Drug treatment effectiveness: an examination of conceptual and policy issues

This paper discusses different concepts or views of what constitutes effective treatment for drug dependence and how these views are involved in policy decisions regarding treatment. The paper reviews the rise of evidence-based medicine, discusses the emergence of efficacy research, effectiveness research, and other types of outcome-based evaluations of drug user treatment, but notes that despite a growing consensus among researchers on the effectiveness of drug user treatment, substantial public skepticism about the value of treatment still exists in the United States. The paper argues that one of the primary reasons for the lack of public consensus in the United States is that there is wide disagreement over which type of problem drug dependence is and for whom it may be a problem. The paper reviews some of the most common models and their implications for evaluating effectiveness, and argues that it is the differences in perspective among these models that are at the heart of policy debate over drug treatment policy in the United States. The paper concludes that because evaluation research as currently practiced does not address these issues, its utility for policy purposes is limited in the American context.     

TREATMENT INSIDE THE DRUG TREATMENT COURT: THE WHO,WHAT, WHERE,AND HOW OF TREATMENT SERVICES

Drug treatment courts provide a new strategy for providing treatment services to offenders within the criminal justice system. With over 400 drug treatment courts in the United States, the courts have evolved to provide treatment services under different models. This article will review the different typologies for delivery of treatment services to drug user offenders in the drug treatment court setting, and it will raise questions about some of the difficult issues underscoring an integrated service delivery model. The paper then identifies some research questions for the future.     

Making drug policy together: Reflections on evidence,engagement and participation

This commentary considers the relationship between evidence, engagement and participation in drug policy governance. It argues that the use of various forms of evidence (for example, statistical data and service user narratives) is critical for meaningful stakeholder engagement and public participation in drug policy, as well as effective policy design and implementation. The respective roles of these different kinds of evidence in consultation processes need to be better understood. It discusses the limits of evidence, which it suggests is rarely conclusive or decisive for drug policy. This is partly because of the incompleteness of most research agendas and the lack of consensus among researchers, but also because issues in drug policy are inherently contestable, involving considerations that lie outside the competency of drug policy specialist as such. In particular, this is because they involve normative and evaluative issues that are properly political (for example, about the relative weight to be accorded to different kinds of harm and benefit). It concludes by supporting calls for a more nuanced understanding of the relationship between evidence, engagement and politics than is implicit in the term ‘evidence based policy’. It also argues that we should view the inherent contestability of drug policy not as something that can or should be resolved by ‘objective’ evidence, but as a source of vitality and creativity in policy development and evaluation.     

Seeing through the public health smoke-screen in drug policy

In deliberations on drug policy in United Nations fora, a consensus has emerged that drug use and drug dependence should be treated primarily as public health concerns rather than as crimes. But what some member states mean by “public health approach” merits scrutiny. Some governments that espouse treating people who use drugs as “patients, not criminals” still subject them to prison-like detention in the name of drug-dependence treatment or otherwise do not take measures to provide scientifically sound treatment and humane social support to those who need them. Even drug treatment courts, which the U.S. and other countries hold up as examples of a public health approach to drug dependence, can serve rather to tighten the hold of the criminal justice sector on concerns that should be addressed in the health sector. The political popularity of demonisation of drugs and visibly repressive approaches is an obvious challenge to leadership for truly health-oriented drug control. This commentary offers some thoughts for judging whether a public health approach is worthy of the name and cautions drug policy reformers not to rely on facile commitments to health approaches that are largely rhetorical or that mask policies and activities not in keeping with good public health practise.     

Treatment inside the drug treatment court: the who,what, where,and how of treatment services

Drug treatment courts provide a new strategy for providing treatment services to offenders within the criminal justice system. With over 400 drug treatment courts in the United States, the courts have evolved to provide treatment services under different models. This article will review the different typologies for delivery of treatment services to drug user offenders in the drug treatment court setting, and it will raise questions about some of the difficult issues underscoring an integrated service delivery model. The paper then identifies some research questions for the future.     

