Comments on Ball and van de Wijngaart's Article

Olympian ideas or pragmatism?
Alex Wodak

There is much to be said for the IMRAD (Introduction, Method, Results, Analysis, Discussion)-type research paper. This highly stylized approach focuses on a specific question subjected to intense scrutiny according to an internationally well-understood methodology. Alas, all too often, the research question is of minimal theoretical or practical interest. Yet another paper appears whose only value is the embellishment of an author's curriculum vitae.

Every now and then, otherwise well-trained researchers drop their guard and examine "the big picture." This usually happens over a chance social meeting at a conference or some other similarly private setting. Unlike their IMRAD cousins, "big picture" contributions are regarded with much suspicion. Scrutinizing the grain of sand in the universe carries much higher status than attempting to see the universe among the grains of sand. In my opinion thoughtful overviews of clinical activity and research are greatly undervalued. The present contribution by Ball & van de Wijngaart, spanning continents and diverse cultural differences, provides more food for thought than many a fine-grained study.

Harm reduction means different things to different people. To some, harm reduction is little more than a device to conceal a view that the use of mood-altering substances is potentially life-enhancing and mind- expanding (Strang, 1993). To others, harm reduction is neither for nor against drug experiences but rather a pragmatic approach taken to minimize the adverse health, social or economic consequences of mood altering substances without necessarily requiring the elimination or reduction of drug consumption (Heather et al,1993). This author subscribes to the latter interpretation and finds the opposition of harm reduction and rehabilitation in the title irksome. Why do these entities have to be regarded as mutually exclusive options?

One of the many threads running through this clash of two cultures and two value systems is the contrast between the more individually focused American approach to interventions and the more community focused European style. The American approach tends to emphasize the standards achieved in centres of excellence. The European approach, less impressed by Olympian excellence, is more concerned to ensure that minimum standards are still acceptable. Although Ball & van de Wijngaart discuss the "better" US programmes, these programmes seem to represent a minority of the existing treatment (D'Aunno, 1992).

It may well be that the effectiveness of the better US methadone clinics, as Ball & van de Wijngaart imply, exceeds the effectiveness of herter clinics in the Netherlands. However, the Dutch appear to have been far more successful in attracting and retaining a larger proportion of persons dependent on heroin in methadone treatment. Achieving higher participation rates may require a lowering of standards so that individuals with less ambitious goals can still be accommodated. Behaviour tolerated in a Netherlands programme would probably result in "involuntary discharge" in the United States. Stripped to its essentials, this comparison is the choice between vaccinating the multitudes or providing an intensive care unit for the select few. A health-care system based on fee-for-service will inevitably tend to favour the intensive care unit approach. A social system designed to make life tolerable in one of the most crowded nations on earth is likely to emphasize community goals. My prejudice is to maximize the participation rates of methadone treatment (even if these do not achieve the magnificent results of the best US centres) but have fewer drug-dependent people languishing in jail.

HIV has changed the way we see many of these arguments. While many of us were mesmerized during the last decade by the enormity of containing an epidemic of HIV infection among and from injecting drug users, epidemics of hepatitis B and hepatitis C sneaked in under our radar. Consideration of epidemics of bloodborne viruses surely adds weight to a more public health-orientated approach to methadone maintenance treatment in the community. Shrinking public sector expenditure in western countries during the last decade has added an additional twist. More must now be achieved with less.

For decades, methadone has been a monolithic entity, prescribed alike for individuals with diverse backgrounds and situations. Treatment followed the Henry Ford principal: you could have whatever methadone treatment colour you wanted provided it was black. Individualizing treatment probably does produce better results although it will be the devil's own job to try and prove this. A dozen or so IMRAD studies might be required to tell us whether Jan would be better or worse off treated in an environment which enforces rehabilitation, rather than a unit which allows individual patients to set their own pace. By the time the results of these studies are available, it is likely that Jan will be a different person. Furthermore, allowing Jan to play a major role in determining his own future by negotiating his own goals with treatment staff is likely to increase the chance that he will choose options which his therapists would have preferred anyway.

Another important aspect of harm reduction is the emphasis on trying to prevent patients from irreparably damaging their health, social or legal status in the knowledge that sooner or later many drug users find their own way of stopping successfully. Simply keeping alcohol- and drug-dependent people alive and well for as long as possible is a very important component of treatment. At some stage the alignment of the planets or some other combination of mysterious factors prompts Jan to realize that his drug-using days are over. The judge who pronounced Jan's last sentence, the staff of the methadone programme or therapeutic community, the family doctor, the hepatologist, parenthood or falling in love may each have been responsible alone or in combination for producing Jan's new drug-free life. Who can ever know which of these competing claims is correct? Will our good friend ever be able to tell us? My suspicion is that Jan is probably as good or as bad as any of us in determining at any time what is best for him. Keeping polymorphous perverse Jan alive and free of HIV infection must be an easier task when he has ready access to a Chevrolet methadone programme reasonably responsive to his requirements rather than when he has to patiently wait for a year to enter a Cadillac programme.

