Treatment

(treatment - types) "Currently, pharmaceutical treatment for substance abuse addiction in the United States is limited to two basic types: (1) replacement therapy; and (2) aversion therapy.²¹ Replacement therapy is characterized by substituting or replacing the drug that the person is addicted to with a “safer drug” under the theory that the individual can be weaned off the replacement drug over time.²² The most prominent examples of this are methadone maintenance for heroin addiction and nicotine replacement drugs for smokers.²³ Unfortunately, there are no “safer drugs” available for individuals with addictions to cocaine, crack, or methamphetamine.²⁴"

"Aversion therapy, on the other hand, involves the use of drugs that interact negatively with the drug of addiction, such as disulfiram, which is used to treat alcoholism.²⁵ This treatment choice posits that the individual will be deterred from using the drug to which they are addicted because, when combined with aversion drugs, it induces nausea, vomiting, and physical pain.²⁶ The problems associated with these treatment methods, however, are numerous. Both require long-term treatment, which greatly increases the chance that an addict will quit treatment and return to using.²⁷ Replacement therapy simply replaces one drug with another, and, as is the case with methadone, the “safer drug” is itself addictive. ... The unpleasant side effects associated with aversion therapy, however, result in many patients stopping treatment and relapsing.³¹"

(treatment - polydrug users) "Nevertheless, managing the care of problem polydrug users requires long-term treatment planning with attention to individual needs and multidisciplinary teams working together with flexible and sometimes innovative treatment options."

(harm reduction) "Harm-reduction services for problematic drug users usually address the associated harms and risk behaviours, such as injecting, with a holistic approach that focuses on the nature and severity of the behaviours and problems experienced by the individual, rather than on a specific substance. Therefore, in response to the elevated health risks associated with problem drug use, including polydrug use, harm-reduction services are generally provided on a case-by-case basis and often according to professionals’ own work experience. Furthermore, harm-reduction interventions usually operate within a broader local prevention strategy that combines other types of services such as outreach work and opioid substitution treatment, which contribute to the reduction of risks and health problems experienced by problem polydrug users. Evidence of the effectiveness of harm-reduction interventions has been reported in other EMCDDA publications (EMCDDA, 2008a) and will be reviewed in a forthcoming monograph on harm reduction."

(treatment with prescription injectable opiates) "Prescribing injectable opiates is one of many options in a range of treatments for opiate-dependent drug users. In showing that it attracts and retains long term resistant opiate-dependent drug users in treatment and that it is associated with significant and sustained reductions in drug use and improvements in health and social status, our findings endorse the view that it is a feasible option."

(dependence among those who try drugs) "Some 4.3 percent of Americans have been dependent on marijuana, as defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision(DSM-IV-TR; American Psychiatric Association,2000), at some time in their lives. Marijuana produces dependence less readily than most other illicit drugs.Some 9 percent of those who try marijuana develop dependence compared to, for example, 15 percent of people who try cocaine and 24 percent of those who try heroin. However, because so many people use marijuana,cannabis dependence is twice as prevalent as dependence on any other illicit psychoactive substance (cocaine,1.8 percent; heroin, 0.7 percent; Anthony and Helzer,1991; Anthony, Warner, and Kessler, 1994)."

(history - heroin treatment) "In the early part of the 20th century, physicians faced with persons addicted to narcotic drugs prescribed heroin and morphine. In 1914 the Harrison Act was passed, and as a result addiction was viewed primarily as a criminal problem rather than a medical concern. The Harrison Act resulted in significant trepidation among physicians treating narcotic addicts. Treatment for addiction was essentially unavailable until 1935 when US Public Health Services started a hospital in Lexington, Ky. The treatments were entirely detoxification-based. Interest in narcotic management began to rise again with the 1955 publication of a position paper by the New York Academy of Medicine.²⁸ In 1963, the New York Academy of Sciences recommended that clinics be established to dispense narcotics to opioid-dependent patients.²⁸

"During the 1960s, heroin addiction was the leading cause of death in African American men in New York City.²⁹ In response to this growing epidemic, Vincent Dole, MD, and Marie Nyswander, MD, from the Rockefeller Institute, New York, pioneered the use of the synthetic opioid methadone for treating heroin addicts. They found oral morphine to be unsuccessful because patients alternated between feelings of intoxication and withdrawal. Methadone, because of its long half-life, could avert this problem if given once daily.³⁰The initial efforts of these two physicians guided development of the methadone maintenance treatment paradigm.³¹

