Methadone maintenance treatment as a crime control measure

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CRIME AND JUSTICE
Bulletin
NSW Bureau of Crime
Statistics and Research
Contemporary Issues in Crime and Justice
Number 29
June 1996
Methadone Maintenance Treatment
as a Crime Control Measure
Wayne Hall, Director, National Drug and Alcohol Research Centre
INTRODUCTION
This bulletin reviews research that is
relevant to answering the question:
should the number of persons enrolled in
methadone maintenance treatment
(MMT) be expanded as part of a larger
strategy to reduce drug and property
crime among opioid-dependent
offenders? First the bulletin summarises
what is known about heroin dependence
and its influence on crime. Then it
reviews research on the impact of MMT
on criminal behaviour among heroindependent offenders. The next two
sections describe the current market for
MMT in Australia and consider the ways
in which we may increase the number of
dependent heroin users who are enrolled
in MMT. The bulletin concludes with a
discussion of ways in which the number of
persons enrolled in MMT can be
increased as one way of reducing crime
committed by dependent heroin users.
HEROIN DEPENDENCE
AND ITS IMPACT ON CRIME
PREVALENCE OF HEROIN
USE AND DEPENDENCE
In household surveys of drug use one to
two per cent of the adult Australian
population say that they have used heroin
at some time in their lives
(Commonwealth Department of Human
Services and Health 1994). These are
likely to be underestimates. Heroin users
are less likely to participate in household
surveys either because they are
unavailable at the time the interviewer
calls or they are reluctant to be
interviewed, and when they are
interviewed, their heroin use is likely to be
under-reported because it is illegal.
Nevertheless, even if surveys
underestimate the number of heroin users
by half, the proportion of the Australian
population that has ever used heroin is
still less than five per cent.
Heroin dependence can be defined as the
loss of control over use, as indicated by
the continued use of the drug in the face
of problems that the user knows or
believes are caused by their drug use,
such as, legal difficulties, interpersonal
problems, and health problems.
Dependent heroin users in Australia are
daily or near daily injectors of heroin.
They are probably a minority of those who
ever use heroin. American community
surveys (Robins & Regier 1991; Kessler
et al. 1994) indicate that about a quarter
to a half of those who report ever using
heroin become dependent on it. This is
between 0.4 per cent (Anthony et al., in
press) and 0.7 per cent (Anthony & Helzer
1991) of the American adult population.
Heroin users do not become instantly
addicted to heroin. Even those who
become dependent on heroin typically
report a one to two year period between
their first use and their first period of daily
heroin use (a reasonable indicator of
dependent use). As is true of other types
of drug dependence, the development of
heroin dependence requires daily use
over weeks or months.
In the absence of Australian community
survey data on the prevalence of heroin
dependence, a variety of imperfect
methods have been used to estimate the
number of heroin users in Australia. The
most recent guesstimate is that there are
59,000 dependent heroin users. The
range of estimates is between 36,000 and
120,000, indicating considerable
uncertainty about the total number (Hall
1995).
Just as not all heroin users become
dependent on heroin, so not all
dependent heroin users become chronic
heroin users. Epidemiological research
indicates that there are many more
persons who are ever heroin-dependent
than come to the attention of drug
treatment services or the legal system
(Anthony et al., in press; Eisenhandler &
Drucker 1993). There is also evidence
that a substantial proportion of dependent
heroin users stop their heroin use without
professional assistance (Biernacki 1986;
Johnson 1978).
THE CAREERS OF CHRONIC
DEPENDENT HEROIN USERS
Once dependent heroin users become
integrated into a heroin-using subculture,
their dependence is more likely to
become a chronic, relapsing condition
with a poor prognosis. US research
indicates that those heroin users who
seek treatment to stop using heroin, and
those who come to attention through the
legal system, continue to use heroin for
decades. In this population periods of
daily heroin use are punctuated by
detoxification, drug treatment and
incarceration for drug-related offences.
The proportion who achieve enduring
abstinence from opioid drugs after any
treatment episode is small, although the
proportion who become abstinent
gradually increases with age (Goldstein &
Herrera 1995; Hser et al. 1993; Vaillant
1973).
B U R E A U
O F
C R I M E
The low rates of abstinence after
treatment are not surprising as most
dependent heroin users enter drug
treatment reluctantly (Gerstein & Harwood
1990). They often do so under informal
pressure from family and friends, or under
legal coercion because they have been
charged with a drug or property offence.
In these circumstances it is unsurprising
that the proportion completing treatment,
and the proportion of these who achieve
sustained abstinence is so low. In the
year after drug treatment, the majority
relapse to heroin use, and over 20 years
or more, the chances of treated
dependent heroin users becoming and
remaining abstinent are approximately
one in three, roughly equal to their
chances of dying prematurely.
Dependent heroin users have a
substantially increased risk of dying
prematurely from: drug overdoses,
violence, infectious diseases spread by
sharing contaminated injecting
equipment, and alcohol-related causes
(Goldstein & Herrera 1995; Hser et al.
1993; Joe & Simpson 1990; Vaillant
1973). Mortality studies among heroin
users treated before the advent of
HIV/AIDS indicated that they were 13
times more likely to die prematurely than
their age peers (English et al. 1995).
More recently, HIV/AIDS has been added
to the causes of premature deaths among
heroin users in the USA and Europe.
Emerging evidence suggests that this will
become a more important cause of
premature death among heroin users in
Australia in the future, as will liver disease
and cancers caused by infection with the
hepatitis C virus (Crofts et al. 1993).
HEROIN USE AND CRIME
Heroin users who come to attention
through the legal system and drug
treatment services typically engage in
high rates of criminal activity, such as
drug dealing; robbery; break, enter and
steal; forgery; and shoplifting. Heroindependent women may be involved in
prostitution (Hall et al. 1993; Bell et al.
1992; Bell et al. 1995). Lehman and
Simpson (1990) found that 99 per cent of
a cohort of 490 American heroin users
reported that they had engaged in some
form of illegal activity during a 12-year
period after treatment, and 60 per cent
had spent a year or more in gaol. High
S T A T I S T I C S
rates of convictions have been reported
among methadone applicants in Australia:
90 per cent had one or more convictions,
76 per cent for drug offences, and 78 per
cent for property offences (Hall et al.
1993).
There is no doubt that heroin use and
crime are associated but there is
disagreement about why they are
associated (e.g. Dobinson 1989; Chaiken
and Chaiken 1990; Hammersley et al.
1989). The interpretation most often
favoured in public discussion is that
heroin users commit property crimes to
finance their heroin use. There are two
alternative explanations. One is that
property criminals are more likely to
become dependent heroin users. The
other is that crime and drug use have
common causes, such as, multiple social
disadvantage, or a criminal subculture
that encourages heroin use and crime
(Clayton & Tuchfield 1982; Hammersley
et al. 1989; McBride & McCoy 1982).
There is some support for each of these
alternative explanations. At least half of
treated heroin users are involved in
property offences before they first use
heroin (Dobinson & Ward 1984, 1987;
Hall et al. 1993) This is especially so
among male heroin users; women are
more likely to be recruited to heroin use
by a heroin-using male sexual partner so
their criminal activities are more likely to
follow their heroin use (Hser et al. 1987;
Hall et al. 1993).