Finally, drug treatment cannot be considered in isolation from drug policy. The provision of methadone in the Netherlands and the United States needs to be considered from the context of powerful social, cultural, historical and drug policy influences. Jan and his methadone programme cannot be simply lifted up and planted in Manhattan or Watts any more than their US counterparts could be transplanted to Delft.

Alex Wodak
Alcohol and Drug Service,
St Vincent's Hospital, Victoria Road
Darlinghurst, Sydney
NSW 2010
Australia

Methadone Maintenance as Heroin Substitution
Nicholas Seivewright

I too have recently been struck by events at an International drug addiction conference. With colleagues from Manchester I have been to Holland twice in the last year, including attending the 4th International Conference on the Reduction of Drug-Related Harm in Rotterdam, referred to here. It was nice to read the account by Dr Ball and Dr van de Wijngaart of the conversations at the methadone programme in Utrecht, as it reminded me of the courtesy and informality characteristic of Dutch treatment centres. Dr Ball was probably a little surprised that the client Jan was able to give a lengthy account of his own views to the visitors without being challenged rather more about his attitude to the programme, and indeed his drug-taking activities. I thought, though, that it seemed typical of the humane treatment that Dutch clients receive, probably in turn a reflection of the stamp of liberalism so evident there. Dr van de Wijngaart neatly summarizes the policies of harm reduction: "restrict your use of numerous illegal drugs; but if you do use various drugs, do not shoot your drugs; but if you do shoot, do not share your works..." These messages, sometimes difficult to reconcile with a clinic setting, are very familiar to the British.

It was of great interest to hear Dr Ball speak in Rotterdam, while the events which really set me thinking along these lines recently were at the Second European Symposium on Drug Addiction and AIDS in Siena. Many of the invited lectures were given by senior American figures in the methadone "movement," and those in Europe who had developed programmes under that particular influence. I was struck by the way in which methadone treatment was portrayed, which seemed strangely unfamiliar to me. Space is short here, but suffice to say that methadone seemed to be viewed as a definitive treatment in which, provided that the correct dose was achieved, the patient's medical condition, behaviour and personality would be normalized, as if by a direct primary pharmacological effect. A key matter here, of course, is the blockade effect achieved by high dosage. Similarly, in the case of Jan in Utrecht, Dr Ball believes that his detoxification will be unsuccessful "because he didn't seem to understand the pharmacology of methadone maintenance treatment."

Pharmacological treatments of various kinds are one of my main interests, and as someone who prescribes methadone every day I agree completely with Dr Ball about the immediate benefits which can be brought about easily and routinely by this drug. However, I see the mechanism as rather different and, related to that, would draw a very different conclusion from either doctor about this addict's management! A case like Jan is by no means typical of Manchester drug users, but he is very similar to a certain subgroup we have. He has had 15 detoxifications and, to me, is clearly not going to manage without maintenance treatment. The only reason I can see for this man being on 12.5 mg oral methadone is that that is what he wants, given the options available. Coming back to my "mechanism," however, I view methadone primarily as a substitution treatment--I actually quite like the media term "heroin substitute"-- and see the behaviour changes which come about as often secondary effects which result from removal from the daily process of heroin taking. Wise colleagues in Siena pointed out that in America it is probably politically less acceptable to portray methadone as a substitute rather than as a straightforward medical treatment (which indeed it is).

Some addicts can make the switch successfully from using euphoriant drugs of abuse to using methadone--in other words, all things considered, the substitute becomes acceptable to them. Others, however, cannot make this transition, and continue to try to enhance the effects of methadone with other drugs (in this country commonly cocaine, temazepam, cyclizine, alcohol, etc) or drop out of methadone treatment. In my view Jan would be very unlikely to make progress on methadone mixture, even in a clinic with the important additional aspects Dr Ball identifies. He is typical of a subgroup who do much better on injectable methadone, or even diamorphine, which would "satisfy" him enough to be able to start worldng within treatment contracts with some hope of success.