"In 1972, the US Food and Drug Administration created stringent regulations governing methadone. This reduced the amount of flexibility for practitioners caring for opioid dependent patients. The 1974 Narcotic Treatment Act established guidelines that limited methadone to opioid addicts. States added their own rules, which further complicated care delivery. Some experts have suggested that the current system emphasizes regulatory process more than medical judgment.³² In part because of these restrictions,many heroin addicts had limited access to methadone maintenance, resulting in a significant treatment gap nationwide.

"The Office of National Drug Control Policy subsequently made changes in the 1995 Federal Regulations of Methadone Treatment to encourage the development of a less restrictive approach³³ and give physicians more latitude in prescribing methadone.³⁴ In 1997 a National Institutes of Health consensus conference published its support for methadone and recommended the medicalization of treatment.³⁵"

Treatment - Data

(2008 - 2010 - federal spending on substance abuse treatment) The US Office of National Drug Control Strategy estimated federal spending on substance abuse treatment and treatment research:

$3.566 billion in 2010 (requested)
$3.415 billion in 2009 (enacted)
$3.244 billion in 2008
$2.943 billion in 2007
$2.942 billion in 2006

(2008 - number receiving treatment for alcohol and illicit drugs) "In 2008, 4.0 million persons aged 12 or older (1.6 percent of the population) received treatment for a problem related to the use of alcohol or illicit drugs. Of these, 1.3 million received treatment for the use of both alcohol and illicit drugs, 0.8 million received treatment for the use of illicit drugs but not alcohol, and 1.6 million received treatment for the use of alcohol but not illicit drugs. (Note that estimates by substance do not sum to the total number of persons receiving treatment because the total includes persons who reported receiving treatment but did not report for which substance the treatment was received.)"

(2008 - where treatment received) "In 2008, among the 4.0 million persons aged 12 or older who received treatment for alcohol or illicit drug use in the past year, 2.2 million persons received treatment at a self-help group, and 1.5 million received treatment at a rehabilitation facility as an outpatient. There were 1.1 million persons who received treatment at a mental health center as an outpatient, 743,000 persons who received treatment at a rehabilitation facility as an inpatient, 675,000 at a hospital as an inpatient, 672,000 at a private doctor's office, 374,000 at an emergency room, and 343,000 at a prison or jail. None of these estimates changed significantly between 2007 and 2008 or between 2002 and 2008, except that the number of persons who received treatment at a rehabilitation facility as an inpatient in 2008 was lower than that in 2007 (1.0 million) and 2002 (1.1 million)."

(2007 - treatment admissions by substance) "Five primary substances of abuse accounted for 96 percent of all substance abuse treatment admissions in 2007: alcohol, opiates (including heroin and prescription painkillers), marijuana, cocaine, and methamphetamine. Criminal justice system referral admissions were more likely than all other referral admissions to report primary alcohol abuse, primary marijuana abuse, and primary methamphetamine abuse and less likely to report primary opiate abuse. The high rate of criminal justice system referral admissions younger than 18 years old may have contributed significantly to the high rate of admissions with marijuana as a primary substance of abuse."

(2007 - criminal justice system treatment referrals) "In 2007, the criminal justice system was the largest single source of referrals to the substance abuse treatment system, comprising 37 percent of all admissions in the Treatment Episode Data Set (TEDS) (approximately 670,500 of the 1.8 million admissions). Moreover, the majority of these referrals were from parole and probation offices (44 percent of criminal justice admissions where detailed criminal justice source information is known)."

(2009 - marijuana - treatment admissions by the criminal justice system) "Primary marijuana admissions were less likely than all admissions combined to be self- or individually referred to treatment (15 percent vs. 33 percent)"

Editor's Note: Criminal justice treatment admissions for 2009 equaled 56.2% of all treatment admissions for which marijuana was the primary substance of abuse. Of these marijuana treatment admissions by the criminal justice system, 47.5% came from probation/parole.

(2006 - marijuana - treatment admissions by the criminal justice system) "More than half (58 percent) of primary marijuana admissions were referred to treatment through the criminal justice system."

