EFFECTIVENESS BANK BULLETIN 28 June 2010

The 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. The Summary is intended to convey 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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Reserve heroin prescribing for methadone failures ...

Can opiate substitute prescribing also curb cocaine use? ...

British drug courts yet to prove their worth ...

Enforcement crackdowns make drug markets more violent ...

Prescription of heroin for the management of heroin dependence: current status.

Lintzeris N.
CNS Drugs: 2009, 23(6), p. 463–476.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Lintzeris at Nicholas.Lintzeris@sswahs.nsw.gov.au. You could also try this alternative source.

Should heroin prescribing be a mass treatment entry route or a niche option for the few who have not done well in optimised (but still cheaper) mainstream treatments? With nearly all the latest studies to hand, this review came down firmly on the 'niche' side of the debate.

Summary This review analyses studies of the prescribing of injectable or smokable heroin to heroin addicts on a maintenance basis (usually indefinite, at doses which substitute for the effects of illegal heroin, and without requiring dose reduction). Generally patients qualified for these trials because they had not done well in more conventional opiate substitute prescribing programmes based usually on oral methadone or sublingual (absorbed under the tongue) buprenorphine. The review extends an earlier review of English, Dutch and Swiss randomised trials by including later trials in Germany and Spain (making six randomised trials in all involving over 1600 patients) and by considering non-randomised studies in Britain and Switzerland.

Placing heroin prescribing in context, the author explains that managed withdrawal programmes alone rarely result in long-term benefits and risk post-withdrawal overdose. It is difficult to ensure that patients transfer to effective follow-on care such as residential rehabilitation, and these treatments can be very costly. The limitations of these approaches has resulted in the broad expansion of substitute prescribing programmes based on methadone or buprenorphine in order to enable patients to stabilise their drug use, improve their health and social functioning, and to curb crime. Heroin prescribing has been developed to help patients who do not benefit from these mainstream approaches. Heroin-based treatment is now routinely available in the UK (where it has been for many decades), Switzerland, the Netherlands and Germany. Generally it has been trialled and implemented according to the 'continental' model which requires all heroin doses to be self-administered (typically two or three times a day) under supervision at specialist clinics. Supervision prevents diversion of medication on to the illicit market and enhances patient safety, thereby allowing for higher and more effective doses.

The review analysed the randomised trials one by one, with special attention to dose and other influences which may have tipped the balance in favour of or against heroin prescribing. In Britain the first such trial may have been affected by low heroin doses, while in Switzerland more intense psychosocial services were offered to heroin than to other patients. In the two (injectable and smokable heroin) Dutch trials, better overall outcomes At least a 40% improvement in at least one of the problem areas where the patient was doing badly before treatment, without deterioration elsewhere or increased resort to stimulant drugs, was considered a good response to treatment. among patients prescribed heroin may have been due to a higher total opioid dose, rather than to the type of opioid or how it was administered. A study in Spain was the first to compare broadly equivalent medication doses in heroin-based and non-heroin based maintenance treatments. Heroin patients reported significantly less illicit heroin use (though this remained high in both groups) and were at less risk of HIV infection, but differences were not significant for other measures such as crime, social functioning and mental health, and equivocal for physical health. A large German trial also prescribed broadly equivalent doses and was the first to use biological tests (special urine screens) capable of distinguishing illicit from prescribed heroin use. After a year significantly more patients remained in the injectable heroin as opposed to the oral methadone treatments, particularly if the 29% of patients who did not start their methadone treatment (presumably disappointed at not being allocated to heroin) are included in the calculations. However, at 12 months the same proportions were in some kind of treatment. The study's criterion for a successful substance use outcome was substantial reduction in illicit heroin use with little or no increase in cocaine use. It was satisfied by 69% of patients on heroin and 55% on methadone, a statistically significant difference. The health of most patients improved substantially in both groups but significantly (if only slightly ) more patients met this criterion in the heroin group. Improvements among heroin patients were sustained over the two years after treatment started when 82% of patients were still in the treatment; non-retained patients tended to be more problematic and socially unstable.