Nicholas Seivewright
Senior Lecturer in Drug Dependence,
University of Manchester School
of Psychiatry and Behavioural Sciences,
Manchester Royal Infirmary,
Manchester M13 9WL, UK

Methadone Maintenance Treatment: Harm Reduction or Rehabilitation?
Brian Wells

The most constructive comment that can be made about Jan's situation is that he is plugged into a system that is apparently supportive and caring; and that could refer him on should he "mature out" and decide to take steps towards change. On one hand, it may be that the system has helped to reduce harm that might have occurred had Jan simply remained on the street. On the other hand, it can be argued that it is simply facilitating or enabling a highly unsatisfactory life-style in someone who still injects drugs (including his methadone), who still resorts to petty crime in order to buy heroin and cocaine and who probably spends his entire time in drug-related pursuits, including fluent debate, albeit misinformed at times, with interested professionals and other "intellectuals" around the local drug-taking community.

It is interesting (and sometimes irritating) to hear about Holland as a Mecca of good practice with regard to drug users. On visiting, one finds many articulate users like Jan and (depending upon who you talk to and what you read), just as high levels of HIV and rates of crime as anywhere else. It would seem that unless pressures are placed upon drug users to make positive change, either via abstinence or methadone maintenance, given in a manner that has been demonstrated to engage clients effectively, markedly reduce illegal drug use and unsafe behaviours, etc., that Jan may well be right. He and his colleagues would probably fare better if they were simply given all the heroin that they wish, free of charge by the Dutch Govennnent. What seems to be taking place in Holland is a halfhearted form of social control in which blind eyes are turned and little encouragement is offered towards rehabilitation and resocialization, unless the impetus comes from the client. Of course, Jan will prefer not to be subjected to the rigours of a US-type methadone programme or indeed (God forbid), encouraged towards abstinence. At present he has no reason to make any effort. The prognostic gloom expressed about him is undoubtedly realistic in the current circumstances. Meanwhile, someone who has a desire to develop a relationship with his children and who may have considerable internal resources, is continuing to use services merely as a part of his less than satisfactory drug-taidng repertoire. Although he expresses otherwise, he is probably not having a great deal of fun.

John Ball's article certainly makes though provoking reading in times when user groups, "drugs and crime" organizations (including the police) and some purchasers are applying pressure on providers to supply a complex variety of prescribing regimes. Many of these groups are passionate, articulate and, like Jan, make comments such as "It's fine to prescribe heroin but probably not cocaine."

Surely, actual policy should be based upon findings of research; and surely, we should be clear about what is a public health strategy (i.e. what shall we try to do about the global drug problem) and what is likely to be therapeutic for individuals. These two perspectives are constantly blurred in the prescribing debate while we continue to go round in circles. The beliefs of users, ex-users and "world problem solvers" are often important, interesting and innovative. There probably will always be grey areas in this field, but we can learn from unfortunate individuals like Jan and move on to implement systems that are supported by hard data.

Brian Wells
The Centre for Research on Drugs and Health
200 Seagrave Road,
London SW6 IRQ, UK

Identifying New Policy Trade-offs
Peter Reuter

The Ball & van de Wijngaart paper raises an interesting point: whether there may be a trade-off between treatment access and efficacy. High percentages of addicts "in contact with the system," a primary goal of Dutch policy, may not maximize the harm reduction effects of treatment.

Low threshold programs were originally intended to provide easy entry into the formal treatment system; patients were to move from low threshold to programs that provided greater services and helped them deal with more of their problems. This would maximize the flow of clients into high end treatment. Instead it has emerged that many, perhaps most, patients become stuck at the low threshold level, where they receive services which improve their quality of life but do not have to make the major behavioral changes required by more rehabilitative regimes. Individually they are better off than they would be in no program and worse than they would be in high end programs. Tle availability of low threshold programs may reduce enrollment in the more demanding and effective programs.

Some hypothetical numbers may help. Assume that under the Dutch regime, of 1000 addicts at any one time 750 are in treatment, but only 250 in high end programs; without the low end programs, 350 would be in treatment, all in high end programs, simply because no altemative is offered. Which rates better on a harm reduction scale?

Clearly, this is a difficult question to answer. The multi-dimensional gains from the two kinds of programs are hard enough to calculate individually and much depends on program interactions; if the low threshold programs have AIDS prevention as a primary goal, then do they encourage needle exchange more than independent, free, syringe exchange programs? The age and experience of the injecting population is also relevant; it may be that younger addicts are more likely to make the jump from low threshold programs to the higher end programs, while experienced addicts (e.g. Jan), more discouraged by treatment failures, are likely to get trapped at the low threshold.

