101

Miscellaneous
Can treatment reduce national drug problems?
Peter Reuter & Harold Pollack

HORIZONS REVIEW SERIES doi:10.1111/j.1360-0443.2005.01313.x

How much can treatment reduce national drug

problems?
Peter Reuter1 & Harold Pollack2
School of Public Policy, University of Maryland and the RAND Corporation, CA, USA1 and School of Social Service Administration, University of Chicago, IL, USA2

ABSTRACT

Aims Treatment of drug addiction has been the subject of substantial research and, in contrast to several other meth-
ods of reducing drug use, has been found to be both effective and cost-effective. This review considers what is known
about how much a nation can reduce its drug problems through treatment alone and what is known at the aggregate
level about the effectiveness of prevention and enforcement. Methods The literature on the effectiveness of treat-
ment, prevention and enforcement are reviewed, and set in a policy analytical framework. Findings Many studies
have found treatment to have large effects on individuals’ consumption and harms. However, there is an absence of evi-
dence that even relatively well-funded treatment systems have much reduced the number of people in a nation who
engage in problematic drug use. For prevention, the scientific literature shows useful and modest effects at the indi-
vidual level but there is little support for substantial aggregate effects. For enforcement, research has failed almost uni-
formly to show that intensified policing or sanctions have reduced either drug prevalence or drug-related harm. Nor—
outside the UK—is there more than a modest effort to improve the evidence base for making decisions about the appro-
priate level of enforcement of drug prohibitions. Conclusions Treatment can justify itself in terms of reductions in
harms to individuals and communities. However, even treatment systems that offer generous access to good quality
services will leave a nation with substantial drug problem. Finding effective complementary programs remains a major
challenge.

Keywords Drug policy, enforcement, harm reduction, prevalance, prevention, treatment.

Correspondence to: Peter Reuter, School of Public Policy and Department of Criminology, University of Maryland, College Park, MD, USA.
E-mail: preuter@umd.edu
Submitted 27 February 2005; initial review completed 5 May 2005; final version accepted 25 July 2005

HORIZONS REVIEW SERIES

INTRODUCTION
The mantra of the drug treatment community is that
‘treatment works’. At least in the United States, that
mantra is chanted in necessary defense of beleaguered
programs that do not receive the public support, funding
or policy attention that they deserve. Yet the treatment
enterprise is inherently frail. For most patients, treatment
is a difficult process that includes significant disappoint-
ments. It does not fully, or immediately, or comprehen-
sively ‘work’ in the way patients, clinicians or society
hope that it would. These frailties can distract from the
great individual and social benefits treatment provides.
Starting from the strong empirical research base that
treatment does indeed bring major social as well as indi-
vidual benefits, this essay addresses two broad questions.
First, how much can treatment contribute to reduction
of a nation’s drug problems? Secondly, what, beyond
treatment, are necessary and appropriate programmatic
interventions?
Our conclusions are readily summarized. The argu-
ment for treatment expansion is strong. However, treat-
ment has key limitations in controlling a nation’s drug
problems. No nation has succeeded in treating its way
out of a major cocaine or heroin problem. Treatment can
substantially reduce the health burden of drug abuse,
related crime and the quantity of drugs consumed. It can
make only relatively modest reductions in the number of
men and women who misuse drugs, or who have ongo-
ing abuse or dependence disorders. Even with a well-
funded treatment sector, a nation will still face chronic
problems of disease, addiction, crime and disorder asso-
ciated with illegal drugs. Advocates for primary preven-
tion and criminal justice interventions—the two main
alternatives—are handicapped by a dearth of empirical
evidence to provide guidance as to how much such pro-

© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction Addiction, 101, 341–347
342 Peter Reuter & Harold Pollack
grams can contribute to reducing drug problems. The
available evidence suggests that each can, on its own,
make only a modest contribution, and it is not clear that
there are synergies between them. On the other hand,
improving the links between enforcement and treatment
is essential for either intervention to achieve its stated
goals.
TREATMENT’S ACCOMPLISHMENTS
A large literature shows that treatment can reduce an
individual patient’s drug use, that treatment is associated
with improved health and employment outcomes and
that treatment can reduce the risk of serious harms
including overdose, crime and HIV infection (e.g. Metzger
et al. 1993; National Consensus Development Panel on
Effective Medical Treatment of Opiate Addiction 1998;
IOM 2000; Stewart et al. 2002). Documented gains
appear most striking in the treatment of opiate use
disorders.
The benefits of treatment have many dimensions that
affect both the individual and the wider community.
Crime reduction provides the most conspicuous, some-
times the dominant, benefit in economic policy analyses
of treatment interventions (Cartwright 1998; Flynn et al.
2003; Godfrey et al. 2004;). Much of the estimated ben-
efit of substance abuse treatment arises from the minority
of patients who (before treatment) commit serious
offenses. The social benefits of crime reduction are much
smaller for the median client, and are smaller for mari-
juana than for other substances which are more corre-
lated with felony offending.
Crime reduction provides important benefits for drug-
users as well. Continued offending exposes users to the
risk of incarceration and criminal victimization, as well
as lost short-term and long-term opportunities for legiti-
mate employment.
Treatment for heroin and cocaine use reduces
demand for these substances. Treatment may also bring
significant supply side effects. Drug-users comprise a
large share of all cocaine and heroin retailers. For exam-
ple, Reuter, MacCoun & Murphy (1990) found that 71%
of a sample of drug sellers active in Washington, DC in
1988, selling mainly cocaine and heroin, had consumed
an illegal drug other than marijuana in the previous 3
months. In Britain, one-third of the National Treatment
Outcome Research Study (NTORS) respondents reported
that they had sold drugs in the 3 months prior to treat-
ment (Gossop et al. 1999). In NTORS, the number of drug
selling offenses after 1 year in treatment was only 13% of
the entry level (Gossop et al. 2003). If broad treatment
provision appreciably shrinks the pool of users willing to
work in the drug trade, it is possible that treatment can
have substantial favorable supply side effects, without the
© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction
large personal and social costs that come with incarcer-
ating non-violent drug offenders. No study of this effect is
available.
Treatment reduces offending rates through several
pathways. Treatment lessens the risk of intoxication-
related crimes. Clients may have less urgent needs for
money and drugs, and consequently less willingness to
take immediate risks. Patients who seek to curb their
drug use are motivated to distance themselves from the
subculture of users and sellers. Treatment may also bring
or reflect increased monitoring or an increase in the per-
ceived penalties associated with drug-selling. Finally, by
shrinking the market, treatment increases the probability
that any individual dealer will be arrested, given a con-
stant level of enforcement resources (Kleiman 1993); this
may raise prices and induce greater caution by sellers.
THE LIMITS
Having noted the breadth of benefits from treatment, it is
time to note the corresponding limits. Most fundamen-
tally, is it possible for a nation to treat its way out of a drug
problem? Assume that a treatment system had the
resources needed to provide adequate services for all who
seek care and that no new users initiated. What would be
left as a drug problem, and what could be done to deal
with that residue?
An informal scan (all that is possible at present) sug-
gests that no democratic nation with a major opiate prob-
lem has managed to cut the number of regular users
sharply within a decade, even when a large proportion of
the eligible individuals are served by treatment services.
Consider the Netherlands, committed to the provision of
treatment for anyone in need. It provided treatment to an
average of 15 000 heroin users annually throughout the
1990s, about 50% of the heroin-dependent population.
Yet in 2001 the estimated number of heroin-dependent
persons was 28–30 000—essentially unchanged from
the 1993 estimate. This is not mere statistical artifact
from the inclusion of some of those in treatment; many
patients remain active heroin users (National Drug Mon-
itor 2003). Similar statements may hold for Australia and
Switzerland, two other countries committed to a gener-
ous supply of decent quality treatment services.
Nor does this stability of numbers in the Netherlands
represent the consequence of high initiation canceling
out the effects of high treatment success. Data on treat-
ment clients suggested that very few of those dependent
on heroin in 1999 had started use during the preceding
decade. In 1989 the median age of those in treatment in
Amsterdam was 32; in 2002 the median age was 43.
(National Drug Monitor 2003). Many other western
nations also experienced an ageing of the heroin-
dependent population during the 1990s.
Addiction, 101, 341–347