Summarising these and other results from the studies, the author concluded that:
• Retention in treatment appears to be broadly comparable in heroin and methadone-only programmes.
• Compared to oral methadone, heroin-based treatment further reduces illicit heroin use, though in both treatments this is markedly reduced. Indeed, some oral methadone patients not only stop using heroin but also stop injecting, a major health-risk benefit. Heroin treatment is not a panacea which abolishes all illicit heroin or other drug use. Cocaine use in particular reduces to roughly the same degree in both types of treatments.
• Heroin-based treatment results in greater improvements in most other outcomes such as crime and psychosocial functioning; for every 100 patients, approximately 7–25 more will significantly improve than if offered conventional substitute prescribing. However, many patients benefit from oral methadone treatment, and heroin treatment has not been universally or substantially superior across all studies and all types of outcomes.
• Heroin treatment is considerably more expensive than conventional substitute prescribing, though this may be offset by savings for the criminal justice system and for the victims of crime. These results derive from the Dutch studies, which also found roughly equivalent gains in terms of years of life adjusted for quality of life, and no immediate healthcare savings. Since savings are in crime but costs are borne by health services, these services may be reluctant to fund the treatment.
• Randomised trials reported similar death rates among methadone and heroin patients. There are however several distinctive safety concerns with heroin treatment, including regular long-term injecting and a high incidence of serious incidents, particularly seizures and overdoses immediately after injection. The latter raises concerns about the long-term effects of recurrent heroin-induced shortage of oxygen.

If heroin-based treatment is to be a costly minority approach, a key question is who should be offered it. Increasingly, heroin treatment providers agree that it should not be a front-line treatment, but reserved for patients who do not respond well to conventional substitute prescribing. How 'failure to respond' should be defined is a matter for debate. It might mean:
• Heroin users who are not attracted to conventional treatment. However, treatment services in most countries are already overstretched.
• Heroin users who did poorly (eg, poor retention, continued drug use) in previous methadone treatments but are not currently in treatment. Heroin treatment may successfully engage these former patients, but so too may a new episode of conventional treatment. For these people heroin treatment is unnecessary, costly and possibly detrimental.
• Patients currently in methadone treatment but not doing well, indicated for example by frequent heroin use, high-risk injecting, and poor health and psychosocial functioning. However, such patients may not require heroin, but optimising adjustments to their current type of treatment and/or further psychosocial assistance. In particular, buprenorphine may be suitable for some unable or unwilling to tolerate high methadone doses.

According to this logic, heroin treatment should only be available for patients who have not responded to a significant period (for example, at least three months) of conventional treatment delivered under optimal conditions (high doses; psychosocial services; supervised dispensing; adequate medical care). Continued regular heroin use and related harms after this time may justify a trial period of heroin treatment. People who still do not do well (regular drug use; no significant improvement in health and social functioning) could be returned to conventional treatment, freeing up expensive heroin treatment places. Another key issue is whether heroin treatment is best seen as a long-term treatment in its own right or a transition to non-injecting treatment modalities.

At a policy level these clinical considerations suggest that diverting considerable resources to the perhaps 5–10% of patients who require heroin treatment should only be considered in jurisdictions which can already deliver optimal conventional approaches to all heroin users seeking treatment.

Heroin prescribing trials have also been reviewed by Findings, for the Cochrane collaboration, and for the Joseph Rowntree Foundation, but none included the latest trials assessed by the featured review.

For Britain a vital trial whose results came too late for all these reviews was the RIOTT trial conducted at clinics in London, Darlington, and Brighton between 2005 and 2008. The questions posed by the study were whether patients who remained wedded to street heroin despite extensive treatment were simply beyond available treatments, whether it was just that their current oral treatment programmes were sub-optimal, or whether they would only do well if prescribed injectable medications. Each of these three propositions was true for some of the patients. A third did seem beyond current treatments even as extended and optimised by the study. For a fifth, 'all' it took was to individualise and optimise dosing and perhaps also psychosocial support and treatment planning in a continuing oral methadone programme. But despite pulling out many stops to make the most of oral methadone, nearly half the patients only did well if prescribed injectable medications, with heroin by far the better option than methadone at suppressing illegal heroin use. The upshot was that the most reliable option in terms of securing a divorce from regular illegal heroin injecting was to prescribe the same drug to be taken in the same way, but legally and under medical supervision. As defined by the study, two-thirds of these seemingly intractable patients responded well to this option. However, from a conference presentation it seems injectable medications and heroin in particular had a far less clear-cut advantage in respect of crime, health, and quality of life.