The problem here is one that faces other kinds of regulation of methadone. For example, the United States (like many nations) has tight controls on the distribution of methadone in drug treatment, aimed at preventing leakage into illegal markets. Such leakage does occur, mostly through sale by addicts with take-home rights. Should this leakage be a policy concern? Impressionistically, many of those buying methadone are attempting to self-medicate their own heroin problems. It would be preferable to have them enter methadone treatment rather than selfmedicate, but tighter regulation that lessened leakage into the black market might induce only a fraction of those currently self-medicating to actually enter treatment. The optimal amount of leakage may be greater than zero.

This reasoning also suggests some principles for the design of low threshold programs. Ease of entry does not require low standards for compliance; a more demanding regime may lead more to stop but also more to become willing to graduate to programs that will induce more significant changes in their drug-taking and lifestyle. The appropriate measure of success is the reduction in drug-related harms from given treatment expenditures, which may come from a smaller treatment population in higher end programs. If this is correct, then studies of which characteristics of programs determine the probability of transition between programs become an important part of the treatment research enterprise.

Peter Reuter
Professor of Public Affairs and Criminology,
School of Public Affairs,
University of Maryland
College Park, Maryland 20762,
USA

Philosophy and Reality in Methadone Treatment
Don C. Des Jarlais

Ball & van de Wijngaart present an interesting comparison of the experiences of a "typical" Dutch patient in a harm-reduction "care" methadone program in Utrecht versus what happens to a patient in the "more structured" environment of the "better" methadone maintenance programs in the United States. The gist of the comparison is that the Dutch "care" programs are characterized by a climate conducive to continued illicit drug use while the "better" US programs "tried to create a rehabilitation environment in which there was group support for rehabilitation and the provision of comprehensive services." The term "better" is used in reference to other US programs, not in cornparison to the Dutch programs. Ball & van de Wijngaart note that both types of programs have strengths and weaknesses. However, while the differences between the Dutch and the "more structured" US programs noted by Ball & van de Wijnaart are certainly important, the similarities between the Dutch programs and the typical US program may be even more important. There are at least five areas of similarity:

(1) Funding for methadone maintenance programs in the US has barely kept pace with inflation, and has certainly not been sufficient to provide for the extra services required for persons with cocaine problems and for HIV- infected methadone patients. Indeed, financing that is sufficient to provide full rehabilitation services is becoming rare, and thus the rehabilitation services actually provided in many programs may not be significantly different from what is provided in the Dutch "care" programs. (Moreover, if one also takes into account the social services available to patients outside the care programs, most Dutch patients are probably receiving higher levels of services than their US counterparts.)

(2) Many programs, particularly in the northeastern part of the US, have increasingly been adopting hann- reduction tactics since the emergence and spread of the HIV/AIDS epidemic among drug injectors. Many programs now teach injectors how to clean injection equipment with bleach and inform their patients about the locations of syringe-exchange programs Many will also no longer discharge patients simply because of continued illicit drug use (i.e. lack of rehabilitation progress). The rationale for not discharging patients is that termination from methadone maintenance would almost certainly increase illicit drug injection, as well as the risk of infection with HIV if the patient is not already infected, or the risk of transmitting HIV to others if the patient is infected.

(3) There is strong local community opposition to the expansion of methadone maintenance treatment in both countries. It is very difficult to establish new methadone clinics in the US because of the "not in my backyard" (NIMBY) syndrome. At least one US city (Boston, MA) has adopted the idea of using a mobile methadone bus, as used in the Netherlands, to circumvent local community opposition.

(4) Many patients in both countries appear not to understand (or to understand but reject) the underlying theory of methadone maintenance. They appear to want low dosages of methadone, failing to appreciate the protection against narcotic craving and the cross-tolerance blockade of heroin euphoria that are achieved with higher dosages. It seems that many patients in both countries believe that it is somehow wrong to be on methadone, and thus the less methadone taken the better.

(5) Many program administrators in the US (and possibly in the Netherlands--I have no direct data on this) also appear to believe that low dosages are better than high dosages, and that true rehabilitation does not occur until the patient is taken off methadone treatment (United States General Accounting Office, 1990).

These similarities suggest that there are powerful forces that shape the actual provision of methadone treatment in both countries, regardless of the avowed drug-problem philosophy of public health officials.

Nevertheless, even if differences in the drugproblem perspective of public health officials do not always translate into meaningful dffferences at the drug treatment program level, a well-articulated perspective is still important in setting forth the directions in which"we should move--if and when public attitudes and financial resources permit taking constructive action to address the problems of drug misuse. Of course, the still fairly new concept of "harm reduction" is rapidly evolving, so that one cannot yet speak definitively about its exact meaning (Berridge, 1992; Brettle, 1991; Des Jarlais & Friedman, 1993; Des Jarlais, Friedman & Ward, 1993).