(2006 - alcohol - admissions to substance abuse treatment) "Nearly half (49 percent) of alcohol-only treatment admissions report-ing daily use were referred to treatment by themselves, a family member, or a friend; over half (55 percent) of alcohol-only treatment admissions reporting less than daily use were referred to treatment by the criminal justice system."

(2005-06 - returns to drug treatment) "Examination of all clients exiting [drug treatment] in 2005-06 revealed that 46% didn’t return to drug treatment nor had a drug related contact with the CJS [criminal justice system] in the following four years. This would suggest the majority of these individuals are managing to sustain their recovery from addiction ... "

(2005 - crime - treatment and crime rates) "Increases in admissions to substance abuse treatment are associated with reductions in crime rates. Admissions to drug treatment increased 37.4 percent and federal spending on drug treatment increased 14.6 percent from 1995 to 2005. During the same period, violent crime fell 31.5 percent. Maryland experienced decreases in crime when jurisdictions increased the number of people sent to drug treatment."

(2005 - those needing treatment, but not receiving it) "In 2005, the number of persons aged 12 or older needing treatment for an illicit drug or alcohol use problem was 23.2 million (9.5 percent of the population aged 12 or older) (Figure 7.6). Of these, 2.3 million (0.9 percent of persons aged 12 or older and 10.0 percent of those who needed treatment) received treatment at a specialty facility. Thus, there were 20.9 million persons (8.6 percent of the population aged 12 or older) who needed treatment for an illicit drug or alcohol use problem but did not receive treatment at a specialty substance abuse facility in the past year."

(2005 - number of substance dependent persons in the U.S.) "In 2005, an estimated 22.2 million persons aged 12 or older were classified with substance dependence or abuse in the past year (9.1 percent of the population aged 12 or older) (Figure 7.1). Of these, 3.3 million were classified with dependence on or abuse of both alcohol and illicit drugs, 3.6 million were dependent on or abused illicit drugs but not alcohol, and 15.4 million were dependent on or abused alcohol but not illicit drugs.

"Between 2002 and 2005, there was no change in the number of persons with substance dependence or abuse (22.0 million in 2002, 21.6 million in 2003, 22.5 million in 2004, and 22.2 million in 2005). "There were 18.7 million persons aged 12 or older classified with dependence on or abuse of alcohol in 2005 (7.7 percent). This estimate has remained stable since 2002."

(2004 - substance abuse treatment in prison) "In 2004, about 642,000 State prisoners were drug dependent or abusing in the year before their admission to prison. An estimated 258,900 of these inmates (or 40%) had taken part in some type of drug abuse program (table 10). These inmates were more than twice as likely to report participation in selfhelp or peer counseling groups and education programs (35%) than to receive drug treatment from a trained professional (15%).

"In Federal prison, a higher percentage of drug dependent or abusing inmates (49%) reported taking part in some type of drug abuse programs. Nearly 1 in 3 took part in drug abuse education classes, and 1 in 5 had participated in self-help or peer counseling groups. Overall, 17% took part in drug treatment programs with a trained professional, and 41% had participated in other drug abuse programs."

(2004 - substance abuse treatment in prison) "The percentage of recent drug users in State prison who reported participation in a variety of drug abuse programs rose from 34% in 1997 to 39% in 2004 (table 9). This increase was the result of the growing percentage of recent drug users who reported taking part in self-help groups, peer counseling and drug abuse education programs (up from 28% to 34%). Over the same period, the percentage of recent drug users taking part in drug treatment programs with a trained professional was almost unchanged (15% in 1997, 14% in 2004).

"Participation in drug abuse programs also increased among Federal inmates who had used drugs in the month before their offense, from 39% in 1997 to 45% in 2004. While there was no change in percentage of these inmates who had undergone drug treatment with a trained professional (15% in both years), the percentage taking part in other drug abuse programs rose from 32% in 1997 to 39% in 2004."

(2003 - insurance coverage for addiction treatment) "In contrast to other chronic diseases, funding for addiction treatment disproportionately comes from government sources. More than three quarters—77 percent—of treatment costs are paid by federal, state and local governments, including Medicaid and Medicare.

"Private insurance covers only 10 percent of addiction treatment costs, with out-of-pocket expenditures and other private funding making up the remaining percentage. In contrast, private insurance pays for approximately 37 percent of general medical costs. The passage of federal parity and health care reform legislation should help address this imbalance in the future.