Longitudinal studies in the US also
indicate that certain personal attributes
and life experiences make young people
more likely to use heroin and to engage in
crime (Elliott et al. 1985; Jessor & Jessor
1977). For example, adolescents who
have a history of poor school
performance, who begin to use alcohol
and tobacco in their early teens, and who
have a juvenile criminal history, are those
who are most likely to associate with
other socially deviant and delinquent
peers, and to use heroin in their late teens
(Elliott et al. 1985; Jessor & Jessor 1977;
Kandel 1993).
Nonetheless, dependent heroin use
affects the frequency with which heroin
users engage in criminal acts. McGlothlin
et al. (1978) studied the criminal and drug
use careers of 590 heroin addicts in
California and Ball et al. (1983) studied
343 heroin users in Baltimore. Both
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R E S E A R C H
groups found a much higher rate of selfreported crime when heroin was used
daily than when users were abstinent in
the community. In Ball et al.’s study when
users were abstinent there was a 75 per
cent drop in the number of days that they
engaged in crime. McGlothlin et al.
showed the same pattern in the frequency
of recorded arrests, indicating that the
relationship between self-reported heroin
use and crime was not the result of
response biases. Similar results have
been reported among heroin-using
property offenders and methadone
maintenance patients in Australia
(Dobinson & Ward 1984, 1987).
THE COMMUNITY IMPACT
OF HEROIN-RELATED CRIME
Only a small proportion of adults ever
become dependent on heroin but the
frequency with which they engage in
crime and the range of their criminal
activity has a major impact on the
communities within which they live.
Studies of the criminal behaviour of
heroin users in New York City indicate
that their major criminal activity was low
level drug dealing (Johnson et al. 1985).
Heroin users in this study committed an
average of 665 crimes related to drug
distribution in a year, activities for which
they were often paid in drugs. Drug
dealing also provided them with an
incentive to initiate friends and
acquaintances into heroin use, thereby
encouraging the spread of heroin use
among their social networks and the
communities in which they lived.
Johnson et al. (1985) found that property
crimes of robbery, burglary, shoplifting
and other forms of theft provided a
substantial part of the cash income used
for drug purchases. The frequency with
which these offences were committed
produced very large numbers of property
crimes. Johnson et al. estimated that 100
daily heroin users in New York City in
1980 committed an average of 20,900
property offences in a year. Each of
these 100 users imposed an estimated
economic cost of $22,840 per annum on
victims of property crimes, such as
householders who were robbed, or the
owners of stores from which goods were
shoplifted for resale.
The property crime committed by
dependent heroin users affects not only
B U R E A U
O F
C R I M E
those whose homes are robbed, but also
those whose household insurance
premiums are increased to meet the
claims of others who have been robbed.
It also affects those who have to pay
higher prices for goods purchased in
stores with high rates of shoplifting. High
rates of property crimes also reduce the
quality of community life more generally
by increasing fear of crime, by increasing
the costs of home security, and by
reducing the amenity of community living.
METHADONE MAINTENANCE
TREATMENT (MMT) AS A CRIME
CONTROL STRATEGY
Methadone Maintenance Treatment
(MMT) involves the substitution of
methadone, a long-acting, orally
administered, opioid drug for the shorteracting heroin that is typically injected
(Dole & Nyswander 1965, 1967).
Methadone provides a legal and
controlled supply of an orally administered
opioid drug which only has to be taken
once a day because its long duration of
action eliminates opiate withdrawal
symptoms for 24 to 36 hours. When
given in high or ‘blockade’ doses, it also
blocks the euphoric effects of injected
heroin, thereby providing an opportunity
for the individual to improve his or her
social functioning by taking advantage of
the psychotherapeutic and rehabilitative
services that are an integral part of many
MMT programs.
There is good evidence that MMT
reduces heroin use among dependent
heroin users (Gerstein & Harwood 1990;
Hubbard et al. 1989; Mattick & Hall 1993).
Given this, and that heroin use is a
contributory cause of crime among
dependent heroin users, a policy worth
considering is expanding MMT as one
way of reducing heroin-related crime.
Other forms of drug treatment also reduce
heroin use and crime (Gerstein &
Harwood 1990) but MMT is the focus of
this bulletin because it has a number of
advantages over alternative approaches.
It is a more popular form of treatment than
its competitors (Marsh et al. 1990) in that
it attracts more users into, and retains
more of them in treatment (Ward et al.
1992). It has the strongest research
evidence for its effectiveness (Mattick &
Hall 1993) and it is also more cheaply and
easily provided to large numbers of
dependent heroin users than other types
S T A T I S T I C S
of drug treatment (Gerstein & Harwood
1990: Hubbard et al. 1989).
THE IMPACT OF MMT
ON CRIME
MEASURING CRIME RATES
Studies of the impact of MMT on criminal
behaviour have typically used one or both
of two methods to measure crime rates:
self-reported criminal behaviour, and
official records of arrests and convictions
for property and drug offences. Selfreported crime is reported over a period
such as a year, either as the number of
specific offences the person reported
engaging in, or as the number of days in
which they engaged in any criminal
offence (‘crime days’). Both measures
are often retrospectively assessed over
the previous year and sometimes over
decades (e.g. Anglin et al. 1993).
Each method of measuring crime has its
strengths and weaknesses. Official
records are affected by variations in
police effort. They also seriously
underestimate crime rates because the
rate of detection of the more common
property and drug offences is so low.
Comparisons of self-reported and records
of convictions suggest that less than one
per cent of property offences (such as
burglary and theft) are detected by police
(Ball et al. 1983).
Self-reported criminal offences provide
better indicators of the rate of the majority
of criminal offences that go undetected
(Ball et al. 1983; McGlothlin et al. 1978).
Studies reveal that when credible
assurances of anonymity and
confidentiality are provided, self-reported
arrests and convictions are reasonably
consistent with official records (Darke et
al. 1992) and reasonably consistent with
each other when repeated over time
(Anglin et al. 1993). Even so, they are
subject to deliberate under- or overreporting of offences, and to the errors
that occur when individuals
retrospectively report on the frequency
with which they engage in common but
variable forms of behaviour (Johnson et
al. 1985).
RANDOMISED
CONTROLLED TRIALS
The gold standard for evaluating the
effectiveness of any treatment is a
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R E S E A R C H
reproducible demonstration in a
randomised controlled trial that the
treatment produces a superior outcome to
no treatment or minimal treatment. The
simplest type of randomised controlled
trial is one in which people with a
condition (e.g. opioid dependence) are
randomly assigned to receive either the
active treatment (e.g. methadone
maintenance) or a comparison treatment
(e.g. detoxification).
The evaluation of treatment effectiveness
requires a comparison treatment so that
one can discover what would have
happened if the patient had received a
different treatment, including no treatment
at all. The aim of randomisation is to
ensure that the subjects who are
allocated to the treatment and the
comparison conditions do not differ in any
systematic way. Only when the two
groups have been assigned in this way
can one be confident that a difference in
treatment outcome reflects the effects of
the treatment rather than the pre-existing
characteristics of the subjects who
received the different treatments.