It is clear that opposing "harm reduction" to "rehabilitation" in the manner of the Ball & van de Wijngaart paper-- that is, as if these two approaches to drug problems were mutually exclusive-entails some fundamental misunderstandings of what harm reduction is. First, harm reduction proponents have repeatedly stressed the importance of providing a variety of services to people with drug-related problems, and of allowing the person to make informed choices as to what services he or she needs at any given time. To the extent that the Dutch system does not simultaneously provide rehabilitation services in conjunction with methadone maintenance, this would, from a harm reduction perspective, constitute a serious shortcoming in implementation. Even more importantly, harm reduction involves pragmatism--first determining which programs effectively reduce drug-related harm, and then implementing those programs. There is, for example, considerable evidence for the greater effectiveness of high dosage methadone maintenance. Indeed, some of the relevant research in this area has been conducted by Ball himself (for reviews, see Cooper, 1992; Ward, Mattick & Hall, 1992).

Finally, however, it must be emphasized that, to the extent that methadone patients remain misinformed about the advantages of higher dosages--and to the extent that program directors do not provide adequate dosages-- neither the Dutch nor the American methadone treatment system is truly practicing either rehabilitation or harm reduction.

Don C. Des Jarlais
Beth Israel Medical Center,
First Avenue at 16th Street,
New York, ArY 10003, USA

Methadone Maintenance Treatment: Harm Reduction or Rehabilitation?
Giovanni Rezza

The topic of methadone maintenance has traditionally been a political one, rarely involving the medical field. In many areas of the world, treatment of drug dependency has been considered to be a social and not a public health concern. Social and health care workers, politicians and opinion leaders have taken a long-time stand against the "medicalization" of this problem and the consequent use of substitutive drugs. As a result, a stigma has been attached to methadone, preventing its use on a large scale in many countries. Other countries have only allowed shortterm methadone programmes aimed at rapid detoxification. This is the case in Italy, where methadone treatment is readily available, yet where high-dosage maintenance programmes have not been officially approved and, when implemented, have been hypocritically defined as "long-term" programmes, in order to avoid the negative associations of the term "maintenance." By contrast, long-term or maintenance treatment has been endorsed in countries such as the United States and the Netherlands.

The ideological pressure to fight all types of drug dependency has always taken precedence over pragmatic approaches aimed at reducing drug-related harm and crime, even in countries with a high incidence/prevalence of HIV infection among IDUs and with high drug-related morbidity and mortality. Negative attitudes towards methadone maintenance programmes in particular derive from past programmes that mainly addressed detoxification, using low doses of methadone for varying periods of time. In these cases, the persistence of injecting behaviour gave birth to the firm belief that methadone does not reduce the risk of acquiring HIV infection. A survey conducted in Italy revealed that almost 50% of the directors of the 250 participating drug treatment centres did not believe that methadone was useful in preventing the spread of HIV infection among drug users. However, more than 90% were in favour of distributing syringes and condoms."(1)

The literature has stressed greatly the importance of methadone maintenance programmes in reducing the risk of HIV infection.(2,3) Studies conducted in the United States have demonstrated that the frequency of heroin injection decreases with increased doses of methadone,(4) suggesting that the long-term use of high doses of methadone may contribute both to risk reduction and rehabilitation.

The article written by Ball & van de Wijngaart and published in this issue of Addiction addresses a topic that is of critical importance in countries with methadone maintenance programmes. The American and Dutch approaches principally differ in that the American approach consists of rigid regulations and strict supervision of participants. Programs are often integrated with psycho-social services and mainly address rehabilitation. By contrast, the Dutch approach focuses mainly on risk reduction. In theory, it would be easy to demonstrate the greater efficacy of long-term comprehensive programmes with high doses of methadone in achieving abstinence from heroin injection,(5) and to highlight the relatively poor results that might be obtained with the risk reduction approach. In fact, an American study has suggested that integration of methadone treatment in comprehensive programmes including counselling and other psychological services is important for improving the likelihood of successful outcomes of methadone maintenance.(6)

However, the use of clinical trials, unfortunately, is not the best method for assessing which of the two strategies is preferable. For instance, low-threshold methadone programmes (interim programmes), even if less effective than comprehensive programmes, have been shown to reduce the risk of HIV infection through the reduction of heroin use.(7,8) It should also be taken into account that provision of comprehensive programmes to a large number of people is not always feasible. Thus, the impact at the population level of strategies aimed at inducing behavioural change in a large community of individuals may be greater than that of programmes addressed at abolishing the risk in a limited number of people. In this light, the population effect of the two different approaches should be assessed on a large scale, taking into account the methodological problems related to evaluating each specific outcome.