On an individual level, nearly half of those receiving treatment reported using their own money to pay for their care, and 34.8 percent report using private health insurance."

(2003 - spending on drug and alcohol treatment) "In 2003, an estimated $21 billion was spent on drug and alcohol addiction treatment. This represents 1.3 percent of all health care spending for that year."

(2001 - state spending on substance abuse treatment) "States report spending $2.5 billion a year on treatment. States did not distinguish whether the treatment was for alcohol, illicit drug abuse or nicotine addiction. Of the $2.5 billion total, $695 million is spent through the departments of health and $633 million through the state substance abuse agencies. We believe that virtually all of these funds are spent on alcohol and illegal drug treatment."

(1999 - number of people needing substance abuse treatment) "According to the ONDCP's 1999 National Drug Control Strategy, there are approximately 4 million chronic drug users in the United States. This closely aligns with the 1998 National Household Survey on Drug Abuse, which found that 4.1 million people were in need of drug treatment. The NIAAA report, Improving the Delivery of Alcohol Treatment and Prevention Services, estimates there are 14 million alcohol abusers, whereas the 1998 National Household Survey on Drug Abuse finds approximately 9.7 million people in need of alcohol treatment. Regardless of the source, a conservative estimate of those in need of substance abuse treatment is between 13 and 16 million people. In contrast, both the 1997 Institute of Medicine (IOM) report, Managing Managed Care, and the 1998 National Household Survey conclude that approximately 3 million people receive care for alcohol or drugs in one year. Although, as previously stated, neither the estimates of need nor the estimates of those in treatment are all inclusive, the picture remains the same - more than 10 million people who need treatment each year are not receiving it."

(1998 - expenditures on treatment) "The justice system spends $433 million on treatment: $149 million for state prison inmates; $103 million for those on probation and parole; $133 million for juvenile offenders; $46 million to help localities treat offenders; $1 million on drug courts. Treatment provided by mental health institutions for co-morbid patients totals $241 million. The remaining $492 million is for the substance abuse portion of state employee assistance programs ($97 million), treatment programs for adults involved in child welfare services ($4.5 million) and capital spending for the construction of treatment facilities ($391 million)."

(1996 - return on investment for prisoner substance abuse treatment) "The cost of proven treatment for inmates, accompanied by appropriate education, job training and health care, would average about $6,500 per year. For each inmate who successfully completes such treatment and becomes a taxpaying, law-abiding citizen, the annual economic benefit to society--in terms of avoided incarceration and health care costs, salary earned, taxes paid and contribution to the economy--is $68,800, a tenfold return on investment in the first year. If a year of such comprehensive treatment turns around only ten percent of those who receive it, it will pay for itself within the next year. Even with the difficult inmate population, success rates are likely to reach at least 15 percent of those who receive such treatment and training."

(1994 - cost of treatment vs. cost of incarceration) "Treatment appears to be cost effective, particularly when compared to incarceration, which is often the alternative. Treatment costs ranged from a low of about $1,800 per client to a high of approximately $6,800 per client. While the cost of incarceration was not examined by NTIES, widely reported studies such as one reported by the American Correctional Association, gave an estimated 1994 cost of incarceration as $18,330 annually."

(1993 - insurance coverage for substance abuse treatment) "One of the main reasons for the higher outlay in public spending is the frequently limited coverage of substance abuse treatment by private insurers. Although 70 percent of drug users are employed and most have private health insurance, 20 percent of public treatment funds were spent on people with private health insurance in 1993, due to limitations on their policy (ONDCP, 1996b). In the view of the Panel, private insurers should serve as the primary source of coverage, with public insurance serving as the safety net."

(1993 - arrest rates after substance abuse treatment) "The results show substantial, and statistically significant, reductions in both criminal behavior and arrests after treatment, with a somewhat smaller decrease in the percentage of clients mostly supported through illegal activities.

"Changes in arrest rates were in the range of changes in drug and alcohol use discussed above; the percentage of clients arrested for drug possession declined by 51 percent while the percentage arrested for any charge declined by 64 percent. Changes in criminal behavior were larger, between seventy and ninety percent."