DRUG USER TREATMENT WITHIN A CRIMINAL JUSTICE CONTEXT

This paper summarizes what is known, and what is uncertain, about strategies what exploit the coercive potential of the criminal justice system to get problem drug users to get treatment for their dependency. It considers the links between problem drug use and crime, the characteristics of effective treatment for problem drug users, the effectiveness of coerced treatment, and the practical obstacles in bridging the gap between criminal justice and treatment services. It draws on experience in Britain, though it is also informed by the English-language research literature, especially that carried out in the United States.     

Addressing smoking in community drug abuse treatment programs: practical and policy considerations

Smoking is the leading cause of preventable death in the United States. This public health problem is of particular concern among individuals with substance use disorders in that they smoke at a greater rate than the general public. Smoking-related illness represents a major source of preventable death in persons with drug dependencies. Substance abuse treatment programs have access to persons with substance use disorders and the opportunity to intervene on their smoking; however, nicotine dependence has historically not been viewed in the same light as other drug dependencies by the treatment field. As a result, many persons in these treatment program settings do not receive opportunities to address their smoking. When substance abuse treatment organizations consider implementing smoking policies and services, many questions and choices arise. In practice, a range of approaches has been developed from simple assessment and referral for smoking cessation treatment to implementing smoke-free grounds and requiring that patients stop smoking concurrent with addressing their other drug dependencies. Smoking cessation policy decisions have the potential to directly affect the patients, the workforce, the referral network, and other major stakeholders related to these organizations. The authors consider a range of both practical and policy issues facing treatment organizations and conclude that advances in smoking policy are possible with current resources.     

Impact of a Large-Scale Narcotics Treatment Program: A Six Month Experience

Economics is the study of choice among alternatives under conditions of scarcity. Drug policy is manifestly an “economic” problem in the sense that these policies are developed under conditions of scarcity: there are not enough police, treatment facilities, and social services to solve the drug problem, however it is defined. This paper argues that a harms reduction approach to drug policy can be characterized as pragmatic cost-effective drug control which attempts to achieve efficient drug policy. Economic aspects of drug enforcement are discussed which reveal that these policies do not necessarily reduce drug problems and can generate unintended consequences. Enforcement remains the dominant drug policy in the United States despite evidence that it is overused, in part because both federal and state asset forfeiture laws and budget processes offer police agencies incentives to focus on enforcement rather than other policy alternatives. An efficiency-based harms reduction approach may be one way to effectively advocate a rational approach to drug issues in the often strident and ideological drug policy debates. [Translations are provided in the International Abstracts Section of this issue.]     

Reducing the harms of drug policy: an economic perspective

Economics is the study of choice among alternatives under conditions of scarcity. Drug policy is manifestly an "economic" problem in the sense that these policies are developed under conditions of scarcity: there are not enough police, treatment facilities, and social services to solve the drug problem, however it is defined. This paper argues that a harms reduction approach to drug policy can be characterized as pragmatic cost-effective drug control which attempts to achieve efficient drug policy. Economic aspects of drug enforcement are discussed which reveal that these policies do not necessarily reduce drug problems and can generate unintended consequences. Enforcement remains the dominant drug policy in the United States despite evidence that it is overused, in part because both federal and state asset forfeiture laws and budget processes offer police agencies incentives to focus on enforcement rather than other policy alternatives. An efficiency-based harms reduction approach may be one way to effectively advocate a rational approach to drug issues in the often strident and ideological drug policy debates. [Translations are provided in the International Abstracts Section of this issue.]     

Substance abuse prevention: moving from science to policy

Substance abuse exacts tremendous social and economic costs in the United States, making a response to this problem a priority for policy makers at all levels of government. Although little argument exists about whether government should play a role in substance abuse control, considerable debate has been generated about exactly what that role should be. Currently, the United States spends about twice as much on supply reduction as demand reduction strategies. Supply reduction strategies, such as law enforcement and interdiction, are often harsh and based on little or no scientific evidence that demonstrates efficacy. As a demand reduction strategy, drug treatment has been demonstrated to be cost-effective. Substance abuse prevention, however, has failed to establish a critical body of research with which to make its case. This paper suggests several direct ways in which prevention science can influence public policy and thus move prevention science to more effective substance abuse prevention policy.     