The AIDS epidemic has taught us that there is no room for absolutism in medicine and prevention.(9) Both of the above described approaches could be improved. Many variables need to be considered when planning methadone maintenance programmes, such as duration (which by definition is long), dosage, integration with other therapies (comprehensive programmes), accessibility, route of drug administration (oral, injecting) and location (drug treatment centre, home). Easier access to methadone treatment should be a primary objective for health authorities in the United States, while many European countries should focus on the provision of comprehensive programmes and the evaluation of the appropriate dosages of the substitutive drug. If both the American and the Dutch approach are adopted, certain issues will have to be faced. First, should the same facilities provide different options to different people, or will specialized facilities be needed? Secondly, should access to comprehensive programmes be based on individual preference? Tlirdly, in the AIDS era, should comprehensive programmes be so inflexible?

The AIDS epidemic has prompted American health authorities to modify their approach and allocate funds for low-threshold treatment (interim methadone programmes), implemented in order to avoid waiting lists and provide treatment for a greater number of persons. (Standards for these programmes were recently issued by the Food & Drug Administration and the Substance Abuse and Mental Health Services Administration.)(9,10) This is a clear acknowledgement of the importance of risk reduction activities and is an example of pragmatism and flexibility prevailing over demagogy and ideological wars.

Giovanni Rezza
AIDS Unit, Istituto Superiore di Sanita,
Viale Regina Elena 299,
00161 Rome, Italy

Some Questions About the Harm Reduction Approach
Gerhard Buhringer

After reading the paper at first I was speechless. The American and Dutch author (and his client) present two worlds with different health-political and ethical opinions on how methadone maintenance should be delivered and behind that, how society should deal with psychoactive substance use, so that no compromise seems to be possible. I can only express my thoughts and doubts in the following comments and questions:

(1) Methadone maintenance might enable an addict to give up his illegal substance use and negative social behaviour, but to support these advantages it is necessary to implement some control and rehabilitation measures in the methadone dispensing process. Tle dilemma is that the less the programme is controlled, the more clients will enter and stay in that programme, but with the price of more negative side effects (e.g. continued heroin abuse, continued crime, high illegal methadone market). Conversely, the more controlled the unwanted behaviour, the fewer side effects occur but also the fewer clients will accept the programme.

(2) The Dutch client and his therapist are in favour of as little control as possible. The therapist seems not to recognize the mentioned dilemma (obviously the client can not see it). The client argues in terms of a nice life, methadone "reduced his compulsive need for opiates, ... he can now use other drugs more selectively for pleasure." The therapist supports this view with the concept of harm reduction, which means for him that every help is acceptable which not only reduces the problems of drug abusers, but positively increases their quality of life.

(3) The question is: could it be that short-term individual harm reduction does not correspond with long- term individual and social harm reduction but on the contrary increases harm for the individual and for society? No one knows the outcome of such a comprehensive evaluation, but I have the feeling that the view of harm reduction in the paper is too narrow and only part of the truth. I estimate that Jan's almost daily intravenous heroin use, regular heavy alcohol and hashish use and a minimum of approximately a thousand dollars a month to be collected for drug-taking by illegal behaviour creates much more short-term and long-term harm for other individuals, for Jan and for the society in general than the Dutch client and therapist believe.

(4) Scientific evaluation of my question is complicated but would give at least some answers; however, but I am not sure that scientific data would be an argument for the Dutch programme director. Could it be that the therapist supports the client's opinion that drug-taking and stealing is a normal facet of social behaviour, a normal "life- style" which is not only to be tolerated but is also encouraged by social and economic support? If this is so, any question concerning the negative effects of such a methadone maintenance programme is obsolete. Why should anyone restrict his illegal behaviour in maintenance programmes or even try to become abstinent, if regular drug- taking and illegal behaviour is accepted and supported by society?

(5) Self-help abstinence groups use the term co-dependence for people in the environment of addicts who pretend to help them, but in reality support the maintenance of addicted behaviour, and thereby increase the negative effects in the long run. It is hard for me at the moment to label the described programme philosophy as a harm reduction or harm-increased measure. Further research might answer some of my questions, but will not remove the obligation of society to evaluate drug-taking as either a negative or positive and supportable way of life.

G. Buhringer
Director,
IFT Institut fur Therapieforschung,
Parzivalstrasse 25, D-80804 Munich,
Germany

Methadone-maintenance and the Prognosis Paradox
Emily Finch, John Strang & Michael Farrell

Who is the right client for a methadone maintenance programme? The report on which we are commenting raises several important questions which are relevant for those planning drug services in the UK. Two particular questions about methadone maintenance treatment will be considered in this commentary: which drug users can benefit from methadone maintenance and what are the minimum treatment conditions to prevent HIV risk behaviours?