We would welcome disproof of our rather pessimistic
argument. Recent suggestive findings from France
(Emmanuelli & Desenclos 2005) suggest that expansion
of treatment and harm reduction services have reduced
overdose mortality and HIV behavioral risks, and have
also reduced heroin-related arrests. Such welcome
results highlight the possibility that interventions can
reduce social harm. Whether such interventions reduce
the number of dependent heroin users is less clear. The
overall pattern from wealthy democracies suggests rea-
sons for doubt.
Is this surprising? Treatment is generally acknowl-
edged to be useful, frail and incomplete. Viewed at the
population level, treatment is cost-effective and perhaps
cost-saving. Viewed at the client level, treatment reduces
but rarely fully halts problem alcohol use or the use of
illicit drugs. Most clients are imperfectly adherent to
‘good’ programs. Many or most clients will continue their
use at some level after treatment is completed.
The NTORS study illustrated both the benefits and
limitations of treatment intervention. Treatment induced
large declines in heroin use and in the use of non-
prescribed methadone and benzodiazepines. Rates of
acquisitive crime and drug-selling also declined by large
margins.
Treatment was markedly less effective in other
domains. Even 5 years later, most respondents continued
to report some recent use of at least one target substance.
Among methadone patients, 61% reported recent heroin
use. Only 26% reported that they had not recently used
any of the examined target drugs. Among residential
treatment clients, 51% reported recent heroin use and
only 38% reported no recent use of any target drug. Com-
pared with results for opiates, treatment proved less effec-
tive in reducing crack cocaine use. Many clients left
treatment within 3 months. Similar results are reported
in the drug abuse treatment outcome studies (DATOS)
(Hubbard et al. 2003).
McLellan (2002) cites a chronic disease model to
argue persuasively that post-treatment relapses are pre-
dictable. These relapses do not undermine the value of
treatment but do indicate the limits.
What else is necessary?
It is reasonable, then, to project that a substantial
drug problem would remain, even if the state were
willing to provide high-quality treatment on request to
any drug user. One way of framing this question is to
ask how much treatment reduces life-time consump-
tion by the average entering client, and how soon after
becoming aggregate dependent users enter into treat-
ment. To assert that dependent heroin use could be
reduced by half within 5 years appears to us as
optimistic.
© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction
Can treatment reduce national drug problems? 343
PREVENTION
Treatment, by definition, helps only those who are
already experienced users. The most effective treatment
policy will not do much to reduce the total number of
users. Even the generous official definition of the
treatment-eligible population in the United States
accounts for less than 25% of those who used drugs in the
last year (Boyum & Reuter 2005, pp. 62–65). Treatment
offers only indirect support, through supply and epidemi-
ological pathways, in reducing initiation.
For primary prevention the research base is scientifi-
cally impressive (see review in Manski, Pepper & Petrie
2001) but programmatically barren. Surprisingly little is
known about the effectiveness of prevention programs as
implemented. There is no counterpart to the series of
observational treatment studies in the United States
(Drug Abuse Research Program (DARP)/Treatment Out-
come Prospective Study (TOPS)/DATOS) or NTORS in the
United Kingdom. Research has been dominated by
school-based programs, which are studied more readily
than those in less controlled settings. The gap between
best-practice and typical interventions is large; many
school-based prevention interventions are poorly imple-
mented. (Gottfredson & Gottfredson 2002). Schools that
serve high-risk children face challenges that are likely to
diminish further the quality of implementation (Gottfred-
son 2001). It has also been suggested (e.g. Manski, Pep-
per & Petrie 2001) that school prevention may be less a
specific program than the creation of an atmosphere and
expectations.
The other frailty of the prevention literature is that
many of the best studies measure short-term outcomes
for programs implemented in 5th to 8th grades (typically
ages 10–14 years) and are focused on marijuana, the ille-
gal drug first used by youth. Less is known about the
effects of prevention on use of cocaine, heroin or meth-
amphetamine. There is only a presumption, eminently
questionable, that the reductions in marijuana use will
generate comparable reductions in use of these more
damaging drugs. Caulkins et al. (1999) find that even full
implementation of the most promising school-based pre-
vention program would reduce future cocaine consump-
tion in the United States only by 2–11%.
Given the limitations and constrained supply of treat-
ment services, it is striking that the prevention literature
places such emphasis on primary prevention, with less
systematic discussion of secondary and tertiary preven-
tion for both in-treatment and out-of-treatment drug
users. Treatment providers and researchers have noted
the chronic, relapsing nature of substance use disorders.
For this reason, harm reduction—by which we mean
interventions to help people to more safely consume drugs
if and when they continue to use—becomes an integral
Addiction, 101, 341–347
344 Peter Reuter & Harold Pollack
part of any prevention program. If treatment clients are
imperfectly adherent, if many or most will experience epi-
sodes of post-treatment relapse, then the proper boundary
