Encyclopedia of Drug Policy

Mark A. R. Kleiman, James E. Hawdon

• Publisher: SAGE Publications, Inc
• Year: 2011
• ISBN:
  9781506338248
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Public Policy
• Index: Politics & International Relations

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Spanning two volumes of approximately 450 entries in an A-to-Z format, this encyclopedia explores the controversial drug war through the lens of varied disciplines. A full spectrum of articles explains topics from Colombian cartels and Mexican kingpins to television reportage; from "just say no" advertising to heroin production; and from narco-terrorism to more than $500 billion in U.S. government expenditures.
Key Themes - Cases - Conferences and Conventions - Countries (Affecting U.S. Drug Policy) - Drug Trade and Trafficking - Laws and Policies - Organizations and Agencies - People -Presidential Administrations - Treatment and Addiction - Types of Drugs

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Addiction Maintenance

Addiction maintenance is the broad concept of prescribing a substitute drug that will maintain an addict so that they do not experience withdrawal effects, but will not achieve a “high.” This approach is often used to stabilize individuals who have a chaotic lifestyle with a high level of risk-taking behavior, and who may be funding their habit through crime. Addiction maintenance treatment is a pragmatic approach that could be considered as coming under the broad concept of “harm reduction,” which gained strength when human immunodeficiency virus (HIV) emerged in the 1980s. Maintenance prescribing in opiate addiction has a strong evidence base, with methadone being the most widely used drug. By contrast, a maintenance approach is rarely used in psychostimulant addiction (e.g., amphetamine substitute prescribing), and the evidence of effectiveness is weak. This entry will offer a synopsis of the types of drugs used in addiction maintenance, the effectiveness of this approach, and what factors influence effectiveness.

Maintenance Treatment in Opiate Addiction

In theory, any opiate drug could be used for addiction maintenance. Methadone, buprenorphine, heroin (diamorphine), and LAAM (levomethadyl acetate hydrochloride) have been used as opiate substitutes, although LAAM is no longer used due to cardiac side effects. Methadone is generally used in the form of an oral liquid. although an injectable preparation is available. Buprenorphine is generally used as a tablet dissolved under the tongue, and diamorphine is only available in an injectable preparation. Methadone has become the preferred treatment because it is long acting, thereby lending itself to a once daily dose, and is available in an oral preparation, eliminating the need for injections.

Methadone maintenance treatment (MMT) has been studied extensively since it was first pioneered in 1965 by Drs. Vincent Dole and Marie Nyswander in the United States. Cochrane reviews comparing buprenorphine and methadone have found that buprenorphine is effective, but less so than methadone at adequate doses. There have been a few trials involving heroin—using diamorphine maintenance compared to other pharmacological treatments.

Diamorphine maintenance can be provided through injecting clinics where patients attend a clinic, often twice daily, for a supervised self-administration of diamorphine. Diamorphine may also be prescribed for take-home administration. Diamorphine maintenance has been found to be effective at reducing use of illicit drugs and retaining people in treatment. Comparisons of diamorphine maintenance with other drugs have reached no definitive conclusion with regard to their relative effectiveness.

Effectiveness of Opiate Maintenance

Many studies have been conducted over the last three decades that demonstrated to varying degrees that maintenance treatment generally can reduce the use of illicit opiates and reduce crime as well as resulting in other positive benefits for the individual and for society as a whole.

The measures used to evaluate the success of maintenance treatment are the following:

• Reduction in crime
• Improvement in employment
• Reduction in injecting and needle sharing (thereby lowering the risk of bloodborne diseases)
• Reduction in illicit opiate use during treatment
• Reduction in mortality
• Retention time in a treatment program.

Entry into maintenance treatment is significantly associated with reductions in criminal behavior, particularly drug-related crime. A 1978 trial in New York found that after 12 months, the control group (no treatment) were 53 times more likely to have been re-incarcerated compared to the methadone maintenance group. In the United Kingdom (UK), acquisitive crime was reduced by 50 percent at one year, and effects were maintained. Some of the greatest reductions in crime were among those with the highest offending rate. Similar positive findings have subsequently been found with diamorphine and buprenorphine.

Employment is often used as a proxy measure for social rehabilitation. A review of the literature that used employment as a measure of social rehabilitation found that three out of four studies reported an increase in employment during or after MMT compared to the start of MMT. Thus, maintenance treatment has a moderate, positive effect on employment. A crucial influencing factor could be whether a particular program incorporates employment support.