(1992 - cost effectiveness of treatment vs. other drug control strategies) The RAND Corporation found that the additional spending needed to achieve a 1% reduction in the number of cocaine users varies according to the sort of program used, and that treatment is the most cost-effective:

(1992 - economics - United States - costs reductions and savings from treatment) A study by the RAND Corporation found, "the savings of treatment programs are larger than the control costs; we estimate that the costs of crime and lost productivity are reduced by $7.46 for every dollar spend on treatment."

(1992) "An additional cocaine-control dollar generates societal cost savings of 15 cents if used for source-country control, 32 cents if used for interdiction, and 52 cents if used for domestic enforcement. In contrast, the savings from treatment programs are larger than control costs: an additional cocaine-control dollar generates societal cost savings of $7.48 if used for treatment."

(2006 - prisons & drug offenders - state - treatment as part of a drug sentence) "In 2006 an estimated 38% of persons sentenced for a felony in state courts were ordered to pay a fine as part of their sentence (table 1.5). Approximately 1 in 4 property offenders was ordered to make restitution and 23% of offenders convicted of drug possession were sentenced to treatment."

(2005 - prisons & drug offenders - state - drug treatment and reduced incarceration rates) "Increased admissions to drug treatment are associated with reduced incarceration rates. States with a higher drug treatment admission rate than the national average send, on average, 100 fewer people to prison per 100,000 in the population than states that have lower than average drug treatment admissions. Of the 20 states that admit the most people to treatment per 100,000, 19 had incarceration rates below the national average. Of the 20 states that admitted the fewest people to treatment per 100,000, eight had incarceration rates above the national average."

(2001 - economics - state & local - cost effectiveness of substance abuse treatment) "Substance abuse treatment is more cost-effective than prison or other punitive measures. The Washington State Institute for Public Policy (WSIPP) found that drug treatment conducted within the community is extremely beneficial in terms of cost, especially compared to prison. Every dollar spent on drug treatment in the community is estimated to return $18.52 in benefits to society."

(1998 - economics - state & local - state spending on substance abuse treatment) "States report spending $2.5 billion a year on treatment. States did not distinguish whether the treatment was for alcohol, illicit drug abuse or nicotine addiction. Of the $2.5 billion total, $695 million is spent through the departments of health and $633 million through the state substance abuse agencies. We believe that virtually all of these funds are spent on alcohol and illegal drug treatment."

(1992 - economics - state & local - cost of substance abuse treatment vs. enforcement) "Domestic enforcement costs 4 times as much as treatment for a given amount of user reduction, 7 times as much for consumption reduction, and 15 times as much for societal cost reduction."

Heroin Maintenance - Law and Policy

(law - heroin maintenance) "Many countries believe (erroneously) that the international drug conventions prohibit the use of heroin in medical treatment. Furthermore, the International Narcotics Control Board (INCB) has exerted great pressure on countries to cease prescribing heroin for any medical purpose. Nevertheless, a few countries, including the UK, Belgium, the Netherlands, Iceland, Malta, Canada and Switzerland, continue to use heroin (diamorphine) for general medical purposes, mostly in hospital settings (usually for severe pain relief). Until recently, however, Britain was the only country that allowed doctors to prescribe heroin for the treatment of drug dependence."

Treatment - Research

(addiction and treatment as a public health, not criminal justice problem) "The Panel anxiously awaits the time when the disease of addiction is no longer treated as a criminal justice issue, but as a public health problem. Moreover, the Panel embraces the notion of a society that enables any individual with a substance abuse problem, regardless of criminal history, to receive treatment in a safe and respectful environment. The Panel hopes to create a climate in which people who are at risk for, suffering from, or in recovery from alcohol or other drug addiction are valued and treated with dignity."

(inadequate funding for substance abuse treatment) "Despite the many factors that contribute to the gap, the Panel agrees with many in the field that inadequate funding for substance abuse treatment is a major part of the problem. Over the last decade, spending on substance abuse prevention and treatment has increased, albeit more slowly than overall health spending, to an estimated annual total of $12.6 billion in 1996 (McKusick, Mark, King, Harwood, Buck, Dilonardo, and Genuardi, 1998). Of this amount, public spending is estimated at $7.6 billion (McKusick, et al., 1998). The public spending includes dollars from Medicaid and Medicare, as well as other Federal funds from the Department of Defense, the Department of Veterans Administration, the Department of Justice, and the Substance Abuse Prevention and Treatment (SAPT) Block Grant. The SAPT Block Grant provides Federal support to addiction prevention and treatment services nationally through State and local governments. Private spending includes individual out-of-pocket payment, insurance, and other nonpublic sources, and is estimated at $4.7 billion (McKusick, et al., 1998)."