Many US methadone programmes exclude clients who are not co-operating with treatment and are therefore excluding the clients who are non-compliant and have a poor prognosis. In the Netherlands the approach is more flexible and they will therefore aim for more modest gains in worse prognosis cases. A "prognosis paradox" may exist: while the best outcome characteristics will be seen with subjects who were least dysfunctional pre- treatment, the greatest health gain could be seen among those whose pre-treatment status was most dysfunctional. Population benefit may be greater if many difficult drug users like Jan make a small change in a methadone programme, rather than fewer well-motivated good prognosis drug-users making major changes. Might this "prognosis paradox" apply to outcome in methadone programmes?

Jan (the Dutch drug-user) is convinced that his harm reduction methadone care is the "best" treatment for him and others like him, but how is "best" to be gauged? A programme in Amsterdam has been shown not to reduce HIV risk behaviours (Hartgers et al., 1992). From Jan's description of his criminal behaviour and his chaotic drug use, it would not be surprising if the treatment is having very little positive effect.

What are the minimum conditions required to reduce Jan's HIV risk-taking behaviour? John Ball, in his own elegant study of methadone maintenance in the United States, describes programme characteristics that predict treatment effectiveness-mainly intensive counselling and medical care, and good staff morale (Ball & Ross, 1991). Yancovitz and his colleagues, however, evaluated an interim methadone programme where there was no intensive counselling input to the patients, only methadone, and found substantial reductions in heroin use although they only followed their sample for a month (Yancovitz et al., 1991). What programme characteristics would be good enough to reduce Jan's risky behaviour, and therefore what components are necessary for a populationbased HIV prevention strategy?

Jan wants to stop using his methadone and in a methadone care service where retention in treatment is more important than short-term outcome; he is allowed to try. Because of this he is taking 12.5 mg of methadone--far below an adequate maintenance dose as judged by US or Australian programmes (Joe et al., 1991; Caplehorn & Bell, 1991). Researchers examining critical factors have studied methadone dose and there is now good evidence that dose is an important variable for positive outcome (Ward et al., 1992). However, this then leads to problems about the extent to which client choice should be taken into account, especially when the patient's choice of treatment has been shown to be inadequate in research.

John Ball emphasizes Jan's inability to understand the pharmacology of methadone maintenance treatment. In the US methadone is thought to provide a pharmacological blockade, which results in opiate-dependent individuals losing the craving for other opiates. In Europe, oral methadone is more usually considered as just another opiate which provides adequate cover for heroin withdrawal and craving, and whose bioavailability characteristics make it commendably boring, and hence less liable to abuse. Street heroin in the US is estimated to be about 5% pure at street level, whereas in the UK the purity is consistently much higher, around 40-50% (ISDD, 1993). This may mean that the European heroin addict may find it much easier to overcome the opiate receptor competitive blockade than the heroin addict in the US. This may be one reason why intensive methadone maintenance programmes in the US succeed in keeping clients off illicit opiates: if so, then this efficacy of "blockade" may break down as street purity of heroin increases in the US.

The questions raised are vital to those of us trying to find the best way to plan and develop methadone progranmes in the UK. While Jan is still in contact with his treatment agency, it is doubtful that he is accruing any significant benefit. We need to learn which treatment factors are the bare minimum for some level of acceptable health gain. John Ball considers the high levels of support and counselling as vital to the treatment of drug users. He fails to provide us with information as to what would be the minimum conditions necessary and therefore what can be dropped in planning treatment.

Is the prognosis paradox important? Perhaps not. The take-home message from the article seems to be that the optimal path is to be found somewhere between the strict US rehabilitation approach and the more laissez- faire approach of the Netherlands.

Emily Finch, John Strang & Michael Farrell
Addiction Research Unit,
National Addiction Centre,
4 Windsor Walk,
London SE5 8AF, UK

Methadone Maintenance: A Reply to the Commentaries
John C. Ball

I agree with Dr Nicholas Seivewright about Dutch hospitality and the unusual candor of drug treatment staff and clients. Not only was Jan a remarkable drug abuser and client, but the program environment was conducive to the discussion of controversial topics. This freedom of discourse was certainly fostered by Professor Wijngaart. The debate about methadone maintenance which we started with Jan in Utrecht has now been expanded to a wider circle. The eight colleagues who have graciously prepared commentaries about the Jan interview have raised additional issues about methadone treatment and provided a diversity of viewpoints about current policy in different nations. Among the questions addressed in the commentaries are: How can opiate addicts and other drug abusers in the community best be brought into treatment? Is it desirable to establish different types of methadone programs for patients with varying needs and motivations? How can "harm reduction" be more accurately defined and how can it be related to drug abuse treatment and prevention? Should methadone programs proide minimum, average or enhanced services?

