EFFECTIVENESS BANK BULLETIN 26 November 2009: reviews and meta-analyses
EFFECTIVENESS BANK BULLETIN 26 November 2009: reviews and meta-analysesThe entries below are our accounts of documents selected by Drug and Alcohol Findings as particularly relevant to improving outcomes from drug or alcohol interventions in the UK. Entries were drafted after consulting related research, study authors and other experts and are © Drug and Alcohol Findings. Permission is given to distribute these entries or incorporate passages in other documents as long as the source is acknowledged including the web address http://findings.org.uk. However, the original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors; if displayed, click Request reprint to send or adapt the pre-prepared e-mail message. Abstracts are intended to summarise the findings and views expressed in the study. Below are comments from Drug and Alcohol Findings. Links to source documents are in blue. Hover mouse over orange text for explanatory notes.
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Long-term continuing care improves treatment outcomes ...
Methadone maintenance outperforms alternatives in randomised trials ...
Modest support for drug-based treatments for alcohol dependence ...
Target enforcement to reduce harm ...
Continuing care research: what we have learned and where we are going.McKay J.R. Request reprint
Journal of Substance Abuse Treatment: 2009, 36, p. 131–145.
Are alcohol and drug dependence best treated as chronic conditions needing extended care, or should we expect patients to recover and leave treatment? Whatever the answer, this review finds that generally the offer of long-term continuing care leads to better outcomes.
Abstract In the US context the review noted that virtually all addiction treatment is provided in time-limited specialist programmes which offer a single type of treatment. The limitations of this approach have led to calls for treatment protocols and systems which address the full continuum of care from detoxification to extended recovery monitoring, considered more appropriate to the patient-centred management of a chronic disorder. The review aimed to look back to analyse findings from continuing care evaluations done over the past 20 years, and then to look forward to how continuing care models might be developed, especially through collaborations between specialist care and other services, and through 'adaptive' treatment strategies which adjust the type and level of care to the patient's progress. The focus was on formal care services rather than self-help or mutual aid, which have already been comprehensively reviewed.
The review was based on 20 studies Plus two which did not use random or quasi-random allocation. which allocated patients at random or in a quasi-random manner to treatment with or without a continuing care intervention, or to different types of continuing care. The dominant initial intervention was residential care, limiting the applicability of the findings to the more typical non-residential settings.
Eleven of the studies compared continuing care with minimal or no continuing care. In terms of each study's main substance use outcome measures, seven of the 11 found a clear That is, not counterbalanced by a negative finding on another primary measure of substance use. and statistically significant advantage for continuing care. In contrast, of the nine studies which compared different types of continuing care, just three found a clear That is, not counterbalanced by a contrary finding on another primary measure of substance use. and statistically significant advantage for one type of care over another. When there were differences, they were large enough to be of clinical significance, but there was considerable variability in how well patients responded, and room for improvements in participation rates and effectiveness. In most studies, about a third of patients had very good Such as sustained attendance in continuing care and high abstinence rates during follow-up. outcomes, another third had mixed outcomes, and a final third did poorly. Such as little or no continuing care participation and low rates of abstinence. Even among studies with significant effects favouring continuing care (or one type of continuing care), patients still varied in how well they responded to the more effective intervention.
Provided the interventions are capable of keeping patients engaged, longer durations of continuing care seem more consistently beneficial. All three studies offering at least 12 months recorded significant beneficial effects, four of nine when the duration was between three and 12 months, but just three of eight with shorter durations. However, randomised studies directly comparing different durations of the same intervention are needed to confirm this possibility. Also, the longer interventions all involved 'taking the treatment to the patient' rather than relying on them visiting a clinic. Other interventions featuring very active efforts to locate patients, to bring treatment to them, or to make it very easy and convenient to access (eg, over the phone), have also been effective. Finally, several studies show that that engagement and retention in continuing care can be increased with relatively low-cost, low-effort tactics which can be widely incorporated in virtually any continuing care protocol (1 2 3).