Dole et al. (1969) conducted the first
randomised controlled trial (RCT) of MMT
in New York. Their subjects were
imprisoned, recidivist opioid addicts who
had at least four years history of opiate
use. Thirty-four men who became eligible
for release over a four month period were
invited to participate in the trial, 32 of
whom accepted the offer. Sixteen were
randomly assigned to methadone
maintenance (with 12 entering treatment),
and 16 were randomly assigned to a no
treatment waiting list. Methadone
maintenance was commenced before
leaving prison and continued after
release.
Both groups were followed up for 12
months after their release and only one
subject in each group was lost to followup. There were dramatic differences in
favour of methadone maintenance when
outcome was assessed by rates of
imprisonment and return to daily heroin
use. Of the 12 persons who entered
methadone maintenance, half were
employed or in school, and three had
been imprisoned, whereas all 16 of those
in the control condition had returned to
gaol. Similarly, whereas all 16 of the
control condition had returned to daily
heroin use, none of the persons in
methadone had done so, even though
10 out of 12 had used heroin since their
B U R E A U
O F
C R I M E
release, and three continued to use
intermittently.
A few additional randomised controlled
trials have involved small numbers of
patients, followed up for short periods
(e.g. Newman & Whitehill 1979; Gunne &
Grönbladh 1981). All such studies have
nonetheless produced positive results.
A more confident judgment of the efficacy
of methadone depends upon the
corroborative results of observational
studies in which statistical forms of control
have assessed the plausibility of the
major alternative explanations of apparent
effectiveness which are dealt with by
randomisation in controlled trials.
S T A T I S T I C S
Bale and colleagues
Bale and his colleagues (1980) conducted
a study in which subjects selected their
own treatment. The outcomes of patients
selecting MMT were compared at 12
months post-treatment with those
selecting detoxification (i.e. supervised
withdrawal from heroin). The two MMT
programs produced larger reductions in
opioid drug use during the past month,
and the number of convictions recorded
during the past year, than detoxification.
Moreover, the differences in outcome
between methadone maintenance and
detoxification persisted after adjustment
for 10 patient characteristics which had
been shown to predict outcome.
OBSER VATIONAL STUDIES
The most convincing observational
studies are controlled studies in which
persons who select MMT are followed
prospectively, and their heroin use, crime
and other outcomes compared with those
of persons who selected other forms of
treatment (e.g. therapeutic communities
and drug-free counselling). The major
problem is that one cannot be sure in the
absence of random assignment that the
persons receiving different forms of
treatment were comparable prior to
treatment. It is accordingly difficult to rule
out the possibility that apparent
differences in treatment outcome are due
to differences in the types of patients who
received them.
The strategy of quasi-experimentation
(Cook & Campbell 1979) provides a way
of making causal inferences from
observational studies. This involves three
processes. First, plausible rival
hypotheses are generated which may
explain any differences between
treatments in outcome. Of these the most
plausible is that the treatments differ in
the number of patients who are ‘good or
bad treatment bets’. Second, patients are
measured on variables which may reflect
a better or worse outcome, such as prior
history of drug use, degree of criminal
involvement, and severity of drug
dependence. Third, statistical methods
are used to see whether the differences in
treatment outcome persist when account
is taken of pre-existing patient
differences. If the differences in outcome
persist after statistical adjustment,
confidence in a treatment effect is
increased.
Anglin and associates
Anglin and his colleagues conducted a
series of studies in California to evaluate
the impact of MMT on heroin use and
crime in patients in a number of MMT
clinics (Anglin & McGlothlin 1984). In
each study, retrospective data were
collected over a decade or more using a
time line in which the interviewer went
over a detailed chart marked with the
subject’s criminal and treatment history.
Comparisons of overlapping periods
reported at different interviews indicated
that there was reasonable consistency in
rates of reported drug use and crime
(Anglin et al. 1993).
The authors studied a group of opioiddependent men who were committed to
compulsory inpatient treatment as an
alternative to imprisonment during 1962–
64 as part of the California Civil Addict
Program (CAP) (Anglin & McGlothlin
1984). Of the 439 subjects in this study,
118 later entered methadone
maintenance treatment in the early 1970s.
Entry into methadone maintenance
brought about a marked reduction in
heroin use which lasted throughout the
three year follow-up period. A similar
pattern of results was found for criminal
activity. The reductions in heroin use and
crime among those in MMT were greater
than those among heroin users who did
not enter MMT.
A second study took advantage of the
closure of the only MMT program in
Bakersfield, California. The nearest clinic
was 70 miles away in Tulare. McGlothlin
and Anglin (1981) compared the
outcomes in the Bakersfield patients with
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R E S E A R C H
those of a group from the Tulare program
who were not involuntarily discharged
from treatment, two years after the
closure of the Bakersfield clinic. The
Tulare group spent 73 per cent of nonincarcerated time during the follow-up
period in methadone maintenance
compared with eight per cent for the
Bakersfield group.
After the Bakersfield program closed, 60
per cent of the men and 56 per cent of the
women became heroin-dependent again,
as indicated by morphine-positive urines.
The Bakersfield group also had about
twice the percentage of individuals
arrested during the follow-up period. The
other outcomes for the Bakersfield group
were poor: 73 per cent were arrested, 61
per cent were imprisoned for more than
30 days, and two died from drug
overdoses.
The Drug Abuse Reporting Program
The Drug Abuse Reporting Program
collected outcome data five to seven
years after drug treatment at 52 drug
treatment agencies in the USA and Puerto
Rico during 1969 to 1973 (Simpson &
Sells 1982). The treatment modalities
represented were MMT, residential
therapeutic communities, outpatient drugfree treatment, and short-term
detoxification programs. Included was a
group of people who applied for, but never
began treatment. A total of 4,627 subjects
were interviewed about their drug use and
crime for each month between the end of
treatment and the time of the interview.
Patients in methadone maintenance had
better outcomes than those who went
through detoxification programs or had no
treatment at all (Simpson & Sells 1982).
This finding was apparent in the year after
treatment, and was still evident, although
the differences had diminished, at the
five-year follow-up (Bracy & Simpson
1982–83). The length of time spent in
treatment predicted improved treatment
outcome for those who were enrolled in
MMT for at least one year.
The Treatment Outcome Prospective Study
The Treatment Outcome Prospective
Study (TOPS) (Hubbard et al. 1989) was
a prospective study of over 11,000 illicit
drug users who applied for treatment in
MMT, residential therapeutic communities,
B U R E A U
O F
C R I M E
and outpatient drug-free treatment. All
applicants in 1979, 1980 and 1981 were
interviewed about their drug use and
criminality, and were then followed up at
three months, one year, two years and at
three to five years after treatment. Illicit
drug use and criminal activity were
assessed by self-reports which were
validated. Statistical methods were used
to control for potential confounding
variables.