Reviews of published research have consistently concluded that there is a reduction in injecting and needle sharing with MMT. It must be emphasized that injecting is generally reduced but not necessarily eliminated in MMT clients. Even in effective programs, a quarter of patients may continue to inject. Therefore, sterile injecting equipment should still be made available to those in treatment, in spite of the mixed message this may give. Similarly, buprenorphine and diamorphine maintenance reduce injecting and needle sharing.

Maintenance treatment has a major impact on illicit opiate use. A 2002 review of randomized controlled trials of methadone all showed a significant reduction in the use of illicit opiates. Studies following individuals in treatment in the UK and in Australia similarly found reductions in illicit opiate use. However, the effect on cannabis, cocaine, or alcohol use is less definitive.

The consistently positive results of MMT in such a variety of settings indicate that illicit opiate use is reduced, although not eliminated during methadone maintenance. Similarly, buprenorphine and diamorphine maintenance reduce illicit opiate use.

Providing maintenance treatment encourages people to continue to be engaged in treatment: while in treatment, other issues can be addressed to improve the user’s health and wellbeing.

Many studies have found that those on methadone have a reduced risk of mortality compared to untreated opioid users. In particular, a 1990 Swedish study found that untreated heroin users had a mortality rate 63 times that for their age group and the mortality rate for those on a methadone program was only eight times higher than for their age group. Although this is still higher than average, the rate is greatly reduced.

Factors Affecting Effectiveness of Maintenance Prescribing

Several factors have been identified as influencing the success of maintenance prescribing. These can be broadly divided into program criteria and people criteria. Treatment progress and outcome are affected by various factors: (1) the dosage of chosen drug; (2) counseling, including employment support and training in the prevention of relapse; (3) the use of contracts and conditions; and (4) urinalysis.

There is strong evidence that higher doses of methadone (more than 60 milligrams) are associated with better retention rates and reduced use of illicit opiates. Careful assessment and induction to higher dose methadone treatment programs are essential to prevent prescribing a potentially fatal dosage. Similarly for buprenorphine, medium to higher doses are more effective (from 8 to 16 milligrams).

There is limited evidence of the effectiveness of low intervention maintenance treatment in which methadone or buprenophine is prescribed but with minimal support services in the form of counseling. Many of the trials discussed previously provided counseling as part of the treatment package. Only one limited study in 1991 looked at the provision of methadone alone at a dose of 60 milligrams. This study followed up people (n=301) for only one month, but it did indicate that methadone alone would reduce the use of heroin during that time. A 1993 study considered the effect of psychosocial services during MMT and found that counseling and the availability of on-site professional services such as a psychiatrist, an employment counselor, and a family therapist were associated with better outcomes. Therefore, it appears that an ideal maintenance treatment should incorporate counseling and support services although the optimal nature of such services is undetermined.

As well as higher doses of methadone and provision of counseling services, the most effective programs have been found to have the following additional characteristics:

• The treatment goal was successful ongoing maintenance rather than abstinence
• Available medical services
• Good staff patient relationships
• Low staff turnover rates

Contingency management has been found to be effective at reducing treatment failures and illicit drug use. This approach uses a reward-based system for keeping in treatment. Random urine testing has also been found to be more effective than regular urine testing.

A number of individual characteristics also affect maintenance treatment outcome: age at first use of heroin (the younger when first used, the less positive the outcome); length of drug use (the longer the drug-using history, the less positive the outcome); use of cocaine before treatment (if cocaine was used, the less positive the outcome); ethnicity (whites are associated with more positive outcomes).

The positive findings of maintenance prescribing in opiate dependence do not translate to psychostimulant dependence. A number of pharmacological agents have been tried, such as cocaine, methylphenidate, and phenteramine, but these have not been demonstrated to be useful and are not recommended.

Cost Considerations

In the UK, findings of the 2001 National Treatment Outcome Research Study estimated that for every £1 spent on drug misuse treatment there is a savings of £3 associated with lower levels of victim costs and reduced demands on the criminal justice system.

In summary, maintenance treatment for opiate addiction has consistently been found beneficial at reducing injecting behavior, illicit drug use, mortality, and crime as well as improving social rehabilitation. The extent to which a maintenance program produces these benefits depends on the features of the program and the individuals taking part. In contrast, maintenance treatment for psychostimulant addiction has not proved efficacious.