Looking forward, effectiveness might be enhanced and patient variability more adequately catered for by interventions which regularly and systematically monitor the patient's progress and in response to this progress, step up or down in the intensity of continuing care, or change the type of care. Such 'adaptive' models may be further enhanced by incorporating patient preference in the choice of continuing care options. Non-specialist settings for the provision of continuing care (and perhaps also initial treatments) may also be more acceptable to some patients and increase the proportion who participate. Primary care medical practices are a promising site and can forge links with specialist services for the times when patients need intensive or specialist inputs. Primary care services can also incorporate long-term medication-based continuing care. Internet-based provision may also be an option. Such alternatives to time-limited specialist care promise to extend effective treatment to the many individuals who do not want long-term contact with traditional, clinic-based specialist care.
The review is associated with a set of recommendations agreed by a panel of experts convened by the US Betty Ford Institute. Generally supportive of the conclusions of the featured review, the panel argued that extended and regular monitoring of the patient's progress was the key component of continuing care and one with the greatest evidence of effectiveness. Rather than minor alterations, they concluded that implementing their recommendations would require major changes in the way continuing care is conceptualised and delivered: "What has been the standard approach – provision of a few months of group counselling along with referral to self-help – clearly works well for some individuals but is ineffective with many others. Moreover, there is no 'plan B' for patients who do not succeed in this standard continuing care model".
These arguments go to the heart of the current debate in UK treatment circles about the appropriateness of the 'chronic and relapsing disorder' model of addiction, and of at least some forms of extended care predicated on this model, particularly methadone maintenance. Without denying the need for long-term care for some patients, the English strategy on drug misuse argued that "Too many drug users relapse, do not complete treatment programmes, or stay in treatment for too long before re-establishing their lives ... In return for benefit payments, claimants will have a responsibility to move successfully through treatment and into employment". In Scotland too the new 'recovery' strategy stressed the need for more patients to "move on from their addiction towards a drug-free life as a contributing member of society", implying a corresponding shift away from extended and/or indefinite treatment options. Perhaps because alcohol treatment services are relatively under-developed, neither the English alcohol strategy nor the Scottish equivalent saw any need to call for an accelerated and/or clearer movement through and out of treatment.
In both countries reintegration in to mainstream society and especially in to employment are seen as the bulwarks which can help prevent relapse and relieve the need for extended care. The model advanced in the featured review and the associated recommendations does not deny that short-term treatment can lead to lasting recovery, but argues that instead of there having been too much reliance on extended care options, there has in the US context been far too little. Given this shortfall, it places the stress not on moving patients out of treatment, but on retaining those who need it in continuing care. This difference in emphasis may partly be due to the prominence of alcohol dependent patients in the minds of the US experts, and partly also to the more marginalised position of long-term substitute prescribing in the US response to opiate addiction. From this starting point, the US experts saw a need for greater stress on extended care, while from the starting point of the balance of the current UK treatment system, some see the need to effectively call for the reverse.
In both cases, much will depend on the receptivity of the broader society to the relapse-preventing reintegration of problem substance users and especially problem drug users. Without sufficient receptivity in the form for example of routes in to suitable work opportunities, decent and stable housing, and social acceptance and support, extended care may be the most realistic way The article cited first in this paragraph put it this way: "But as the task of change becomes harder (i.e. dependence is greater), and the environment is less supportive, the intervention itself must become more extensive to compensate. Put another way, if the environment lacks positive enduring features, then the intervention must become one. This is what we mean by 'extensity'". to prevent or intervene early in health- and life-threatening relapse.
Last revised 25 November 2009 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Aftercare calls suit less relapse-prone patients NUGGET 2005
Are we right to spend more? IN PRACTICE 1999
Warning sign aftercare for drinkers improves attendance and avoids relapse NUGGET 2006
Improving public addiction treatment through performance contracting: the Delaware experiment STUDY 2008
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
The grand design: lessons from DATOS KEY STUDY 2002
Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence.Mattick R.P., Breen C., Kimber J. et al.
Cochrane Database of Systematic Reviews: 2009, 3, Art. No.: CD002209.
A surprisingly small basket of randomised controlled trials (but one confirmed by other studies) supports the superiority of methadone maintenance over detoxification for patients prepared to be allocated to either option.
Abstract This update of a review first published in 2002 incorporates studies available for analysis up to the end of 2008. It adopted the rigorous Cochrane review process to analyse randomised controlled trials which compared methadone maintenance against treatments for opioid dependence which did not involve a similar (ie, opioid replacement) therapy. Comparison treatments may for example have been detoxification, drug-free rehabilitation, or placebo medication, or comparison patients may have been on a waiting list for methadone maintenance. The question addressed was whether patients dependent on heroin-type drugs do better when offered methadone as a long-term substitute medication, than when not offered any form of long-term substitute prescribing.