All three treatment modalities were
associated with a reduction in illicit drug
use but MMT had the best retention rates:
after three months, 65 per cent of
methadone patients remained in
treatment, whereas less than 40 per cent
of the outpatient drug-free clients and 44
per cent of the residents in therapeutic
communities remained in treatment more
than three months. At the end of six
months 50 per cent of patients were still in
methadone maintenance treatment.
Patients in methadone maintenance
substantially reduced their heroin use
while in treatment, with less than 10 per
cent regularly using heroin (weekly or
daily) after three months. Criminal activity
was also reduced. A third of patients in
MMT reported committing a predatory
crime in the year before treatment. This
dropped to 10 per cent during the first
month of treatment. Significant
reductions in self-reported predatory
crime were only observed while patients
remained in methadone maintenance.
PRE-POST STUDIES OF
TREATMENT EFFECTIVENESS
Pre-post observational studies are those
in which persons entering MMT are
followed over time to assess changes in
their drug use and crime. In the absence
of any comparison treatment condition,
the contribution of MMT to changes in
behaviour is assessed by examining the
relationship between length of time in
treatment and patient outcome. Such
studies are weaker than controlled
observational studies because it is difficult
to rule out the alternative explanation that
the patients who were the least
dependent on opioids, and the most
motivated to discontinue their drug use,
were the most likely to remain in
treatment.
The quasi-experimental strategy can
provide a limited test of this alternative
explanation. First, the hypothesis that
S T A T I S T I C S
patients with a good outcome were more
likely to be those retained in treatment
can be tested by comparing the
characteristics of those who do and do
not remain in treatment. Second, if there
are differences between those who stay
and those who leave, statistical methods
can be used to discover whether the
relationship between treatment duration
and patient outcome persists when
differences in patient characteristics are
taken into account.
Gearing and Schweitzer
Gearing and Schweitzer (1974) provided
an independent evaluation of the outcome
of 17,500 patients admitted to Dole and
Nyswander’s long-term methadone
maintenance program between January
1964 and December 1971. The
demographic characteristics of patients
entering the program changed over the
period of study but retention in treatment
was high (namely, 90% after one year,
80% after two years and 75% after three
years). Retention in treatment was
associated with improved social
productivity, reduced crime and a reduced
mortality rate. The rates of arrest
decreased with time in treatment, namely,
7 per cent in the first year, 5 per cent in
the second year, 3 per cent in the third
year, and 3 per cent in the fourth year.
Gearing and Schweitzer’s results are
noteworthy in showing very high rates of
retention in treatment, and that positive
outcomes were sustained over four
cohorts of 17,500 patients who were
admitted to their program over a period of
eight years.
Ball and colleagues
Ball and Ross (1991) evaluated six MMT
programs, two in each of Baltimore,
Philadelphia and New York, over a threeyear period between 1985 and 1987.
During 1985–86, 633 male patients were
interviewed, and 506 were interviewed a
year later about their drug use history,
their last period of injecting drug use, and
their past and current criminal activity. At
follow-up 388 remained in treatment and
107 had left treatment at some time
during the intervening year.
Prior to entering MMT the sample had a
total of 4,723 arrests, a mean of nine
arrests for the 86 per cent of the sample
who had been arrested. Sixty-six per cent
of the group had spent some time in gaol
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R E S E A R C H
and 36 per cent had been imprisoned for
two years or more. The sample admitted
to 293,308 offences a year prior to MMT
entry, with each offender committing an
average of 601 crimes per year (range 1
to 3,588) on an average of 238 days a
year.
After entry to MMT, the total number of
self-reported offences declined to 50,103
crimes per year, while the mean number
of crime days per year decreased from
238 to 69. The number of crime days
continued to decline with the number of
years spent in treatment. The estimated
reduction in the number of crimes
committed was 192,000 offences per
year. The study may have over-estimated
the impact of MMT in that it compared
self-reported crime during the last period
of addiction with that during treatment.
Nonetheless, the magnitude of the
reduction in crime is consistent with that
observed in comparisons of crime rates in
periods of daily heroin use and
abstinence in the community. It is also
unlikely to be due to regression to the
mean because it was so large and it was
sustained as long as the user remained in
treatment.
A COMPARISON OF RANDOMISED
AND OBSER VATIONAL STUDIES
The observational studies generally
support the randomised controlled trials in
showing that MMT reduces heroin use
and criminal activity but the average
retention rates and rates of heroin use in
MMT in the observational studies were
not as impressive as those reported from
the randomised controlled trials. There
are a number of possible explanations for
this.
First, the randomised controlled trials
have probably provided an optimistic
estimate of treatment effectiveness. In
order to produce clear results, such
studies usually exclude some of the more
difficult patients and they often have a
greater degree of control over the quality
of the treatment than usually occurs under
the exigencies of clinical practice.
Secondly, many current MMT programs in
the USA have departed from the original
model of Dole and Nyswander in
directions that are likely to reduce
average effectiveness, namely, by
reducing average methadone dose and
by placing pressure on patients to
become abstinent from all opioids,
B U R E A U
O F
C R I M E
including methadone (D’Aunno & Vaughn
1992).
Thirdly, there have been important
changes in patterns of illicit drug use
between the time when MMT was
introduced and when the more recent
observational studies were conducted.
Cocaine use in particular has become
widespread among methadone patients.
Since methadone neither blocks the
effects of cocaine nor averts withdrawal
symptoms, it has had minimal impact on
the use of this and other non-opioid illicit
drugs (Hubbard et al. 1989).
THE RELEVANCE OF US
RESEARCH TO AUSTRALIA
There has been limited Australian
research on the impact of MMT on drug
use and crime. In its absence, it has
been assumed that the results of
American research are applicable in
Australia. On the whole, this is probably a
reasonable assumption for reductions in
heroin use and HIV. It may require some
qualification in the impact of MMT on
crime.
The goals and policies of Australian
methadone programs (Burgess et al.
1990; Baillie et al. 1991) are similar to
those in American MMT programs (e.g.
D’Aunno & Vaughn 1992; General
Accounting Office 1990). The Dole and
Nyswander model of MMT was
substantially modified during the
popularisation of methadone treatment
during the 1970s (Gerstein & Harwood
1990; Burgess et al. 1990), with the goal
in many programs shifting from long-term
maintenance towards the achievement of
abstinence from all opioid drugs within a
few years (D’Aunno & Vaughn 1992;
Gerstein & Harwood 1990). MMT
expanded greatly in Australia during the
middle 1980s (Ward et al. 1992). With
the advent of the HIV epidemic and the
National Campaign Against Drug Abuse
goal of harm minimisation, the prevention
of HIV transmission among injecting drug
users was given a higher priority than the
traditional goal of eliminating illicit drug
use.
American and Australian methadone
patients have long histories of opioid
dependence (e.g. Dobinson & Ward 1987;
Hall et al. 1993; Reynolds & Magro 1976)
but they differ in ethnic composition.
