"We can't arrest our way out of our drug problems" has become a familiar mantra in recent years among advocates for more spending on addiction treatment and prevention, including some progressive law-enforcement officials. In a new report, however, noted drug-policy researcher Peter Reuter and colleague Harold Pollack offer a sobering counterpoint: the U.S. can't just treat its way to a drug-free society, either.

"Even with a well-funded treatment sector, a nation will still face chronic problems of disease, addiction, crime and disorder associated with illicit drugs," wrote Reuter and Pollack in the March 2006 issue of the journal Addiction.

"There does seem to be a population prevalence of the disease [of addiction], similar to population prevalence of other diseases. Treatment alone does not make that prevalence disappear," agreed David Rosenbloom, director of Join Together. "Since we have never had a comprehensive treatment strategy in the country, we don't know what the population prevalence really is."

Reuter, director of the program on economics of crime and justice policy at the University of Maryland School of Public Policy, and Pollack, an associated professor at the University of Chicago School of Social Service Administration, are quick to note that "the argument for treatment expansion is strong." Reuter told Join Together that although the risk exists that someone outside the addiction field might conclude from the paper that treatment doesn't work, "a little skepticism for the faithful is just fine."

Broad But Limited Effect

Not only can addiction treatment reduce individual drug use, crime, and incarceration costs, Reuter and Pollack say, but there is evidence that treating dealers who also are addicts may also reduce drug supply. "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 supply-side side-effects, without the larger personal and social costs that come with incarcerating nonviolent drug offenders," write Reuter and Pollack.

However, research from several countries that -- unlike the U.S. -- have offered treatment more-or-less on demand has shown that treatment alone cannot solve the problems of addiction to drugs like heroin or cocaine. "No democratic nation with a major opiate problem 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," the paper notes.

In the 1990s, for instance, the Netherlands provided treatment to about 50 percent of its heroin-dependent population, but failed to put a dent in the number of heroin users, a 2001 study found. Reuter and Pollack note that the stubbornly high number of Dutch heroin users could not be explained by new users taking the place of those who quit using the drug. Rather, they said, many treatment clients simply continued to use heroin, albeit often at a reduced rate.

"Treatment is generally acknowledged to be useful, frail, and incomplete," the authors wrote. "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."

Prevention, Enforcement Outcome Data Lacking

For all of its limitations, however, treatment has a stronger research base and proven track record of effectiveness than other anti-drug strategies, namely prevention and law enforcement and interdiction.

"For primary prevention, the research base is scientifically impressive but programmatically barren," write Reuter and Pollack. "Surprisingly little is known about the effectiveness of prevention programs as implemented ... 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 implemented."

The research landscape on supply reduction is even more bleak, with the authors citing a "near-total absence of impact or outcome evaluation and a near-total absence of public or policymaker demands that such evaluations be performed."

"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 competing enforcement approaches for society," Reuter and Pollack write. "... Prevention and treatment have been studied much more carefully, in part because policymakers and clinicians have demanded that these evaluations be performed to justify program funding."

Call for Harm Reduction, Support for Coerced Treatment

The authors' recommendations for improving the U.S. approach to the drug problem is an interesting mixed bag: an endorsement of coerced treatment via drug courts on the one hand, and a call for pragmatic harm-reduction strategies on the other.

Reuter and Pollack note that interdiction does help keep drugs like heroin and cocaine more expensive; they point out that while Federal Express could ship a kilo of cocaine from Bogota to Miami for about $100, it currently costs smugglers about $15,000 to avoid law enforcement and deliver the same amount of drugs.

Street-level law enforcement, they add, can make dealers more discreet, hinder new users from getting drugs, and (potentially) sweeping addicts into treatment programs. When Swiss officials cracked down on an open heroin scene in Zurich in the 1990s, for example, demand for methadone maintenance programs rose. The authors stressed the need for better coordination between law enforcement and the treatment system to reduce drug use among criminal offenders.

"Treatment may be frail, but it is likely to work more effectively if providers have many opportunities to treat the same person," write Reuter and Pollack. "Existing evidence suggests that treatment episodes motivated by criminal-justice pressure are no less successful than those with other motivations."

If primary prevention is not fully capable of deterring drug use, and relapse is an acknowledged part of addiction treatment and recovery, more attention needs to be paid to secondary and tertiary prevention aimed at users both in and out of treatment, argue Reuter and Pollack. "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 part of any prevention program," they write, even while acknowledging that "abstinence is the right ultimate goal."

Reuter told Join Together that harm reduction is best construed as a framework for examining the harms caused by drug policy itself, not as a definition of individual interventions. In this sense, he said, even drug courts can be considered a form of harm reduction. "Drug courts are willing to take a risk that people who are drug-court clients may use more drugs, but the overall harm to individuals and society will be reduced," he said.

A "drug-free America" is an impossible goal, Reuter and Pollack conclude, and the U.S. should feel no shame in failing to eliminate its drug problems. However, they said, the nation's failure to contain the social harms related to drug use -- such as more than 193,000 AIDS cases among injection drug users, many of which could have prevented via clean-needle programs -- "deserves greater condemnation."

"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," write Reuter and Pollack. "... Harm reduction remains essential because, despite our best use-reduction efforts, drug misuse will remain prevalent and socially costly."

Reuter said that despite the advent of drug courts and innovations like Proposition 36 in California, he remains pessimistic that U.S. political leaders are ready for fundamental drug-policy reform. Few politicians think well of the drug war, he said, but "because there's so little interest, nobody sees the benefits of taking the risk of making significant changes."