Eleven relevant studies were found involving altogether 1969 participants. All seven studies for which retention could be analysed found patients stayed longer in methadone than in comparison treatments. Among the four newer studies published since 2000, without methadone typically 15% of patients were retained for the periods measured in the studies; with methadone, 68%. Retention is of little use unless accompanied by improvements in targeted outcomes. Here the clearest finding was in relation to biological tests indicative of continuing use of illegal heroin. All six studies reporting this outcome found lower use rates on methadone, combining to an estimate that typically 70% of patients not offered methadone maintenance test positive, a figure reduced to 46% by methadone. Largely the same set of studies also asked patients how often they had used heroin. Generally their answers confirmed the reductions found by hair or urine tests, but with considerable variability across studies.
Across just three studies which reported on crime, there were substantial relative reductions in patients allocated to methadone which just failed to reach statistical significance. Similarly across the four studies which reported on deaths, which were halved among the methadone patients.
The analysts observed that patients have withdrawn from trials when assigned to a drug-free programme, so randomised trials have generally compared methadone maintenance with placebo 'methadone' or with methadone-based detoxification. These trials show that methadone (usually allied with services such as counselling, psychosocial therapy, medical services and often psychiatric care) can reduce the use of heroin in dependent patients and retain them in treatment. Beyond these trials, a broader international literature confirms methadone's impact on heroin use, crime and mortality, and on HIV infection and behaviours (such as sharing injection equipment) which risk infection.
It is important to understand the limited questions which can be answered by the randomised trials in the featured review. These demonstrated the impact of methadone maintenance among patients who were prepared to accept allocation to this treatment or to an alternative, or who had opted for methadone but had to wait. In terms of comparing one approach with another, the most such studies can do is show which is preferable when either seems appropriate and is acceptable to the patients, at least to the degree that they are prepared to countenance random allocation. Such studies cannot demonstrate which is the preferable option overall. There will be other patients determined to opt for detoxification or set against methadone maintenance, for whom methadone would be unacceptable or clearly unsuitable; still others would not join such studies because they want to be sure of a maintenance treatment and/or feel in no position to make a success of detoxification. Considerations like this probably explain why none of the comparisons involved residential rehabilitation. Caseloads suitable for non-residential substitute prescribing, and those suitable for residential drug-free services, would normally overlap so little that random allocation would simply be unacceptable, or would have to be limited to just a few highly selected patients.
Also the trials afforded only a limited range of outcome measures; too few recorded wellbeing and social reintegration measures (important to current policy in the UK) for these to be analysed by the review. The degree to which non-drug related services such as counselling and case management contributed to the outcomes is unclear. Strong patient preferences, and ethical prohibitions against denying patients an effective treatment to find out just how effective it is, are among the reasons why randomised trials comparing methadone maintenance against no treatment or non-drug treatments are rare, and often date back decades to when maintenance was experimental and the benefits were unclear. But as the featured study comments, there are many other non-randomised trials which confirm that the benefits found in randomised trials are replicated in more real-world conditions.
None of the trials included in the review were from the UK. Since in Britain most methadone maintenance is provided outside prison (for prison studies see an earlier review analysed by Findings), and at least some form of alternative treatment is normally available, the most relevant studies concern community programmes in which methadone is one of several active treatments on offer. From this perspective, the background notes on this entry detail the individual studies in the review. This more fine-grained view suggests that retention, crime and mortality gains were probably underestimated, and finds evidence of reduced illegal opiate use not incorporated in the featured analysis. Summary below.
With respect to retention in treatment, two studies clearly demonstrated the superiority of maintenance over detoxification plus aftercare and another (conducted in Sweden and not included in the analysis) that there are patients who simply will not accept further drug-free treatment but will accept, remain in, and benefit from methadone maintenance.
This was one of the studies which clearly demonstrated reduced illegal opiate use among patients allocated to methadone maintenance. In this and in another study in Thailand, patients had repeatedly relapsed after previous detoxifications. Possibly they were poor candidates for a further attempt and prime candidates for a maintenance option. Among first-time detoxification triers earlier in their addiction careers, the results might have been different. However, there are two other (both US, one not included in the analysis) studies which did not specifically recruit patients with a history of unsuccessful detoxification, yet still found maintenance reduced heroin use more effectively than detoxification.