(marijuana - regular adolescent use) In an ethnographic study of adolescents who were regular marijuana users, researchers at the University of British Columbia, concluded,

"Thematic analysis revealed that these teens differentiated themselves from recreational users and positioned their use of marijuana for relief by emphasizing their inability to find other ways to deal with their health problems, the sophisticated ways in which they titrated their intake, and the benefits that they experienced. These teens used marijuana to gain relief from difficult feelings (including depression, anxiety and stress), sleep difficulties, problems with concentration and physical pain. Most were not overly concerned about the risks associated with using marijuana, maintaining that their use of marijuana was not 'in excess' and that their use fit into the realm of 'normal.'

Conclusion: Marijuana is perceived by some teens to be the only available alternative for teens experiencing difficult health problems when medical treatments have failed or when they lack access to appropriate health care."

(heroin vs. methadone maintenance) "The German model project for heroin-assisted treatment of opioid dependent patients is so far the largest randomised control group study that investigated the effects of heroin treatment. This fact alone lends particular importance to the results in the (meanwhile worldwide) discussion of effects and benefits of heroin treatment. For the group of so-called most severely dependent patients, heroin treatment proves to be superior to the goals of methadone maintenance based on pharmacological maintenance treatment. This result should not be left without consequences. In accordance with the research results from other countries, it has to be investigated to what extent heroin-assisted treatment can be integrated into the regular treatment offers for severely ill i.v. opioid addicts."

(medical cannabis - drug substitution) "Eighty five percent of the BPG [Berkeley Patients Group] sample reported that cannabis has much less adverse side effects than their prescription medications. Additionally, the top two reasons listed by participants as reasons for substituting cannabis for one of the substances previously mentioned were less adverse side effects from cannabis (65%) and better symptom management from cannabis (57.4%).

"Conclusion
"The substitution of one psychoactive substance for another with the goal of reducing negative outcomes can be included within the framework of harm reduction. Medical cannabis patients have been engaging in substitution by using cannabis as an alternative to alcohol, prescription and illicit drugs."

(stigma of drug and alcohol problems) "Changing The Conversation initiated the first intensive exploration of the stigmas and attitudes that affect people with alcohol and drug problems. The Panel addressed stigma as a powerful, shame-based mark of disgrace and reproach that impedes treatment and recovery. Prejudicial attitudes and beliefs generate and perpetuate stigma; therefore, people suffering from alcohol and/or drug problems and those in recovery are often ostracized, discriminated against, and deprived of basic human rights. Their families, treatment providers, and even researchers may face comparable stigmas and attitudes. Ironically, stigmatized individuals often endorse the attitudes and practices that stigmatize them. They may internalize this thinking and behavior, which consequently becomes part of their identity and sense of self-worth.

"Public support and public policy are influenced by addiction stigma. Addiction stigma delays acknowledging the disease and inhibits prevention, care, treatment, and research. It diminishes the life opportunities of the stigmatized."

(marijuana dependency treatment with THC) "Only orally given THC and, to a lesser extent, nefazodone have shown promise [in treating marijuana dependence]. THC reduced craving and ratings of anxiety, feelings of misery, difficulty sleeping, and chills (Haney et al., 2004). In addition, participants could not distinguish active THC from placebo. These findings were replicated in an outpatient study, which found that a moderate oral dosage of THC (10 mg, three times daily) suppressed many marijuana withdrawal symptoms and that a higher dosage (30 mg, three times daily) almost completely abolished withdrawal symptoms (Budney et al., 2007)."

(heroin assisted treatment) "A few key conclusions and discussion points regarding the state and future of HAT (heroin-assisted treatment) can be offered based on the above review of completed or ongoing studies.