Conclusions similar to those reached by the featured review have been reflected in UK national clinical guidelines and in guidance issued by England's National Treatment Agency for Substance Misuse. In particular the latter is clear that injectable prescribing should be considered only for the minority of patients with persistently poor outcomes despite optimised oral programmes, and that the priority should be improving the effectiveness of oral maintenance treatment for the majority.

Apart from the obvious and serious issue of cost, there is in any event a major logistical problem in extending heroin prescribing programmes based as recommended on supervised consumption at the clinic. Studies in continental Europe and Britain have shown that requiring on-site injecting or smoking of heroin several times a day is feasible. However, this can only work for patients who can easily and quickly get to the clinic. Unless the network of heroin prescribing centres is greatly expanded, on-site consumption will leave large parts of Britain unserved, especially rural areas. There are other options (such as supervised consumption in a pharmacy, local surgery or drug service) but these will not be easy to organise and may be considered unsafe. The same problem arises even if on-site consumption is limited to the early stages of treatment, a precaution which may be considered necessary on patient safety grounds and one recommended by national guidelines. The inconvenience of on-site consumption can be tempered by allowing patients to skip visits and take oral medication instead, an opportunity most took advantage of in Swiss trials. Insisting instead on the return of used ampoules – a tactic used with seeming success in a study in London – may be a less intrusive and less expensive way to prevent diversion.

Last revised 28 June 2010

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Optimising the core maintenance intervention

No studies were found which tested opiate maintenance against no treatment or against an inactive placebo drug, but six did test variations of maintenance prescribing. Three of these studies enabled an assessment of the impact of low Under 50mg a day for methadone, 6mg for buprenorphine, or 120mg a week for levo-alpha-acetymethadol (LAAM). versus higher doses of maintenance medications. Across these studies, higher doses significantly increased retention, the proportion of patients who sustained heroin abstinence, and the proportion of heroin-free urine tests, but there was no significant impact on either indicator of cocaine use.

Across the four studies to test this, at equivalent doses methadone substantially and significantly outperformed buprenorphine (these are the two main maintenance medications) in enabling more patients to sustain abstinence from cocaine. It also increased retention and (but non-significantly) improved heroin abstinence on both measures.

Supplementary interventions targeting cocaine use

The issue addressed next was the impact of adding a cocaine-oriented therapy to the core maintenance programme. Of these 34 studies, 20 tested medications. Across the relevant studies, the only class of drugs shown to significantly help patients stay free of cocaine (both in terms of sustained abstinence and the proportion of cocaine-free urines) were those which raise brain levels of a neurotransmitter (dopamine) thought responsible for some of the pleasurable effects of cocaine, and which becomes depleted after regular use of the drug. These medications included bupropion, amphetamine, disulfiram, and mazindol. They also improved retention in treatment and, prescribed as a supplement to methadone, increased the proportion of patients sustaining abstinence from heroin.

Additionally there was tentative evidence (from just two studies) that desipramine, a drug which acts on a different neurotransmitter system, also helps patients sustain cocaine abstinence. Other medications were not shown to have improved substance use outcomes and one class of drugs (GABAergic agonists such as tiagabine and gabapentin) was associated with significantly shorter retention in treatment, possibly due to aversive side effects.