In two of the three studies used to assess crime reductions, the impact of methadone was probably substantially greater then could be incorporated in the analysis. Another study set in Hong Kong was not included, but did find convictions were halved among maintenance patients compared to those unknowingly detoxified from methadone and then prescribed a placebo.
The most dramatic indication of the lifesaving potential of methadone was provided by a Swedish study, where typically four years later four of the 17 patients offered only drug-free treatments (which all refused) were dead, but none of the 17 offered methadone maintenance. This was somewhat, but perhaps falsely, countered by a study in Honk Kong, in which the impression of a higher death rate among methadone patients was possibly due to their staying in touch with treatment and with the study far longer than detoxified patients.
As the featured study comments, among the other benefits of methadone maintenance and allied treatments are that they consistently and significantly reduce the risk of transmission of blood-borne viruses and curb the spread of HIV. This was the prime reason why in 2005 the World Health Organization added methadone (and buprenorphine) to its List of Essential Medicines, though the argument for doing so also documented its crime reduction and treatment retention qualities. 'Essential medicine' status reflects not just the effectiveness of the treatment among patients recruited to it, but also the fact that methadone maintenance is capable of widespread implementation and the engagement of a large proportion of the at-risk population in treatment. This conclusion was boosted by an analysis for the European Union which found methadone maintenance cost-effectively prolongs and improves the lives of a population of opioid injectors by averting HIV infections, and that the cost of doing so is typically below the cost of treating the infections, creating health service savings. Importantly, the mathematical model used in this analysis showed that as the proportion of local drug users engaged in treatment increases, costs per averted infection dramatically decrease, and benefits across all drug users in or out of treatment escalate. This is because the treatment is capable of removing a large proportion of drug users from the networks who share injecting equipment, leading to a form of 'herd immunity'.
Thanks for their comments on this entry in draft to David Best of the University of the West of Scotland. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 07 November 2009 Background notes Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
International review and UK guidance weigh merits of buprenorphine versus methadone maintenance NUGGET 2008
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
Methadone maintenance as low-cost lifesaver NUGGET 2004
Lofexidine safe and effective in opiate detoxification NUGGET 2003
Opiate antagonist treatment risks overdose NUGGET 2004
Under-dosing and poor initial assessment undermine success of British methadone services NUGGET 2001
Role Reversal THEMATIC REVIEW 2003
A meta-analysis of retention in methadone maintenance by dose and dosing strategy REVIEW 2009
High risk of overdose death for opiate detoxification completers NUGGET 2008
The state of pharmacotherapy for the treatment of alcohol dependence.Garbutt J.C. Request reprint
Journal of Substance Abuse Treatment: 2009, 36(suppl. 1), p. S15–S23.
Review finds some but inconsistent and often modest support for each of the four medications approved by the US administration for the treatment of alcohol dependence: disulfiram; acamprosate; oral naltrexone; and once-monthly, injectable, extended-release naltrexone.
Abstract This US review focuses first on the four preparations approved by the US Food and Drug Administration for the treatment of alcohol dependence: disulfiram; acamprosate; oral naltrexone; and once-monthly injectable, extended-release naltrexone. All four have demonstrated some ability to reduce drinking and/or increase time spent abstinent, but results have not always been consistent. Except disulfiram, which has an aversive mechanism of action, effective pharmacotherapies for alcohol dependence are thought to work by blocking the rewards people experience from drinking or by stabilising systems dysregulated by chronic alcohol intake. Topiramate and baclofen have also demonstrated some efficacy in treating alcohol dependence. The efficacies of many of these regimens are modest and are limited by patient non-adherence to treatment and differences in the manifestations and causes of alcohol dependence. Their effectiveness could be enhanced through increased knowledge of the pathophysiology of alcohol dependence, through the identification of predictors of response to specific medications, and by modalities which improve adherence to medication regimens. Further details below.