between treatment and prevention services and between
treatment and harm reduction becomes more permeable
than either treatment professionals or harm reduction
advocates often assume. Although abstinence is the right
ultimate goal, treatment providers face a key challenge to
provide appropriate services to clients at varying stages of
recovery, within a life-cycle of episodic or recurring drug
use. At the same time, harm reduction interventions
merit careful inclusion within a continuum of care, so
that clients of syringe exchange or other services are
brought into contact with more intensive interventions
which address a broad range of individual and social risk.
A remarkable study by Strang et al. (2003) under-
scores the need for secondary and tertiary prevention in
treatment services. Detoxification is a precursor to treat-
ment. It is not, by itself, an accepted modality of care.
However, detoxification creates particular risks by lower-
ing drug tolerances. Examining the experiences of 137
opiate clients receiving detoxification and subsequent in-
patient services, Strang et al. classified 37 clients as hav-
ing ‘lost tolerance’ after completing detoxification and
subsequent in-patient services. Among the remaining cli-
ents who failed to complete the program, 43 were classi-
fied as ‘still tolerant’ because they failed to detoxify; while
57 were classified as ‘reduced tolerance’ because they
failed to complete in-patient treatment. Treatment com-
pleters experienced markedly higher mortality rates than
were observed in the other two groups. Within 4 months,
three of the 37 ‘lost tolerance’ clients had died from over-
dose. None of the ‘still tolerant’ or ‘reduced tolerance’ cli-
ents experienced a fatal overdose over the same period.
Our point is not to disparage treatment interventions,
but to note that clients encounter predictable threats to
well-being at different points in their drug-using careers.
The above findings highlight the importance of preven-
tion education, currently provided in many programs, to
warn clients about post-treatment overdose risks. Clients
also require services such as hepatitis B vaccination and
basic medical services that are sometimes, but not
always, provided within treatment settings. (IOM 2000)
ENFORCEMENT
Even compared to treatment and prevention, enforcement
is a heterogeneous category of interventions, ranging
from efforts to eradicate poppy-growing in Afghanistan to
street sweeps against buyers outside the Frankfurt train
station. Two general characteristics of these interventions
are (1) a near-total absence of impact or outcome evalu-
ation and (2) a near-total absence of public and policy-
maker demands that such evaluations be performed.
© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction
There is, at present, no empirical basis for estimating
how much any of these enforcement efforts contribute to
reductions in drug use and related problems, let alone a
basis to evaluate the broad costs and benefits of com-
peting enforcement approaches for society. Research
gaps reflect methodological problems (for example, the
absence of small area drug indicators to match with
enforcement intensity measures) and the view that drug
enforcement is a moral obligation, for which the term
‘crusade’ is not too strong in the United States. Preven-
tion and treatment have been studied more carefully, in
part because policymakers and clinicians have demanded
that these evaluations be performed to justify program
funding. In the absence of similar demands, we have no
comparable body of evaluation research pertaining to
law enforcement interventions.
The case for enforcement aimed at higher levels of the
drug trade is narrow. Interdiction and source country
controls aim to raise prices, reduce availability, signal
social disapproval and (perhaps) reduce the political
influence of drug suppliers in source countries. Yet the
impact of these policies remains hard to measure credibly.
Only one study has found that interdiction raised prices
and treatment admissions (Crane Rivolo & Comfort
1997), but it has been critiqued extensively for method-
ological flaws by the National Research Council (Manski,
Pepper & Thomas 1999). Other simulation studies have
found that interdiction, at least in the United States, is
unlikely to raise drug prices or to notably restrict drug
availability (e.g. Caulkins, Crawford & Reuter 1993).
Current research does not imply that interdiction
should be eliminated. Smuggling cocaine and heroin is
expensive. It costs approximately $15 000 to move 1 kg
of cocaine from Bogota to Miami; Federal Express would
charge less than $100 to move (much more reliably) 1 kg
of legitimate white powder between the same cities. The
combination of illegality and some enforcement seems to
generate somewhat higher prices and thus somewhat
lower drug use. Illegality surely deters some potential
users, in part because of availability effects (MacCoun &
Reuter 2001). Yet because of gaps in the available
research, there is no empirical basis for assessing whether
current interdiction efforts, at the margin, should be
increased or reduced.
Because US interdiction strategies appear somewhat
unsuccessful in raising drug prices, the available research
does not provide much guidance about what would actu-
ally happen if supply-side enforcement policies achieved
greater market effects. Recent intriguing data suggest
that some interdiction-like activity may have been respon-
sible for a sharp decline in Australia’s heroin availability
starting at the end of 2000 (Degenhart et al. 2005). Anal-
ysis of this Australian experience may provide useful
insights for policymakers in other industrial democracies.
Addiction, 101, 341–347