See Also: Antagonist Medications; Buprenorphine; Drug Treatment Programs; Evaluative Evidence of Rehab/Treatment Programs; Heroin; Methadone; Methadone Control Act; Needle Exchange Programs; Rehabilitation/Treatment Programs; Workplace: Role, Prevention, and Programs.

Further Readings

Ball, J. C. and A. Ross. The Effectiveness of Methadone Maintenance Treatment: Patients, Programmes, Services, and Outcome. New York: Springer-Verlag, 1991.

Bertschy, G. “Methadone Maintenance Treatment: An Update.” European Archives of Psychiatry and Clinical Neuroscience, v.245 (1995).

Farrell, M., et al. “Methadone Maintenance Treatment in Opiate Dependence: A Review.” BMJ, v.309 (1994).

Gossop, M., J. Marsden, and D. Stewart. “NTORS After Five Years, The National Treatment Outcome Research Study.” http://www.ntors.org.uk (Accessed December 2009).

Gronbladh, L., L. S. Ohlund, and L. M. Gunne. “Mortality in Heroin Addiction: Impact of Methadone Treatment.” Acta Psychiatrica Scandinavica, v.82/3 (1990).

McGlothlin, W. J. and M. D. Anglin. “Long Term Follow Up of Clients of High and Low Dose Methadone Programmes.” Archives of General Psychiatry, v.38 (1981).

McLellan, A. T., I. O. Arndt, and D. S. Metzger, et al. “The Effects of Psychosocial Services in Substance Abuse Treatment.” Journal of the American Medical Association, v.269 (1993).

Ward, J., R. P. Mattick, and W. Hall. “The Effectiveness of Methadone Maintenance: An Overview.” Drug and Alcohol Review, v.13/3 (1994).

Yancovitz, S. R, et al. “A Randomized Trial of an Interim Methadone Maintenance Clinic.” American Journal of Public Health, v.81 (1991).

Catriona Matheson

University of Aberdeen

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Afghanistan

Afghanistan has served throughout its history as a vital point for human migration and international trade. As a result of its geographic location bordering China, Iran, Pakistan, Tajikistan, Turkmenistan, and Uzbekistan, Afghanistan has long been the target of potential invasions and conquests by those nations eager to control it. Many of these invasions have been spurred by Afghanistan’s numerous natural resources. Afghanistan has rich deposits of gold, silver, zinc, and iron ore in the southeast area of the nation. Petroleum and natural gas are found in the north. A collection of natural riches including uranium, coal, sulfur, and lead exist throughout the rest of the nation. As a result of the Soviet intervention of the 1980s, the subsequent civil war, and conflict with the United States, many of these natural resources remain untapped. One of the poorest nations in the world, poppy cultivation and opium production represent over one-third of Afghanistan’s gross domestic product. Although Soviet authorities, the United States, various Afghan governments, and others have attempted to eradicate opium production since 1980, these efforts have proved mostly unsuccessful. As a result, Afghanistan remains the largest producer of illegal opium.

The population of Afghanistan is approximately 28 million. This population is composed of a multiethnic and multilingual society that has emerged because of its historical location between popular trade routes. The official languages are Pashto and Persian. Despite the multiple languages and ethnicities within the country, 99 percent of the country remains of the Islamic faith, with 80 percent belonging to the Sunni branch and 19 percent adhering to the Shia group. The influence of Islam grew during the Soviet invasion and served as the basis for opposition to the invaders. Islamic traditions, codes, and practices serve as the main means for enforcing personal conduct and settling legal disputes.

Golden Crescent

The Golden Crescent is the name given to Asia’s principal area of opium production. This area spans three different countries—Afghanistan, Iran, and Pakistan. The geography of this region suggested the name, with the mountainous peripheries forming the boundaries of the golden crescent. In this area, Afghanistan and Pakistan are the sole producers of opium, with Iran being a transnational transporter for the smuggled opiates. In 1991 Afghanistan became the world’s leading opium producer. The Golden Crescent’s rise to dominance came from government-imposed eradication and poor growing seasons in Myanmar, which historically had been the prim...

Table of contents

• Cover Page
• Title
• Copyright
• Contents
• About the Editors
• Introduction
• Reader’s Guide
• List of Articles
• List of Contributors
• Chronology of Drug Policy
• Articles A to L
• Cover 2
• Title 2
• Contents 2
• Articles M to Z
• Glossary
• Resource Guide
• Appendix A: President Richard Nixon’s Remarks
• Appendix B: Controlled Substances Act
• Index
• Photo Credits