By blocking the breakdown of alcohol in the body, disulfiram produces unpleasant reactions in response to even low levels of drinking, so acts as an aversive deterrent. Specifically it inhibits the action of the liver enzyme aldehyde dehydrogenase, preventing the conversion of acetaldehyde to acetate. As a result, after drinking alcohol, acetaldehyde accumulates, causing flushing, throbbing headache, nausea, vomiting, and chest pain. Its potential role and its shortcomings were highlighted in an early randomised trial which suggested that it could work as long as patients took it, but that most would fail to do so. Later work has emphasised the need for patients to agree to a trained associate (such as a supportive family member or friend) supervising their disulfiram consumption to help ensure the drug is taken.
Numerous trials mainly conducted in Europe have shown that acamprosate raises abstinence rates among recently detoxified patients. Some research also suggests it may be effective among patients who have not yet become abstinent. However, two major US trials were negative, possibly because patients had to sustain relatively short periods of abstinence before entering the studies. When naltrexone was already being prescribed, two studies found that adding acamprosate conferred no further benefit.
By blocking the body's own opiate-type chemicals, oral naltrexone is thought to reduce the rewarding feelings patients gain from drinking. Analyses of over 20 trials involving about 4000 patients have found convincing evidence that it reduces the likelihood of relapse to heavy drinking. There is also some evidence that it enhances abstinence rates. Overall the impacts are modest, though some patients do strongly benefit. These may include patients with a family history of alcoholism, relatively intense craving for alcohol, and certain genetic variants of cellular receptivity to opiate-type drugs, but the clinical utility of these indicators has yet to be demonstrated. Benefits are also more likely among patients who take medication as recommended.
Extended-release naltrexone helps overcome the problem of patients failing to take the oral form of the drug. As approved in the USA, it takes the form of a long-acting intramuscular injection which blocks the action of opiate-type drugs for a month or possibly longer. Two randomised controlled trials have confirmed that such preparations do reduce drinking. The most recent tested the approved product and found that over a six-month period repeated injections curbed heavy drinking, particularly among men and patients who had sustained several days abstinence before entering the study.
Of the other agents which have been tested, evidence is greatest for the anticonvulsant topiramate. In trials which randomised patients to the drug or to a placebo, topiramate reduced heavy drinking and increased abstinence rates, though side-effects were common. Three similar trials have been completed with baclofen. The two European trials found that it increased continuous abstinence rates, but a US trial found no effect on either heavy drinking or abstinence.
In Britain disulfiram and acamprosate have been approved for the treatment of alcohol dependence. No extended release naltrexone product has been licensed for any medical purpose. Non-licensed products or products licensed for another purpose can be used subject to the discretion and extra responsibility of the individual prescriber. A review published by England's National Treatment Agency for Substance Misuse concluded that naltrexone and acamprosate show minor positive effects when combined with psychosocial interventions, that naltrexone is most clearly indicated for patients who have lapsed or 'slipped', and acamprosate for supporting abstinence among patients who fear craving will lead to a lapse. Guidance partly based on this review stressed that drugs should be seen as an adjunct to psychosocial therapies, not as a treatment in their own right.
Without being conclusive either way, two major British studies have provided greater support for naltrexone than for acamprosate. Both studies were plagued by high drop-out rates and poor compliance with treatment, but in the naltrexone study, those patients who did complete the study and largely complied with treatment drank substantially less on naltrexone than on placebo pills. One lesson from both studies seems to be that among typical British alcohol clinic caseloads, the support available from the staff and/or from families and friends is often insufficient to enable patients to sustain their commitment to treatment. Details in background notes.
Head-to-head trials of naltrexone versus acamprosate within the same study help to eliminate the possibility that caseload or regimen differences account for their relative impacts. Like the UK studies, such studies conducted in Spain, Germany, the USA, and Australia, have consistently favoured naltrexone. The Australian study applied minimal filters to who could participate. Caseloads in the other studies (though often severely dependent) were relatively socially integrated. In all these studies the patients can be assumed to have been relatively highly motivated to tackle their drinking problems. Details in background notes.
The featured US review usefully complements clinical guidelines drawn up by a panel of experts convened by the US health department on how the four US-approved medications can be incorporated in to medical practice. All these medications are best seen as helping to create a relatively intoxication-free space during which patients can be helped to find other ways to cope and to construct lives incompatible with a return to heavy drinking. Each has its own strengths and limitations.