Low-level enforcement has a broader set of mecha-
nisms to address drug problems. In particular, a police
focus on street distribution can make dealers more dis-
creet and thus hinder new users finding suppliers.
Even if street enforcement aimed at retailers and buy-
ers has little ultimate effect on drug availability, the arrest
process itself can further secondary and tertiary preven-
tion by sweeping users into treatment. Kuebler et al.
(2000) found that enforcement aimed at closing down
open drug scenes in Zurich led to an increase in the
demand for methadone maintenance treatment. If sub-
stantial relapse poses a high risk of arrest and thus return
to treatment as an alternative to penal sanctions, crimi-
nally involved drug users are more likely to halt or reduce
their substance use. Treatment may be frail, but it is likely
to work more effectively if providers have many opportu-
nities to treat the same person. Existing evidence suggests
that treatment episodes motivated by criminal justice
pressure are no less successful than those with other
motivations (e.g. Gostin 1991).
Drug courts are an interesting attempt to combine
criminal justice and treatment resources for drug-
involved offenders. Drug court participants appear to
have better legal and drug-use outcomes than apparently
comparable non-participants (Gottfredson, Najaka &
Kearley 2003). In a similar fashion, Kleiman (2001)
argues for ‘coerced abstinence’, in effect making the
criminal justice system an explicit recruiter for treatment
and other ways of reducing individual drug use. The few
evaluations available on this regime are promising; re-
offending and drug use rates are lower for those coerced
than for those subject to standard pre-trial or probation
conditions (Harrell, Cavanaugh & Roman 1998). Faced
with such pressures and incentives, many of those who
succeed do so without formal treatment. Both drug
courts and ‘coerced abstinence’ interventions deploy fre-
quent monitoring and chemical tests with the threat of
graduated penal sanctions to deter re-initiating drug use
and to reduce the probability of more serious offending
and subsequent criminal sanctions.
Other enforcement measures may also have promise.
Stricter controls on precursor chemicals appear to have
at least short-term effects on methamphetamine con-
sumption (Cunningham & Liu 2003). Work-place testing
is argued by some to have led to reductions in adult drug
use, by threatening job loss (French et al. 2004). Evalua-
tions of school testing programs provide hints that these,
too, might reduce adolescent substance use.
CONCLUSION
We cannot treat, prevent, deter or incarcerate ourselves
out of ‘the drug problem’, although each measure is a
valuable component of drug policy. For the foreseeable
© 2006 The Authors. Journal compilation © 2006 Society for the Study of Addiction
Can treatment reduce national drug problems? 345
future, under any feasible policy regime, intoxicating ille-
gal substances will pose large concerns. Treatment is no
total solution to a nation’s drug problem; neither is any-
thing else. Millions of men and women in industrial
democracies will continue to suffer the consequences of
chronic use of intoxicating illegal substances.
America’s inability to eliminate drug-related prob-
lems is no special failure of national policy. The United
States has not fared much worse in reducing its depen-
dent population when compared with treatment-focused
peers. Its inability to contain social harms connected
with drug use deserves greater condemnation, because