Of the psychosocial interventions, contingency management has been the most studied and has the best record. Typically these interventions systematically applied rewards (such as shopping vouchers) and/or sanctions in response to the results of urine tests for cocaine and/or heroin use. When cocaine was the sole drug targeted, the effect was to substantially and significantly raise cocaine abstinence rates on both measures and also to increase the proportion of heroin-free tests. In contrast, rewards/sanctions targeting both heroin and cocaine were generally Of the four substance use measures, only the proportion of cocaine-free urines was improved, and then only slightly. ineffective. This pattern of results probably reflects the fact that stopping cocaine use in response to the rewards is easier than stopping heroin use. In the few studies which tested these approaches, contingency management allied with cognitive-behavioural therapy improved sustained cocaine abstinence rates, the therapy on its own narrowly failed to have a significant impact, while acupuncture affected neither retention nor the proportion of cocaine-free urines.

It seemed that the effective interventions (drugs which raised dopamine levels; contingency management) were most effective among patients starting treatment rather than established patients, but this proposition had not been tested within a single study.

Authors' conclusions

The authors said their analyses showed that among dual heroin and cocaine dependent patients, higher doses of maintenance medications improved heroin use outcomes without affecting cocaine use. Methadone outperformed buprenorphine on sustained cocaine abstinence, retention in treatment and (narrowly non-significantly) heroin use measures. High-dose methadone was the most effective combination of drug and dose, possibly because it best helps patients stop using heroin, which also helps divorce them from circles within which cocaine is traded. However, the relative safety of buprenorphine and its suitability for primary care settings may make it preferable in clinical practice, and dose adjustments beyond those tested in the reviewed studies may alter its effectiveness relative to methadone. Of the supplementary interventions targeting cocaine, evidence of an impact on cocaine use was strongest for contingency management (especially when cocaine was the sole drug targeted), and for which raise brain dopamine levels.

In 2005/06, 25% of patients in drug treatment in England were there primarily to address problems involving both crack cocaine and opiates like heroin. By 2008/09, the figure had risen to 30%, in numbers a rise from about 21,000 to nearly 25,500 patients. In Scotland this combination is far less common; instead benzodiazepines are the dominant drug accompanying heroin. In 2009, just 7% of patients starting treatment for heroin addiction in Scotland said they also used crack cocaine. These and similar patients in the other nations of the UK are candidates for the interventions assessed by the featured review.

Routine monitoring statistics cited above have been supplemented by national studies. In 2006 researchers attempted to recruit and then track the progress of a representative sample of patients starting drug treatment in England. Of these, 44% had used crack in the four weeks before seeking treatment. While it seems all or nearly all 47% of the sample considered their crack use a problem. these felt their crack use was a problem, just 1 in 8 (12%) of treatment-seekers considered it their primary problem. For the bulk of problem crack users, the drug was subsidiary to their heroin use, the type of patient investigated by the studies in the featured review. This was also the case in Scotland among patients starting addiction treatment (other than in prison) in 2001 and 2002. Though in the past three months around 30% each had used crack or cocaine powder, this was rarely their main drug and most did not see their use as a problem. Given that 9 in 10 of all patients had used heroin and that for the vast majority this was seen as their main problem drug, it seems likely that cocaine was usually subsidiary to heroin use.

In the English study, after a few months in treatment only 15% of crack users recalled receiving a crack-specific intervention, and whether they had was unrelated to whether crack use ceased or continued. Despite this lack of targeted attention, crack users did as well as anyone else in terms of short or longer-term retention In fact, over the first 12 weeks a higher proportion were in treatment because slightly more had started treatment. in treatment, in employment, increase in legitimate income, accommodation, and increase in the proportion of parents living with all their children. If anything, crack seemed easier to give up than heroin; 53% of crack users had stopped using by the first follow-up and 61% by the second, respectively 9% and 12% higher than the corresponding figures for heroin and heroin users. The implication is that while there was considerable scope for therapeutic enhancements to tackle crack use among opiate-dependent patients (enhancements which the featured review sought to identify), the core treatments offered these patients were in themselves accompanied by substantial improvements.