Patients committed to abstinence who have strong home-based or clinical support, especially in the form of someone to supervise consumption, can sustain disulfiram therapy and remain abstinent as a result, though some will not be suitable due to medical contraindications. The possibility of a severe reaction to drinking means that it would be unacceptable to use the drug in patients who have little chance of sustaining abstinence. In other circumstances, pharmacotherapies like naltrexone and acamprosate – which do not demand total abstinence – are more likely to be adhered to and can cut consumption. Even with these drugs, 'compliance' – the degree to which patients take the pills as intended – is a key issue. It can be improved by counselling designed to motivate compliance and to minimise side effects such as fatigue and nausea, and by engaging family members or other associates to monitor consumption of the pills. Naltrexone may be the better option for people who are not aiming for or find it hard to stop drinking altogether, and for those with a strong desire to drink in order to achieve what they experience as a pleasurable state of intoxication. However, side effects are more common and more severe (though only rarely such that patients have to stop taking the drug) than with acamprosate, and the drug is contraindicated in patients with certain liver problems or who are also dependent on opiates. There is also the complication that in a medical emergency, patients who have recently taken naltrexone will find that opiates fail to control pain, one reason why some prefer not to take the drug. This is a greater problem with the irreversible long-acting naltrexone injection.
Though there are these pointers to which types of patients might benefit most from which medication, the review points out that there is no secure way of deciding which is preferable at the level of the individual patient. Fortunately, all the US-approved medications have a good safety profile and (in their oral forms) are easily terminated without problems, allowing patients and doctors to take a trial and error approach to finding a medication which works. Greater risks due to administration by injection and its irreversibility, higher costs, and especially its non-approved status in the UK, mean that injectable long-acting naltrexone will for the time being best be seen as a possible reserve option for patients who have not done well with other therapies and who cannot be supported to consistently comply with oral naltrexone, especially if when they have taken the pills, they have responded well to the medication.
Last revised 25 November 2009 Background notes Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
'Real-world' studies show that medications do suppress heavy drinking NUGGET 2005
Review of treatment for cocaine dependence STUDY 2010
The search for medications to treat stimulant dependence REVIEW 2008
Naltrexone prevents return to heavy drinking NUGGET 2001
Take the network into treatment THEMATIC REVIEW 2004
Convincing evidence that acamprosate and naltrexone help prevent alcohol relapse NUGGET 2002
Anti-alcohol drug also reduces cocaine use NUGGET 2005
Naltrexone helps GPs and practice nurses manage alcohol dependence NUGGET 2004
Refocusing drug-related law enforcement to address harms.UK Drug Policy Commission.
London: UK Drug Policy Commission, 2009
'Target enforcement to reduce individual and community harm' is the premise of this report from a UK drug policy think tank, one which seems widely understood, though in some quarters, deeply contested.
Abstract This report describes the findings of a project intended to identify and promote the contribution that drug-related enforcement activity can make to reducing drug harms, and to develop a framework for considering enforcement from a harm reduction perspective. It was informed by the observation that while increased The report admits of localised and/or temporary impacts and that a 'background' level of enforcement does curtail supply. The issue is whether ramping this up will lastingly affect overall supply of drugs in Britain. enforcement generally does not significantly curtail overall supply, nor necessarily reduce (can even aggravate) drug problems, it can change the nature of drug markets. Since some markets cause more harm than others, this provides a largely untapped opportunity for enforcement agencies to target the most harmful drug markets, and shape the more resilient into less 'noxious' forms, with potential benefits even if the amount of drugs sold and used remains the same.
Methods to explore this proposition included commissioned essays to introduce the concept of a harm-reduction approach to enforcement personnel and to stimulate debate, literature reviews, assessment of the degree to which current guidance is compatible with the proposed harm reduction framework, and consultations on this framework with enforcement agencies and local partnerships responsible for planning drug services. Summary findings below.
The concept of using enforcement to reduce harms is already embedded to some extent within policy and practice internationally and in the UK, and there are good examples of the harm-generating features of drug markets being considered and guiding responses. A problem-oriented approach to policing lends itself well to such a strategy, as does the focus on neighbourhood policing, and the shift to performance measures based on community confidence in policing and public perceptions of the extent of drug problems in an area.