American programs contain large
proportions of African and Hispanic
Americans whereas there is no large
S T A T I S T I C S
ethnic group among Australian opioid
users. The importance of this difference
in ethnicity is diminished by the
effectiveness of MMT in controlled clinical
trials in Bangkok, Hong Kong, New York,
and Stockholm. Similar relationships
have also been observed between
program characteristics (e.g. dose and
duration of treatment) and outcome in
America (Ball & Ross 1991) and Australia
(e.g. Bell et al. 1995; Caplehorn & Bell
1991). MMT patients in both the USA and
Australia have extensive histories of
criminal involvement and experiences of
incarceration, with the majority of
Australian MMT patients having criminal
convictions and engaging in a wide range
of offences to fund their drug use
(Dobinson & Ward 1987; Hall et al. 1993).
There are differences in the cost of illicit
drugs and in the availability of social
welfare between Australia and the USA
which need to be considered when using
US studies to estimate the impact of MMT
on crime in Australia. Until recently, street
prices of heroin in Australian cities have
been considerably higher than those in
New York (Australian Bureau of Criminal
Intelligence 1995; Johnson et al. 1985).
This might be expected to encourage
more Australian heroin users to engage in
crime to finance their heroin use.
Operating in the opposite direction is the
greater degree of social welfare and
health services available to Australian
than American heroin users. This might
reduce the need of Australian heroin
users to engage in crime to provide for
food and shelter, as happens among New
York addicts who are more often
homeless and have limited social welfare
income (Johnson et al. 1985).
Despite these differences, the limited
Australian evidence on the impact of MMT
on crime is consistent with American
research. Bell et al. (1992) for example,
conducted a prospective cohort study in
which they examined the impact of MMT
on rates of conviction for drug and
property offences. They found that the
rate of property convictions dropped by
approximately a third for each year that
dependent heroin users spent in MMT.
Moreover, this relationship persisted after
statistical adjustments were made for
differences in the characteristics between
those who remained in MMT and those
who did not.
More recently, Bell et al. (1995) partially
replicated the Ball and Ross (1991) study
6
A N D
R E S E A R C H
by following a cohort of 300 patients in
three Sydney private MMT programs over
a year. Self-reported crime days in the
last 30 days of active addiction were
compared with the number in the last 30
days on MMT. The percentage reporting
drug selling declined from 40 per cent to
12 per cent and the percentage engaging
in property crimes declined from 35 per
cent to 9 per cent. The number of days in
the last 30 on which they reported
engaging in each type of offence declined
from 21 to 11 for drug selling and from 18
to 9 for other crime. The percentage
engaging in any income-generating crime
in the previous 30 days declined from 59
per cent to 20 per cent (Bell et al. 1995).
Analyses of changes in rates of
convictions for property and drug offences
from before treatment to after treatment
confirmed the self-reported reductions,
with rates of property offences declining
from 0.75 per annum to 0.22, while those
for drug offences declined from 0.30 to
0.06.
AN OVERALL APPRAISAL
The overall impact of MMT on crime can
be evaluated by the degree to which the
evidence satisfies a modified set of
criteria for causal inference (Hill 1965).
Although no single criterion is necessary,
the more that are satisfied, the greater our
confidence that a causal relationship
exists between MMT and a reduction in
crime.
Strength of association: The relationship
between MMT and a reduction in criminal
behaviour is, on average, a reasonably
strong one. The rate of both self-reported
crime and convictions approximately
halves with each year that a patient
remains in treatment.
Consistency: A relationship between
methadone treatment and reduced drug
use and criminal behaviour has been
consistently observed in controlled trials,
quasi-experimental studies, comparative
studies, and pre-post-studies in the USA,
Sweden, Hong Kong and Australia. This
relationship is most consistent in MMT
programs that use methadone doses
above 60 mg and which have
maintenance as their treatment goal. It
has been consistently found for both selfreported and officially recorded crime.
Specificity: The effects of MMT are most
evident on those outcomes it has been
designed to change: opioid use and
B U R E A U
O F
C R I M E
criminal behaviour motivated by the need
to finance illicit opioid use.
A dose-response relationship: First, there
is a relationship between the dose of
methadone received and treatment
retention and reduction in drug use and
crime. Both within individual programs
and between programs, the higher the
dose of methadone, the longer the
retention in treatment and the greater the
reduction in drug use and criminal
behaviour. Secondly, there is a
relationship between treatment duration
and benefit: the longer patients remain in
treatment, the better the outcome. This
relationship does not appear to be
explained by a higher retention rate
among patients who have a good
prognosis.
Plausibility: The rationale for the
effectiveness of methadone maintenance
is plausible. Opioid dependence is
characterised by a preoccupation with
procuring illicit opioid drugs which persists
to the detriment of the user’s health and
well-being. The provision of methadone,
in doses which avert withdrawal and
reduce the positive effects of illicit opioid
use, reduces opioid use and the necessity
for users to engage in drug dealing and
property crimes to procure opioid drugs.
Coherence: The evidence on the effects
of methadone maintenance is coherent
with what is known about the natural
history of opioid drug use: by the time
patients present for treatment they have a
long history of opioid use so it takes time
for methadone maintenance to achieve its
benefits; opioid dependence is a chronic
condition with a high rate of relapse, so
the effects of methadone maintenance
treatment appear to last only while people
remain in treatment.
Experiment: Although there is limited
experimental evidence of the
effectiveness of methadone maintenance,
it is consistently positive. There are only
three controlled trials of comprehensive
methadone maintenance over periods of
a year or more (Dole et al. 1969; Newman
& Whitehill 1979; Gunne & Grönbladh
1981), all involving small numbers of
patients and conducted in three very
different cultural settings. All found that
MMT produced substantial reductions in
opioid drug use and crime.
Thus, when the available evidence is
taken as a whole there are good reasons
S T A T I S T I C S
for believing that on average MMT
reduces injecting heroin use and
criminality. The phrase ‘on average’
implies a number of caveats.
First, MMT substantially reduces but does
not eliminate crime committed by opioiddependent persons. About half of those
who enter MMT leave within 12 months
and a substantial proportion of those who
stay in treatment continue to use heroin
and engage in criminal behaviour,
although at much lower rates than before
they entered treatment.
Second, there is considerable variability in
the effectiveness of different MMT
programs in reducing drug use and
criminal acts. The factors responsible for
this probably include the clientele of the
programs, the dose of methadone given,
the treatment philosophy, the duration of
treatment, the quality of the therapeutic
relationships, and the intensiveness of
ancillary services (Ball & Ross 1991).
Third, the most effective MMT programs
are those which resemble the model
introduced by Dole and Nyswander in
providing higher doses of methadone as
part of a comprehensive treatment
program with maintenance rather than
abstinence as a treatment goal (Ward et
al. 1992).
Fourth, the benefits of methadone
maintenance only continue as long as
patients remain in treatment. Patients
who discontinue treatment seem to
relapse to opioid use at a high rate. Any
expectation that MMT will increase
abstinence post-treatment is misplaced,
although long-term MMT does not appear
to reduce the chances of achieving
abstinence (Maddux & Desmond 1992).
THE MARKET FOR MMT
IN AUSTRALIA
Could the amount of heroin-related drug
and property crime in the Australian
community be reduced by increasing the
number of heroin users who are enrolled
in MMT? An answer to this question
requires a description of the current
supply of MMT in Australia, an analysis of
the factors that influence the demand and
uptake of MMT, and a discussion of the
costs and benefits of various ways of
increasing the numbers of heroin users
enrolled in MMT.