In terms both of size and reliability, the strongest anti-cocaine impacts identified by the featured review were associated with contingency management programmes applying rewards and punishments for cocaine abstinence/use. Such programmes have the potential to create a cocaine-free period during which other ways of coping and sources of pleasure can become established. Typically however studies have tracked patients only while the rewards are being applied. These in-treatment gains generally do not persist or have not been shown to persist, and there is concern that intrinsic motivation can be undermined if patients see themselves as 'just doing it for the prizes'. There are also ethical concerns about the aggravation of inequality if the most dependent patients find themselves unable to achieve the rewards, and about paying people to do what they 'should' be doing anyway – complying with the law and with programmes to safeguard and improve their health.

Last revised 23 June 2010

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Background to the featured study

In the first months and years of the courts, implementation of this new form of justice was relatively smooth. As intended, court reviews replaced the normal adversarial atmosphere with problem-solving dialogue directly between sentencer and offender. Both felt this led to better decision-making. Offenders felt listened to and treated 'as a human being' and motivated to do well. Sheriffs accented the positives, accepted that progress might be incremental and bumpy, and set achievable goals for the next review. Pre-court meetings between the judge and the multidisciplinary team working with the offender usefully set the agenda for the reviews. Perceived shortcomings related to the lack of comprehensive, individualised and flexible service provision for the offenders.

While generally appreciated by offenders and staff, crime impacts were questionable. Within a year 50% of drug court offenders had been reconvicted and within two years 71%, and the average frequency of reconvictions only slightly dipped in the two years after the order was imposed compared to the two years before. There was no clear crime-reduction benefit from supervising DTTOs through the drug courts (at an average cost of nearly £18,500 per order) as opposed to normal adjudication. However, this might have been because the courts had not been working long enough for a robust analysis. In 2006 the Scottish Government extended the courts for three years subject to a further evaluation, the results of which are documented in the featured report.

Findings of the featured study

Interviews with staff showed that the generally positive views of the courts documented earlier had been sustained and some teething problems had been resolved. Perceived advantages over usual procedures included more in-depth assessment, intensive treatment by a specialist multidisciplinary team, the continuity of supervision by the sentencing judge, their specialisation in drug cases, and the fact that the courts improve efficiency by dealing in a single hearing or series of hearings with all outstanding offences, warrants and complaints.

Over the years 2005 to 2008 (when data was available from both courts), on average 267 offenders a year were assessed for their potential receptiveness and suitability for a drug court order. Of these, on average 60% were sentenced to an order, of which nearly three quarters were drug treatment and testing orders, accounting for about a quarter Over years 2005 to 2007 the courts made on average 132 DTTO orders a year. Across Scotland, over the financial years 2005/6 to 2007/8 there were on average 559 orders a year. of all such orders in Scotland. Over the years 2004 to 2008, 47% of the 779 finished drug court orders had been completed successfully without being revoked or irretrievably breached due to non-compliance. By way of comparison, over roughly the same period, across Scotland 35% of DTTOs had been successfully completed; this figure includes orders made by drug courts.

However, the main indicator of recidivism – convictions – was less promising. Within a year, 70% of drug court offenders had been reconvicted and within two years 82%. Offenders who had successfully completed their orders were less likely to be reconvicted – 62% were within one year compared to 78% whose orders were breached or revoked; by two years the figures were 74% and 89%.

The critical question was how these rates compared to those of offenders not processed through the drug courts. In summary, the answer was very little, and not always in the direction of fewer convictions. To improve comparability, the analysis focused on offenders given drug treatment and testing orders either by drug courts or by other courts. In summary proceedings only to match the procedure in drug courts. This should have ensured that both groups were serious drug-related offenders facing possible custodial offences, considered suitable for and prepared to accept the drug treatment and testing regimen. In the same areas (Fife and Glasgow) in the two years before drug courts were established, 66% of these offenders had been reconvicted within a year and 80% within two years; once drug courts were operational, the figures were slightly worse – 70% and 82%. Another comparator was offenders given drug treatment and testing orders across Scotland Presumably including oders imposed by drug courts. from 2002 to 2006. Here too reconviction rates (72% at one year and 82% at two) were virtually identical to those of the drug courts (70% and 82%).