A complex picture emerges from the limited Limited partly because many operations do not target harms, focusing instead on arrests and seizures. research evidence on the impact of enforcement on drug-related harms. Some harms have been increased by some activities and decreased by others, while many studies found no impact one way or the other. The very limited evidence relating to enforcement further back along the chain of production and supply fails Though this may reflect absence of evidence rather than absence of impact. to support seizures or crop eradication strategies. Open street drug markets (often a priority for communities) are temporarily disrupted by high intensity enforcement ('crackdowns'), but later tend to return or are displaced elsewhere. In contrast, partnership approaches using civil penalties such as nuisance abatement orders have restricted drug dealing and often crime and disorder more generally. There is also considerable potential for public health and social harms to be generated by drug market enforcement activities, particularly at street level, for example, by causing hurried injecting or increased violence following market disruption.
Research (mostly not from the UK) highlights the need for clarity about the harms or problems being targeted; different approaches are more or less effective against different types of harms. One approach is to target specific individuals or groups, such as the Boston project which directly warned rival gang members that further violence would bring a swift and heavy response, resulting in a dramatic reduction in violence. Other targeted interventions include arrest referral and schemes to divert arrestees or offenders out of the criminal justice system, for which the evidence on crime and health outcomes is generally fairly positive. In contrast, the two identified evaluations of undercover operations conducted in isolation from other initiatives showed no impact on drug use, drug offences, supply or demand for drugs, or on violent or property crimes.
Beyond the formal research, the report included case studies of enforcement activities in Britain and their impact on harms. Initiatives included those targeting individuals or groups identified as being particularly harmful, more effective use of the law to recover criminally gained assets, targeting areas where drug problems are particularly damaging, and use of civil powers against nuisance-generating or anti-social behaviours. The case studies documented the development of partnership approaches between enforcement agencies at different levels, and between enforcement agencies and local partners, especially treatment agencies. These have considerable (if patchily realised) potential to reduce harms associated with the production and supply of drugs. Increasingly, reducing harms is being made an explicit target of enforcement operations, but often the objective is limited to curbing acquisitive crime by diverting offenders in to treatment. As a result, operations may not maximise benefits and may have unintended consequences. Even when harms are the target, often this is not carried through systematically into the planning, conduct and evaluation of the operations.
Building on current trends in enforcement practice, the report proposed a new framework for harm-focused drug law enforcement in the UK. The issues covered included:
• defining the problem in terms of the harms caused and the features of drug markets which lead to those harms;
• prioritising areas for action through consultations with the community to understand their concerns and perceptions of how drug markets affect their lives;
• considering possible responses and their likely impact to ensure that, even if there are potentially harmful unintended consequences or displacement, there is likely to be a clear net reduction in harm;
• identifying measures of success and impact which go beyond arrests, seizures or drug prices and purities, to explicitly demonstrate gains in reducing drug problems;
• implementing enforcement operations in ways which mitigate any likely increases in harms, while maximising the potential for reductions;
• evaluating to understand the impact of operations on harms and whether there are sustainable improvements for the relevant communities.
The authors argue that the report highlighted the clear potential for a more harm-focused approach to drug law enforcement. As well as reducing harm, this promises to further integrate enforcement with community priorities and institutions and offers a way to evaluate success in ways which matter to the public. Given the level of investment in enforcement activity, yet the lack of evidence on its impact on drug harms, it is essential that new harm-focused measures are developed and used to evaluate this activity.
The featured report has been criticised on the one hand for simply proposing "smarter weapons" in a failed and unethical war on drugs, and on the other for surrendering ground to less harmful dealers and markets. Within the context of current and probable future law and policy, and the reality of limited resources, it is perhaps best seen as a pragmatic response aiming to promote the transformation of enforcement from an unquestioned good in its own right, to an ally in the securing of national and community objectives shared with treatment and prevention initiatives.
UKDPC believes
Personal communication from Nicola Singleton, Director of Policy and Research, UKDPC, October 2009.
that rather than surrendering ground, following the report's principles is more likely to mean enforcing laws differently with much more community involvement and partnership working.