7
A N D
R E S E A R C H
THE SUPPLY OF MMT
IN AUSTRALIA
As at June 1994, there were 14,996
persons enrolled in MMT in Australia.
Just over half of these (55%) were
enrolled in New South Wales, with the
remainder distributed across the other
States and Territories as follows: Victoria
19 per cent, Queensland 13 per cent,
South Australia 6 per cent, Western
Australia 4 per cent, Australian Capital
Territory 2 per cent, and Tasmania 0.6 per
cent (Commonwealth Department of
Human Services and Health 1995).
The number of persons enrolled in MMT
has increased steadily over the past
decade from 4,446 in June 1987 to
14,996 in June 1994 (and an estimated
18,000 by June 1995). The participation
rate per 100,000 of the population aged
15 to 44 has increased from 59 in June
1987 to 182 in June 1994
(Commonwealth Department of Human
Services and Health 1995). In New South
Wales, the numbers enrolled in MMT
have increased from 3,195 in June 1987
to 9,479 in June 1995, and the
participation rates from 73 to 199 per
100,000 of adults aged over 15 years
(New South Wales Drug and Alcohol
Directorate 1996).
Within New South Wales, the regions with
the largest numbers of patients enrolled
and the highest participation rates have
been in the Sydney metropolitan area. As
at June 1995, Eastern Sydney had 1,838
MMT clients (a participation rate of 681
per 100,000), Western Sydney had 1,480
clients (308 per 100,000), Central Sydney
had 974 clients (356 per 100,000) and
South Western Sydney had 1088 clients
(206 per 100,000). MMT clients have
been predominantly male (62%) for most
of the past decade but their average age
has increased by about six months per
year between June 1987 and June 1994
(from 31 to 35 years for males and from
29 to 33 for females) (New South Wales
Drug and Alcohol Directorate 1996).
In the past seven years, the largest
increase in the supply of MMT places has
come from the expansion of MMT
provided in the private sector, rather than
from an expansion of publicly funded
MMT programs (Commonwealth
Department of Health and Human
Services 1995). That is, there has been a
larger increase in persons receiving MMT
from private medical practitioners than
B U R E A U
O F
C R I M E
from publicly-funded MMT programs.
Nationally, the number of clients enrolled
in public programs increased from 2,701
in June 1987 to 6,541 in June 1994 while
over the same period the numbers
enrolled in private MMT programs
increased from 1,745 to 8,449. The
participation rates have increased over
the same period from 36 to 79 per
100,000 for public programs and from 23
to 102 per 100,000 in private MMT
programs (Commonwealth Department of
Human Services and Health 1995). One
of the largest increases in private sector
MMT places has been in New South
Wales where the percentage of MMT
places provided in private programs
increased from 49 per cent in June 1987
to 68 per cent in June 1995 (New South
Wales Drug and Alcohol Directorate
1996).
Private MMT programs are run by general
practitioners and psychiatrists who are
licensed by the State governments to
dispense methadone to opioid-dependent
persons. The direct medical costs of
these programs are paid by the
Commonwealth government through
Medicare by bulk-billing for medical
services and urinanalyses. Patients also
pay a dispensing fee which averages $40
to $50 a week.
Private MMT programs generally do not
provide any formal counselling for clients
but prescribers regularly see their clients
(3 times a month on average) for which
they receive a consultation fee that is
bulk-billed to Medicare. Private programs
typically give a higher average
methadone dose (64 mgs compared with
59 mgs in public programs) and until
recently they had more liberal policies
towards giving out take-away methadone
doses than the public clinics (giving out
an average of 16 per month as against
less than 3 per month in public clinics)
(Bell et al. 1995).
The most recent data indicate that it costs
approximately $2,662 per annum to
provide MMT in Australia in public
programs ($2,623 per annum in New
South Wales). The direct costs of private
MMT programs to government are
considerably less: $552 per annum for
programs run by general practitioners and
$1,728 for those run by psychiatrists.
These estimates do not include the direct
costs paid by clients ($2,340 per annum
at $45 per week over 52 weeks). When
the clients’ contribution is added, the
S T A T I S T I C S
average costs of MMT provided in private
programs ($2,892 for general practitioners
and $4,068 for psychiatrists) are higher
than MMT provided in public programs.
In 1993/94 it was estimated that the
States and Commonwealth governments
contributed $15.2m and $15.3m
respectively to the costs of providing
public and private MMT in Australia
(Commonwealth Department of Health
and Human Services 1995).
THE DEMAND FOR MMT
The most recent estimate is that there
were approximately 59,000 dependent
heroin users in Australia in 1991 (Hall
1995). Even if there has been no major
increase since then, it would be unwise to
assume that the potential demand for
methadone treatment is equal to 41,000,
that is, the discrepancy between the
estimated number of regular heroin users
in the population (59,000) and the number
who are currently enrolled in methadone
maintenance treatment (18,000).
First, the size of the heroin-using
population may have increased recently
(Hall 1995). Second, not all dependent
heroin users are interested in drug
treatment in general, or in MMT treatment
in particular. A substantial minority
become abstinent without seeking
professional assistance (Biernacki 1986;
Johnson 1978), and a substantial
proportion of those who enrol in drug
treatment, including MMT, drop out.
Studies of street heroin users have also
identified heroin users who actively avoid
involvement in MMT (Beschner & Walters,
1985; Johnson et al. 1985).
Factors influencing
demand for MMT
The demand for MMT treatment will be
affected by the balance of the benefits
and costs of the heroin-using lifestyle.
Among the costs that push dependent
heroin users into treatment has been the
advent of HIV/AIDS among injecting drug
users a decade ago. The threat of lifethreatening and chronic infectious
diseases has been accentuated by the
recent recognition of the high incidence
and prevalence of hepatitis C infection
among Australian injecting drug users
(Crofts et al. 1993). Other costs of heroin
use that push dependent users into
treatment may include the impact of law
enforcement strategies on the street price
of heroin (Weatherburn & Lind 1995).
8
A N D
R E S E A R C H
Very little research has been conducted
on the reasons why dependent heroin
users decide to stop their heroin use. Joe
et al. (1990) report data on reasons given
by 372 daily heroin users. The most
commonly cited reasons were feeling
‘tired of the hustle’ involved in maintaining
daily heroin use (83%) and the feeling
that the individual had ‘hit bottom’ and
needed to make a dramatic change in his/
her life (82%). The next most common
reasons were having experienced a major
personal or special life event, such as
entering a new relationship or having
children (66%), fearing being gaoled
(57%) and having family responsibilities
(56%). Specific aspects of heroin-using
life style included: the high cost (40%)
and the poor quality of heroin (36%),
being tired of having no money (34%),
fearing a drug overdose (31%) and fear of
being sent to gaol (30%). A sample of
247 Sydney methadone clients
interviewed by Weatherburn and Lind
(1995) gave similar reasons for stopping
their heroin use: 97 per cent were ‘tired of
the lifestyle’, 67 per cent thought that
heroin was ‘too expensive’, and 30 per
cent had been in trouble with the police.