Organizational Issues in Conducting Tuberculosis Screening at a Syringe Exchange Program

There has been a rise in tuberculosis (TB) cases in the United States and there is a potent link between human immunodeficiency virus (HIV) and tuberculosis. In New York City it is estimated that 40% of the 200,000 injecting drug users are infected with HIV. In addition, the tuberculosis case rate is approximately four times the national average, and one third of these cases occurred in those persons infected with HIV. Drug users have a high prevalence of latent tuberculous infection and are at high risk for progression to active tuberculosis. Drug users are at high risk for both HIV and TB. Although studies have shown the value of incorporating TB services into drug treatment programs, the majority of drug users in the United States are not in drug treatment. We have been evaluating the feasibility of conducting TB screening and directly observed TB preventive therapy for active injecting drug users at a syringe exchange program in New York City. This paper describes issues relating to the implementation of the TB screening program and discusses general and operational issues relevant to integrating medical and public health programs into existing programs serving drug using individuals.     

Methadone treatment: experiment and experience.

The relationship between public policy and scientific investigation is explored by a review of the experience with methadone maintenance treatment for narcotic addiction. The implementation of a widespread treatment effort in Hong Kong in the 1970s is contrasted with recent policies in regard to methadone treatment expansion in the United States. In neither case did research findings form the basis for public policy. In Hong Kong, rapid expansion of methadone treatment was initiated before scientific evidence was available to support this course, and in the United States treatment expansion has been rejected despite extensive evidence of its utility and safety. Decisions by government officials and health care providers, as in the case of addiction treatment, may be influenced more by philosophy and intuition than by scientific evidence. Scientists must recognize and address this reality if they are to play a meaningful role in shaping public health policy.     

Services Research Outcomes Study: Overview of Drug Treatment Population and Outcomes

The study examined a representative sample of the 1,060,000 individuals discharged from drug user treatment in the United States in the 12 months before September 1990, and compared self-reports of behavior 5 years before to 5 years after treatment. Self-reports about recent drug use were compared with urine samples, and the agreement between self-report and drug-test results was high. The key findings are that the number of alcohol and drug users declined markedly, ranging from one-seventh to more than one half; those who continued using drugs after treatment used them less frequently than before treatment; criminal behavior fell between one-quarter to one-half, and primary criminal support fell by one third; full-time employment did not change; homelessness, drug injection, and suicide attempts decreased by more than one-third.     

INTRODUCTION: PROGRESS AND ISSUES IN DRUG TREATMENT COURTS

The first drug treatment court began in Miami, Florida in 1989, in direct response to the backlog of court cases for drug possession and trafficking. By mid-2001, there were 700 operational drug treatment courts and 400 more in the planning stages in the United States. In addition to providing an overview of the growth and development of drug treatment courts in the United States, this special issue examines their development in Australia, Canada, and the United Kingdom. The primary focus is the evaluation research conducted to date, which identifies some of the critical unresolved issues facing drug treatment courts.     

Receiving marijuana and cocaine as gifts and through sharing

This paper presents estimates of the probability that individuals who use marijuana and cocaine receive some of their drug as a gift or through sharing. The analysis utilizes data from the National Household Survey of Drug Abuse in the United States of America. This research expands upon the observation of field researchers that sharing and gift giving are common distribution mechanisms in drug markets. The likelihood an individual marijuana or cocaine user receives drug gifts or receives drugs through sharing by others depends on age, race, gender, income and the amount they consume. These findings should assist policy makers designing drug abstinence programs and drug rehabilitation administrators trying to prevent relapse.     

A synthesis review of exemplary drug abuse prevention programs in the United States

In the United States, there has been a concerted emphasis during the past 30 years toward identifying and implementing evidence-based drug prevention programs. The wealth of prevention efficacy research has contributed to the publication of several recent reports on promising, model, and effective programs. We identified five such recent reports, four from the federal government and one from a private foundation, that had nominated and described 100 exemplary prevention programs. Of these 100 programs, 70 reported on evidence of effectiveness. We conducted a qualitative analysis on these 70 exemplary programs. Based on a systematic review process, we identified 10 elements that were characteristic of most (at least 75%) of the programs. These 10 elements are described and discussed in light of public policy issues.