Even if they had not kept more people free of convictions altogether, it remained possible that the courts had reduced the number of convictions. This too did not seem These comparisons may have been prejudiced by the fact that drug courts were more likely to process prior offences at the same time as the current offence. to be the case. Neither in comparison with the same areas before the drug courts, nor with Scotland as a whole, had drug court offenders consistently or substantially been less frequently reconvicted.

Implementing orders through drug courts cost substantially more than similar orders imposed by other courts. In 2007/8 each order made by the Glasgow court averaged £23,742, by the Fife court, £16,386, while a drug treatment and testing order made by other courts cost on average £12,205. This differential carried through to the cost per successfully completed order; around £50,000 in the drug courts and £36,000 in other courts.

The conclusion was that there was no reliable The numbers involved were too small to be confident about relative performances. evidence that orders imposed by drug courts were more effective than similar orders imposed by other courts. Both the proportion of offenders reconvicted, and the frequency of convictions, were very similar to those of offenders on drug treatment and testing orders imposed by other courts. It was, however, clear that orders imposed by drug courts cost substantially more per order and per successfully completed order, a gap which might best be narrowed by streamlining assessments. Nevertheless the courts enjoyed overwhelming support from staff and stakeholders. The report stressed that offenders targeted by the drug courts are extremely challenging, often living chaotic lives and with a long history of drug misuse and offending; their rehabilitation is likely to be a long-term process with many setbacks.

These comments are documented and expanded on in the background notes. For one eminent authority, drug courts seemed a potential way to forge the strong working relationship between criminal justice and treatment systems so far lacking in Britain. Such a relationship was seen as essential to the implementation of programmes which seek to marry the two in a mutually reinforcing crime-reduction partnership, court supervision helping place and keep offenders in treatment, treatment helping them overcome the dependence which drives their offending. Disappointingly however, the featured study found no detectable crime-reduction benefit from adding drug court enhancements to sentences which already involve the close supervision and treatment requirements of drug treatment and testing orders. Instead the main impact seems to have been to substantially raise costs. Studies of drug courts in England have not been able to answer questions about their effectiveness compared to normal proceedings, but did confirm that there too they cost several thousand of pounds more per offender background notes.

The Scottish findings were a surprise because generally it is thought that helping more offenders complete treatment and supervision programmes (as the drug courts did) will also mean these programmes have greater benefits, including the reduction of crime. A possible explanation is that actually there were crime-reduction benefits, but these were not picked up by the conviction indicator and might, for example, have been reflected in arrests. More radically, it could that the experience of being sentenced and supervised by a drug court was less important than what the offenders themselves brought to the process (such as motivation and social and psychological resources) or the treatment and monitoring imposed by the comparison drug treatment and testing orders. For more background notes.

If (as it seems) drug courts did not improve on DTTOs imposed by normal courts, it could mean these options were equally effective, or that they were equally ineffective compared to alternative procedures. Pilot DTTO studies in the same Scottish areas and in England suggest (but the evidence is methodologically very weak) that offenders given DTTOs are convicted less often than during the corresponding period before the order, and in England that they improved on probation with a treatment requirement. Another comparator for DTTOs is treatment entered in to via non-criminal justice routes. British studies and studies of similar programmes elsewhere suggest (but in the case of the UK, again only weakly) that given the same sort of treatment, the characteristics of the patient are more important than whether they have opted for this treatment by agreeing to a court order or in some other way. For more background notes.

International experience and research

Beyond Britain ( background notes) the evidence almost entirely derives from the USA. It also features few and sometimes flawed randomised trials, yet these are the best way to isolate the impacts of the courts uncontaminated by differences in the offenders seen by these as opposed to other courts. Across all the studies, drug courts have significantly outperformed normal adjudication in reducing indicators of crime (mainly arrests), but in the stronger randomised trials the effect was weaker and no longer statistically significant, meaning that chance variation could not be ruled out. This pattern suggests that non-randomised studies have suffered from various forms of bias which elevated outcomes from drug courts, but that some real advantage probably remains even after these biases have been eliminated.

