel
on drug policy (Manski, Pepper and Petrie, 2001) lamented the U.S. 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.
11
Before this research is in, 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 conjecture also 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 fully mitigated 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.
12
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