Less is known about what factors
influence whether or not treatment is
sought and, if so, what type of treatment
is selected. The attractiveness of
different forms of treatment to users is an
obvious factor. In the USA, MMT attracts
the largest proportion of dependent heroin
users (Marsh et al. 1990). If this finding is
applicable to Australia, then the increased
availability of MMT over the past decade
has probably contributed to an increased
use of MMT. Evidence from both
Australia (Bell et al. 1994) and the US
(Woody et al. 1975) also suggests that
reducing the barriers to MMT entry by
providing rapid assessment and intake
increases its attractiveness to heroin
users and its success in retaining them in
treatment.
Changes in the method of delivering MMT
in Australia over the past decade have
probably had conflicting effects on
demand for MMT. Demand for MMT has
probably been increased by more liberal
policies towards continuing heroin use
while in treatment. The more liberal
provision of take-away doses, especially
in private MMT programs, has also
increased the attractiveness of MMT
since the requirement of daily dosing is
one of the aspects of MMT most disliked
B U R E A U
O F
C R I M E
by MMT clients (Beschner & Walters
1985; Hunt et al. 1986). The adoption of
higher methadone doses and a
maintenance approach to treatment in
many Australian programs have been
shown to increase retention in MMT
(Caplehorn & Bell 1991; Caplehorn et al.
1993).
On the other hand, the imposition of direct
dispensing charges on users in private
and some public MMT programs in some
States have probably reduced demand
and they may have reduced retention.
Concerns have also been expressed that
the liberal provision of take-away doses in
many private programs provides an
incentive to sell methadone and a motive
for continued criminal activity to cover
dispensing costs. There is, however, little
evidence to evaluate these concerns
about private MMT programs.
INCREASING THE UPTAKE
OF OPIOID MAINTENANCE
TREATMENT
INCREASING THE PUSH
INTO TREATMENT
Not all of the factors that influence
demand for MMT can be easily changed.
In the case of law enforcement, for
example, the ability of police activity to
produce short-term fluctuations in the
market price and purity of heroin appears
to be limited. Law enforcement may
nevertheless encourage entry to MMT by
maintaining a high street price for the
drug (Weatherburn & Lind 1995). Street
level law enforcement may increase the
inconvenience of being a regular heroin
user, thereby encouraging more
dependent heroin users to seek MMT. It
remains to be seen, however, whether
short-term changes produced by street
level enforcement have enduring effects
on entry to MMT and, if so, whether these
benefits are purchased at the price of
counterproductive public health effects,
such as, increasing unsafe and risky
patterns of drug use (Maher 1996).
THE ROLE OF
TREATMENT COERCION
A popular proposal for increasing the
number of dependent heroin users in
treatment is to divert them from the
criminal justice system into drug
S T A T I S T I C S
treatment. This option may be especially
appropriate for the most criminally
involved dependent heroin users who
may avoid treatment (Beschner & Walters
1985; Johnson et al. 1985; Kaplan 1983).
The evidence from American studies
suggests that coercion does not impair
the effectiveness of drug treatment,
provided that the threat of return to the
criminal justice system remains credible
(Anglin 1988; Anglin & Hser 1990; Brecht
et al. 1993; Gerstein & Harwood 1990;
Hubbard et al. 1988; Simpson & Friend
1988).
Elsewhere (Hall 1996) it has been argued
that the most ethically defensible form of
legally coerced drug treatment is that in
which offenders still have a choice as to
whether they accept treatment or
imprisonment. If they choose to be
treated, they should also have a choice of
treatment options, rather than being
compelled to enter a particular form of
drug treatment.
There are two reasons for avoiding an
over-enthusiastic embrace of treatment
under coercion as a crime control
measure. First, it requires funding of
additional treatment places for persons
under coercion. The failure to do so will
place an undue burden on existing
community-based treatment services and
deprive those who voluntarily seek
treatment from receiving it. Second, there
is a need to monitor and evaluate drug
treatment under coercion to ensure that
scarce treatment resources are not
wasted on unsuitable clients, that the
programs provide effective and humane
treatment, and that they provide a
credible alternative to imprisonment rather
than being seen by offenders and
correctional staff as a ‘soft option’ to be
exploited by those who wish to evade
imprisonment (Gerstein & Harwood
1990).
INCREASING THE
ATTRACTIVENESS OF
OPIOID MAINTENANCE
TREATMENT
Our ability to increase the attractiveness
of MMT by increasing its availability is
limited by the willingness of government
(either Federal or State) to fund an everincreasing number of MMT places.
Sooner or later a limit will be imposed on
9
A N D
R E S E A R C H
funds for MMT and this will require more
efficient and less expensive ways of
delivering opioid maintenance treatment.
Some of these alternative methods of
delivery may also prove more attractive to
dependent heroin users than the current
ones.
One alternative is to experiment with
general practitioners as prescribers and
community pharmacies as dispensers of
methadone. The more expensive
multidisciplinary public MMT clinics, and
the specialist private MMT programs,
could be restricted to stabilising new, and
dealing with more difficult, clients. These
alternative community MMT programs
may be more attractive to dependent
heroin users than the large, highly visible
and controlling specialist clinics. The
mainstreaming of MMT within primary and
generalist health services may also
increase MMT uptake by reducing the
stigma of being a MMT patient. It remains
to be seen how many general
practitioners and pharmacists are
prepared to be involved in providing this
type of MMT.
Another approach may be to use longeracting opioid drugs, such as
buprenorphine and LAAM, as
maintenance agents. Because these
drugs have a longer half-life than
methadone, the frequency of dosing
would be three times a week rather than
daily. In addition to reducing costs, it
would remove the need for daily dosing
and supervision that many MMT clients
dislike. Buprenorphine has the additional
advantages of a lower risk of overdose,
and an easier withdrawal than methadone
which has a bad (if not always deserved)
reputation among heroin users for its
addictiveness, side effects and overdose
risk (Beschner & Walters 1985; Hunt et al.
1986; Rosenblum et al. 1991).
We should also consider increasing the
number of MMT spaces by providing
more systematic assistance to stable
MMT patients who want to withdraw from
methadone. This should be done without
placing pressure on clients to become
abstinent. That is, it should be the choice
of the client to stop, not the result of
imposing an arbitrary time limit on
enrolment in MMT. It may be achieved by
improving relationships between MMT
and drug-free treatment services, or it
may require the development of
organised aftercare and support services
in some MMT programs.
B U R E A U
O F
C R I M E
The attractiveness of MMT to heroin
users can be most directly achieved by
various changes in program policies and
philosophies. These include increasing
average methadone doses, giving clients
greater control over their dose, being
more tolerant of intermittent heroin use
earlier in treatment, and adopting more
liberal policies on take-away doses of
methadone. ‘Streaming’ may also be
introduced into some programs. This
involves providing, in addition to standard
MMT, low threshold programs that have a
less onerous assessment process and
which make fewer demands upon patients
to change drug use or behaviour. Some
of these changes have been made in
Australian MMT programs in response to
HIV/AIDS; they may partly explain the
increase in the numbers of heroin users
seeking MMT.