A randomised trial of the Baltimore City Drug Treatment Court stands out as the most convincing demonstration that drug courts can exert a lasting anti-crime impact background notes. Over the three years after offenders were allocated to the court or to normal proceedings, the average numbers of new arrests and charges were significantly fewer among drug court offenders. However, confidence that the court caused these gains is weakened somewhat by two other features or findings of the study. First, though all but one of the other crime indicators favoured the drug court, none did so to a statistically significant degree and differences were in some cases minor. In particular, the average number of new convictions was almost identical in drug court and normally adjudicated offenders. Second, there is a risk that some of the many differences the study tested for might crossed the line in to statistical significance purely by chance. Importantly, this study did convincingly confirm that benefits relative to normal proceedings are concentrated among the more serious offenders, and that frequent resort to short prison terms as a sanction can eliminate the cost advantages of drug courts.

Other mainly US studies ( background notes) offer further clues about what makes for an effective drug court. Courts which predictably levy sanctions for non-compliance by waving prosecution or waving the imposition of a suspended or deferred sentence are significantly more effective than courts with less clear-cut sanctions. Also, the intensity of supervision of typical drug courts is generally wasted on low-risk offenders. More broadly, international experience and research suggests it is important for courts to emphasise rewards as well as punishments, see offenders frequently enough to apply these swiftly in response to progress, deploy a range of rewards and sanctions short of revocation which are consistently applied, have a strong and sure ultimate sanction when the programme fails, make these consequences absolutely clear to offenders, have rapid access to a range of treatment options, maintain continuity in the judge dealing with the case, and attend to the range of the individual's needs. Willingness to continue despite some initial offending makes the structure imposed by stringent requirements and monitoring a positive feature rather than one which leads most offenders to fail. Consistent judicial supervision, the fact that this forces addicts (back) in to treatment, and drug testing which provides a shared measure of how treatment is progressing, probably all play their parts.

Last revised 20 June 2010

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A link yes, but did enforcement cause crime?

It is likely that the reviewers analysed the studies in considerable detail, but the published review does not critique each study or indicate the degree to which its methodology was capable of answering the question it addressed. A key issue, for example, is whether a study takes steps to eliminate the possibility that a link between enforcement and violence is due to the stepping up of enforcement to counter an increasing threat from drug-related violence – in other words, to eliminate the possibility that rather than enforcement having caused violence, the reverse was the case. It is big leap from observing that two things vary together to determining which (if either) caused the variation in the other. Making this leap is aided by a plausible explanation or 'mechanism' via which one might affect the other, in this case, an explanation for how increased enforcement might increase violence. The one put forward in the review is that "removing key players from the lucrative illegal drug market ... may have the perverse effect of creating significant financial incentives for other individuals to fill this vacuum". Crackdowns can it suggests disrupt a settled market dominated by a few players and split it in to competing fiefdoms, generating violence in the fight for the spoils. While analysts agree that this can happen, one problem with this explanation is that indices of enforcement intensity in the reviewed studies seem to bear little relation to the removal of key players. Numbers of drug arrests or seizures and spending on enforcement seem at least as likely to reflect generalised enforcement activity which affects drug users and low-level dealers rather than surgical operations targeted at major financiers and organisers.

There are, of course, other explanations for such a link, prime amongst which is that intensified enforcement raises the price of illicit drugs by constricting supply and because dealers raise prices to compensate for heightened risk. In turn, greater rewards lead to greater violence in order to secure those rewards. Such a mechanism is thought to account for the relationship between heroin prices and total or drug-related killings in the USA and several European countries and regions. The prime difficulty with this argument is securing evidence that intensified enforcement has actually led to an increase in price. Indeed, the review highlights the decrease in illicit drug prices in the USA – where most of the studies it reviewed were conducted – as proof that intensified enforcement since the 1990s has not curtailed supply.