these harms were often more avoidable. By 2001,
193 000 American injecting drug users had been diag-
nosed with AIDS. Injection drug use accounts for signif-
icant numbers of other secondary infections; 57% of all
AIDS cases among women are now traceable to injection
drug use (CDC 2003). Two decades of desultory policy
responses account for a real, if never knowable fraction of
these cases. The high homicide rate connected with exist-
ing drug markets should be counted another distinctive
failure of American social policy.
The social costs of substance use—and of efforts to
deter and police such use—have been higher than in
other industrial democracies. The problem is not that the
United States has failed to achieve the impossible, but
that it has failed to achieve things that could readily be
achieved.
HIV points to the set of interventions commonly
denoted as harm reduction. Writing as Americans, we
regard harm reduction as an approach, a set of guiding
questions for assessing and designing interventions,
rather than a category of programs itself. It is striking
that harm reduction programs to date, powerful though
they are, generally address only one slice of drug
problems. Needle exchange, naloxone distribution, safer
injecting rooms—these iconic programs of the harm
reduction movement all focus on injection drug use. Few
interventions have been offered or deployed to address
harms associated with crack or methamphetamine use.
Opportunities surely exist for harm reduction in these
domains, but these opportunities remain mostly unex-
ploited, unstudied and unproven.
For interventions other than treatment, policymakers
must rely on impression and image; the empirical base for
policymaking is lacking. The National Academy of Sci-
ences panel on drug policy (Manski, Pepper & Petrie
2001) lamented the US government’s failure to fund any
significant quantity of research on the effectiveness of
drug enforcement. The United Kingdom provides a rare
exception to the data-free discourse regarding the effec-
tiveness of enforcement interventions. The Home Office is
funding an ambitious research agenda to assess what var-
ious kinds of enforcement can contribute to drug control.
Addiction, 101, 341–347
346 Peter Reuter & Harold Pollack
Before this research is completed, we conjecture that
enforcement would be most valuable and effective when
authorities work closely with treatment providers to
reduce substance use among criminal offenders. We also
conjecture that treatment itself proves most effective
when it expresses the value of abstinence as an ultimate
goal, while paying great attention to secondary and ter-
tiary prevention for clients likely to continue some drug
use. We are confident that both use reduction and harm
reduction will remain essential pillars of sound drug con-
trol policy. Use reduction—in the form of primary preven-
tion, enforcement, and treatment—is essential because
continued drug abuse and dependence cast so many dark
shadows on the user and on others that can never be mit-
igated fully by available interventions. Harm reduction
remains essential because, despite our best use-reduction
efforts, drug misuse will remain prevalent and socially
costly. Defining acceptable and attainable base rates of
drug use disorders remain important subjects for another
essay.
Acknowledgements
We thank Keith Humphreys for suggesting the topic.
Helpful comments were received from Stan McCracken,
Mike Trace and three anonymous reviewers.
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