As the report says, it swims with We are grateful to Tim McSweeney of the Institute for Criminal Policy Research at King's College London for raising the points made in this paragraph. rather than against the tide of modern thinking on policing in Britain. In an article for the featured report, the Director of Intelligence at the Serious Organised Crime Agency wrote that, "The concept of harm-reduction now sits at the heart of the UK's strategy for tackling serious organised crime". Most English and Welsh police force areas now routinely use a standard methodology to assess the threats and harms posed by organised crime groups, target their resources/activities accordingly, and assess impact (though the latter is universally recognised as the weak link in the chain). Among other strands, this standard 'threat matrix' incorporates risk of injury, economic damage, and community harm. Initiatives like the Street Level Up Approach (being developed by the government's interagency group responsible for combating class A Of the Misuse of Drugs Act, the most serious class including heroin and cocaine. drug use) aim to coordinate enforcement agencies to address the harm that problematic drug markets cause at street level, where communities notice the difference. For all these initiatives, a key challenge will be to develop tangible and meaningful performance indicators to measure impact against what are likely to be amorphous and fluid 'organised' crime structures, and to incorporate data on impacts on (for example) health and treatment entry. Selecting and weighting these different types of impact depends partly on practicality, but mainly on values – on what matters most to elements in society in a position to set this agenda.
In a broader sense too, values rather than evidence is the fundamental issue addressed by this report and the responses to it. The report argues that harm reduction, broadly defined to include crime and community harms as well as those directly affecting the user, should be the overarching objective to which all policy strands direct their investment and against which success is measured. If this is accepted, then in the current legal framework, the report's approach is simply a logical extension to enforcement. Since reducing harms is an important overriding national objective and one broadly accepted, this seems to have been the mainstream reaction to the report.
Reconciling a harm reduction approach with one focused on reducing drug use may not just be difficult but impossible, because rather than being complementary, these stem from profoundly different moral positions and ways of thinking which cannot be wished away in pursuit of a comforting consensus or at least co-existence. Even within a harm reduction context, there remains the issue of which/whose harms matter most and should be targeted. Beyond harm reduction are contesting strategic and moral positions, such as freedom of the individual (even if that allows self-harm), zero tolerance of crime and illegal drug use, and recovery/abstinence agendas, from which some degree of harmful side effects might be seen as worth enduring in the service a greater good, and perhaps even as an instrument in achieving that good. For example, the common presumption that dependent substance users must hit 'rock bottom' (ie, experience extreme harm) before they really see the need to stop using, legitimises strategies which at the least do not try to stop this happening (in this perspective, such efforts are denigrated as 'enabling'), and even promote it through imprisonment and the withdrawal of housing, employment and family relationships. 'Hassle' from the uncomfortable and risky life forced on illegal drug users by conventional enforcement is commonly cited as a reason for 'early retirement' and treatment entry, driving dependent users towards a possible route to abstinence and/or recovery. Evidence that such strategies risk harm could be met by the answer that risking harm is exactly the intention in order in order to promote recovery and abstinence. From this perspective, making (especially illegal) drug use safer/less harmful is questionable because it is seen as making it easier to start and stay using drugs. As an essay written for the featured report points out, an opposing view, from which harm reduction is primary, would be willing to accept increased drug use if on balance harm was reduced.
As a reaction to the report showed, from some moral positions, all drug use is harmful and distinctions in levels of harm are a misguided and invidious collusion, a position which extends to any degree of selectivity in attempts to punish dealers and eliminate illegal drug markets. Counter arguments that enforcement pressures marginalise dependent users into an addict identity, and rob them of the social, physical and psychological resources needed to recover, or that with limited resources, some degree of selectivity is inevitable, may not address the values base on which such criticisms are founded. Vice versa too, the values which promote harm reduction above competing objectives will remain unmoved by criticisms made from an alien values base.
Other than in circles within which harm reduction or resource limitations are not overriding considerations, the project and its final report seem to have generally been received (1 2 3 4 5 6 7) as realistically addressing mainstream concerns.
Thanks for their comments on this entry in draft to Nicola Singleton of the UK Drug Policy Commission and Tim McSweeney of the Institute for Criminal Policy Research of King's College London. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
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Drug and alcohol services in Scotland STUDY 2009
Community solidarity and civil law important tools in reducing drug-related nuisance and crime NUGGET 2000
Review of the Glasgow & Fife drug courts STUDY 2009
Dedicated drug court pilots: a process report STUDY 2008
Force in the sunshine state OLD GOLD 2000
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Evidence-based practice? The National Probation Service's work with alcohol-misusing offenders STUDY 2009
Motivational arm twisting: contradiction in terms? THEMATIC REVIEW 2006
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