The review also notes that the illegality of the market closes off formal dispute-resolution mechanisms like the courts, professional discipline, or reputation-damaging publicity, leaving arguments to be settled by force. While this may be the case, it seems a result of prohibition in itself; it does not explain why the vigour with which it is enforced would influence the extent of resort to force. Yet another possible mechanism is that if police really do focus on what in some countries is a huge illicit drug market, this would significantly detract from the focus on other crimes. Analysis of crime trends suggests this has been the case for property crime in Florida and Portugal; a similar effect may extend to violent crime. Another mechanism is that corruption generated by drug money undermines the effectiveness of enforcement and prevents the imposition of deterrent penalties. Stimulating a defensive 'arms race' is also a well known and counter-productive impact of intensified enforcement which might increase violence if (for example) market participants arm themselves and threaten potential witnesses and informers to avoid capture. Similarly, undercover tactics and the recruitment of informers could undermine trust between market participants and fracture the market in to tight antagonistic cliques which compete rather than cooperate.

Neither should we assume (and the review does not) that drug market participants resort easily and naturally to violence. A small study based on interviews with convicted drug traffickers and law enforcement personnel found this was generally not the case in Britain. As long as those who might countenance violence are making money from a well functioning market, "not only is there no need for violence ... it is to be positively avoided" because it risks police or internal market reactions which are "'bad for business'". The study did however agree that overt as opposed to implied or threatened violence might be a result of market dysfunction and instability. In so far as enforcement contributes to that kind of dysfunction and instability, and if there are no mitigating counter-measures, the effect may be tip the balance from violence being bad for business, to it being seen as a way to retain or incorporate bits of a fragmented market and to regain a kind of fraught stability.

Maybe it depends on the type of enforcement, not just the amount

Possibly the type of enforcement is critical to whether the result is a drug market of much the same size which simply becomes more violent, or a market which – along with related crime – has been sustainably suppressed. Indices of enforcement intensity (such as arrests and seizures) in the reviewed studies seem most likely to reflect traditional policing which reacts to drug markets with 'crackdowns', raids, undercover operations, saturation patrolling and/or stop-and-search policing. Generally these tactics on their own are ineffective, effective only in the short-term, or simply displace the market to other locations or other forms (1 2 3). For a discussion of the benefits and limitations of these approaches see these Findings notes.

But there are other and, from the research, more effective ways to counter illicit markets (1 2). These involve partnerships with community bodies and local people initiated on the basis of an analysis of the underlying problem and intended to alter the social and/or physical environment to make it more resistant to illicit drug markets. Tactics include persuading or forcing landlords to secure and maintain buildings used for drug transactions and to control their tenants, community policing which socially and physically integrates police with the neighbourhood, the mobilisation of local residents and businesses, changing the physical environment by for example eliminating hiding places and removing rubbish and abandoned vehicles, and offering routes out of the market through treatment and reintegration services.

Deploying these or similar tactics alongside conventional law enforcement may mitigate the risk of aggravating violence. Such tactics can also be used to 'secure the ground' cleared by enforcement crackdowns and saturation patrolling. Their impacts are more appropriately measured not in terms of numbers of arrests or seizures, but the improved quality of life of residents and decreased drug-related problems including violent crime. However, implementation involves a much more complex and failure-prone process than straightforward policing, one which requires both the willingness and ability of other groups and services to cooperate – for example, the ability of treatment services to rapidly absorb dependent users who decide to leave an increasingly difficult market.

Maybe it depends on the nature of the market too?

What the review does not (and given the nature of the evidence, may have been unable to) address is whether all types of illicit drug markets are equally likely to become more violent as law enforcement intensifies. For example, 'open' markets which do not rely on sellers and buyers being known to each other have been known to react by becoming more closed. Semi-open (pub- and club-based), closed, 'dealing house', social network and prison-based markets might also respond differently. The drug(s) being marketed may be associated with these different types of markets and different types of market players, so markets in for example, opiates, stimulants, 'dance drugs' or cannabis might also respond differently to enforcement pressure.

Thanks for their comments on this entry in draft to Tim McSweeney of the Institute for Criminal Policy Research at King's College, London, England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 31 March 2011

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