Even if public funds were inexhaustible,
there may be limits on public tolerance of
new MMT clinics being opened within
residential areas (Senay 1988). There
may also be limits on public tolerance of
certain program policies. Reductions in
the therapeutic demands made on MMT
clients to reduce their opioid drug use, for
example, risk blurring distinctions
between drug substitution for a
therapeutic purpose and the provision of
socially sanctioned opioids, albeit under
medical supervision. The adoption of
take-away policies that are too liberal may
lead to increased diversion of methadone
to finance MMT and heroin use. This
may, in turn, lead to increased methadone
overdose deaths, including deaths among
heroin users who are not enrolled in MMT,
and it may facilitate the injection of oral
methadone syrup with adverse health
consequences for users (Darke et al.
1995). These program changes may also
impair the average effectiveness of MMT
in reducing heroin use and crime.
SHOULD WE CONSIDER
INJECTIBLE HEROIN
MAINTENANCE?
One way of attracting more heroin users
into drug treatment may be to offer
injectible heroin maintenance treatment
(HMT). Its principal attraction is that it
provides dependent heroin users with
their preferred drug, heroin, by their
preferred route of administration,
injection. There are reports of successful
clinical experience using this form of
maintenance treatment (e.g. Marks 1987).
Heroin maintenance treatment is also
S T A T I S T I C S
currently undergoing a controlled
evaluation in Switzerland (Rihs, 1994;
Uchtenhagen et al. 1994), and there is a
proposal for a trial of HMT in the ACT
(Bammer 1995).
Even if we assume that HMT, like MMT,
reduces illicit heroin use and crime among
those receiving it, its impact at a
population level is likely to be small
because it is unlikely to reach as large a
proportion of the heroin-using population
as MMT has over the past decade (Hall
1995). The major restraint upon the
number of clients in HMT is societal
concern about providing injectible heroin,
even when it is restricted to dependent
heroin users who receive it under medical
supervision.
But even if there were strong public
support for HMT the scale of its provision
would be modest because its costs are of
the order of two to three times those of
providing MMT (Rihs-Middle, 1995,
personal communication). Given this cost
differential, MMT seems preferable on the
grounds of cost-effectiveness to HMT if
we assume a rough equivalence between
HMT and MMT in their impact on heroin
use and crime (Hartnoll et al. 1980).
Expectations of HMT need to be realistic.
It may provide an additional option for
those dependent users who have failed to
respond to other forms of treatment,
including MMT. It may also have modest
benefits for the larger community if it
reduced the criminal activity of a small
actively criminal group of dependent
users, and if it reduced their risks of
contracting or transmitting HIV and other
infectious diseases.
ETHICAL ISSUES IN
EXPANDING MMT
Any expansion of MMT to reduce drugrelated crime must strike a balance
between benefiting heroin users and the
wider community. An over-reliance upon
legal coercion and punitive law
enforcement policies to drive dependent
heroin users into MMT runs the risk that it
will become primarily a form of social
control, rather than a therapeutic
alternative to imprisonment. If this were
to happen, MMT programs would become
progressively more punitive and less
attractive to users and the staff who work
in them. The high rates of patient and
staff turnover would impair the
effectiveness of MMT in reducing heroin
10
A N D
R E S E A R C H
use and crime. The net effect of these
policies would be to put public support for
MMT at risk.
Conversely, an over-reliance on providing
user-friendly MMT programs could
produce an expensive form of State­
subsidised opioid distribution which had
minimal therapeutic benefits to dependent
heroin users. It would also be achieved at
considerable social cost: the increased
economic costs of providing MMT, the
costs of the methadone diversion, and
perhaps, an increase in methadone
overdose deaths, including deaths among
individuals who were not enrolled in MMT
programs. These outcomes would also
reduce public support for MMT programs.
CONCLUSIONS
Many dependent heroin users in contact
with law enforcement and treatment
agencies engage in high rates of drug
dealing and property crime to finance their
drug use. Their criminal activity usually
begins before their heroin use but the
development of heroin dependence
intensifies criminal activity and entrenches
users in a criminal lifestyle.
There is consistent evidence that MMT
reduces heroin use and crime while
heroin-dependent persons receive
adequate doses of methadone in
programs with a maintenance treatment
goal. The evidence comes from a small
number of randomised controlled trials,
the findings of which are supported by a
substantial body of observational studies,
primarily from the US. There are good
reasons for believing that the impact of
MMT on crime observed in American
studies also occurs among opioiddependent persons in Australia who
receive MMT.
The number of heroin-dependent persons
enrolled in MMT in Australia has
increased steadily over the past decade.
The factors pushing heroin users into
MMT include: the unavailability, high cost
and low purity of heroin, possibly the level
of police activity directed at user-dealers,
and the use of legal coercion to
encourage heroin users convicted of
drug-related offences to seek treatment.
The factors pulling dependent heroin
users into MMT include: the increased
availability of drug substitution treatment,
its increased attractiveness to heroin
B U R E A U
O F
C R I M E
users with reductions in the therapeutic
demands made upon them, and more
liberal take-away doses.
An approach which may be worth a trial is
the use of longer-acting opioid drugs like
buprenorphine to reduce the frequency of
supervised dosing. Alternative methods
of MMT delivery also can be trialed,
including GP prescribing and pharmacist
dispensing of methadone. Heroin
maintenance may be one option that
could increase the attractiveness of opioid
maintenance treatment for a small group
of severely dependent heroin users who
have failed at other forms of drug
treatment. Its impact on heroin use is
likely to be modest because of the high
costs of providing it and because
community concerns will limit its
application to large numbers of dependent
heroin users.
Any decision to expand availability of
MMT as a crime control measure should
begin cautiously and be accompanied by
sufficient resources to ensure that MMT is
adequately delivered. Care should also
be taken to ensure that MMT is provided
in a way that balances the potentially
conflicting interests of dependent heroin
users and the general public. A fair
balance needs to be struck between
benefiting MMT clients (by improving their
health and quality of life, reducing their
risk of contracting HIV/AIDS and other
infectious diseases and reducing their risk
of imprisonment) and benefiting the wider
community (by reducing the prevalence of
HIV/AIDS, and reducing drug-related
crime and correctional costs).
ACKNOWLEDGMENTS
I would like to thank the following persons
for their assistance in the preparation of
this bulletin: Danny O’Connor and his
staff at Drug and Alcohol Services,
Central Sydney Area Health Services
(Gladstone Hall) provided a congenial
work environment in which to work while
on Special Studies Program from the
University of New South Wales; Eva
Congreve, Archivist, the National Drug
and Alcohol Research Centre, showed
her usual unfailing diligence in locating
fugitive literature; Peter Congreve, parttime research assistant, was expeditious
in obtaining books and copies of articles;
Gail Merlin checked references and proof­
read the text; and the following persons
S T A T I S T I C S
commented on an earlier draft: Drs Jan
Copeland, Shane Darke, Lisa Maher, Jeff
Ward, Don Weatherburn (and staff at the
Bureau of Crime Statistics and Research),
and Deborah Zador.
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