"First, although the basic goal of the different HAT studies is similar, each of the studies is distinct in key aspects, thus limiting direct comparisons and meta-analyses. ...⁴⁰

"Second, the discussed studies above have demonstrated in several different contexts that the implementation of HAT is feasible, effective, and safe as a therapeutic intervention. ...^21,24,26,30

"Third, even within the contexts of relevant methodological constraints, e.g., the Swiss study relying purely on prospective observational data, and most of the other RCTs comparing HAT outcomes against a control intervention (MMT), which participants have previously either rejected by choice or proven to be ineffective, ^32,42 the reviewed HAT studies have demonstrated rather robust and consistently positive therapeutic outcomes on the various indicators chosen for a population of high-risk heroin addicts for whom currently no effective alternative therapies are available. ...

"Fourth, also given the current expansion and diversification of alternative oral opioid maintenance therapies (e.g., buprenorphine and morphine) and considering the complex logistics (on both providers and patients_ ends), high costs, and sociopolitical controversy around (especially injection) HAT, the most sensible role of HAT is likely that of an exceptional 'last resort' option for heroin addicts who cannot be effectively attracted into or treated in other available therapeutic interventions.^44,45

"Finally, after extensive HAT research efforts over the past decade, the principal onus of action has shifted from the scientific to the political arena in the jurisdictions under study.^12,18 Despite the overall positive results of completed HAT trials undoubtedly justifying some role of HAT in the addiction treatment landscape, authorities in only two countries, Switzerland and the Netherlands, have decisively acted on this issue.³⁴

(heroin maintenance in Switzerland) "Heroin misuse in Switzerland was characterised by a substantial decline in heroin incidence and by heroin users entering substitution treatment after a short time, but with a low cessation rate. There are different explanations for the sharp decline in incidence of problematic heroin use. According to Ditton and Frischer, such a steep decline in incidence of heroin use is caused by the quick slow down of the number of non-using friends who are prepared to become users in friendship chains. Musto's generational theory regards the decline in incidence more as a social learning effect whereby the next generation will not use heroin because they have seen the former generation go from pleasant early experiences to devastating circumstances for addicts, families, and communities later on."

(Swiss heroin prescription program) "With respect to the group of those treated uninterruptedly during four years, a strong decrease in the incidence and prevalence rates of overall criminal implication for both intense and moderate offenders was found. As to the type of offense, similar diminutions were observed for all types of offenses related to the use or acquisition of drugs. Not surprisingly, the most pronounced drop was found for use/possession of heroin. In accordance with self-reported and clinical data (Blaettler, Dobler-Mikola, Steffen, & Uchtenhagen, 2002; Uchtenhagen et al., 1999), the analysis of police records suggests that program participants also tend strongly to reduce cocaine and cannabis use probably because program participants dramatically reduced their contacts with the drug scene when entering the program (Uchtenhagen et al., 1999) and were thus less exposed to opportunities to buy drugs. Consequently, their need for money is not only reduced with regard to heroin but also to other substances. Accordingly, the drop in acquisitive crime, such as drug selling or property crime, is also remarkable and related to all kinds of thefts like shoplifting, vehicle theft, burglary, etc. Detailed analyses indicated that the drop found is related to a true diminution in criminal activity rather than a more lenient recording practice of police officers towards program participants.

"On average, males had higher overall rates than females in the pretreatment period. However, no marked gender differences were found with regard to in-treatment rates. Taken as a whole, this suggests that the treatment had a somewhat more beneficial effect on men than women. This result is corroborated by self-report data (Killias et al., 2002). With respect to age and cocaine use, no relevant in-treatment differences were observed. As to program dropout, after one year, about a quarter of the patients had left the program, and after four years, about 50% had left. Considering the high-risk profile of the treated addicts, this retention rate is, at least, promising."

(Swiss heroin prescription program) "Finally, the analysis of the reasons for interrupting treatment revealed that, even in the group of those treated for less than one year, the majority did not actually drop out of the program but rather changed the type of treatment, mostly either methadone maintenance or abstinence treatment. Knowing that methadone maintenance treatment – and a fortiori abstinence treatment – is able to substantially reduce acquisitive crime, the redirection of heroin maintenance patients toward alternative treatments is probably the main cause for the ongoing reduction or at least stabilization of criminal involvement of most patients after treatment interruption. Thus the principal post-treatment benefit of heroin maintenance seems to be its ability to redirect even briefly treated high-risk patients towards alternative treatments rather than back 'on the street'."