The debate about the scope and character of methadone treatment will undoubtedly continue in Europe, the United States, Australia and elsewhere in the years ahead. Hopefully, policy decisions in each nation (and often in each city) will be based upon relevant research and program evaluation. In this regard, a few comments about the current situation in the United States seem apt.

There are some 650 methadone maintenance programs in the United States with a combined census of approximately 120,000 patients. These programs provide daily on-site oral doses of methadone to patients, bi- weekly counselling and limited medical services. These average methadone maintenance programs have been quite successful in rehabilitating most opiate addicts who remain in treatment. Thus, most patients cease intravenous drug use and their criminal behavior is markedly reduced after one or more years of treatment.

None the less, we find ourselves beset with several difficult problems. First, as Don Des Jarlais notes, there has been a shortfall in funding for methadone maintenance treatment at a time when patients' need for services has increased; the result is that most programs are unable to provide the comprehensive medical and rehabilitative services required. Secondly, recent program evaluations have established that some methadone programs are markedly more effective than others. In some programs 90% of patients have ceased intravenous drug use, while in others the majority are still injecting and sharing needles. This raises the question of whether we should continue support for ineffective programs; or, stated differently, how can we improve program effectiveness?

Finally, with respect to our discussion of methadone treatment in various nations, it is significant that all of the commentaries appeared to support this modality of treatment as a means of coping with opiate addiction. The diverse viewpoints expressed primarily addressed the questions of whether this modality should provide more (or provide less) comprehensive treatment and rehabilitation, and whether it should be expanded to additional drug abusers. T'hese two issues seem likely to continue as a focus for debate in the years ahead.

John C. Ball
Professor, Department of Psychiatry,
School of Medicine, University of Maryland,
Baltimore, Maryland, USA

References: Wodak

D'aunno, T. & Vaughn, T. E. (1992) Variations in methadone treatment practices: results from a national study, Journal of the American Medical Association, 267, pp.253-258.

Wodak, Heather A., Nadelmann, E. A., & O'Hare, P. A. (Eds.) (1993) Preface. Psychoactive Drugs and Harm-reduction: From Faith to Science, pp.v-ix (London, Whurr Publishers).

Strang, J. (1993) Drug use and harm reduction: responding to the challenge, in: Wodak, H. A., Nadelmann, E. A., & O'Hare, P. A. (Eds.) Psychoactive Drugs and Harm-reduction: From Faith to Science, pp. 3-20 (London, Whurr Publishers).

References: Des Jarlais

Berridge, V. (1992) Harm reduction: An historical perspective, presented at the Third International Conference on Reduction of Drug-Related Harm, Melbourne, Australia.

Brettle, R. P. (1991) HIV and harm reduction in injection drug users, AIDS, 5, pp.125-136.

Cooper, J. R. (1992) Ineffective use of psychoactive drugs: methadone treatment is no exception, Journal of the American Medical Association, 267, pp. 281-285.

Des Jarlais, D. C., & Friedman, S. R. (1993) AIDS, injecting drug use, and harm reduction, in: Wodak, et al. (Eds.) Psychoactive Drugs and Harm-reduction: From Faith to Science, pp. 293-305 (London, Whurr Publishers.

Des Jarlais, D. C., Friedman, S. R., & Ward, T. P. (1993) Harm reduction: a public health response to the AIDS epidemic among injecting drug users, Annual Review of Public Health, 14, pp. 413-450.

United States General Accounting Office (March, 1990). Methadone Maintenance--Some Treatment Programs are not Effective: Greater Federal Oversight Needed, Publication No. GAO/HRD-90-104.

Ward, J., Mattick, R., & Hall, W. (1992) Key Issues in Methadone Maintenance Treatment (Kensington, Australia, New South Wales University Press).

Endnotes: Rezza

1. Salamina, G., Binkin, N., Gianzi, F. P., Latanzi, A., & Rezza, G. (1993) Attitudes and practices of public drug treatment center directors regarding HIV prevention among injecting drug users, Italy, 1992, IX International Conference on AIDS. Berlin, June 6-11 (PO-D17-3933).

2. Cooper, J. R. (1989) Methadone treatment and acquired immunodeficiency syndrome. Journal of the American Medical Assoctiation, 262, pp. 1664-1668.

3. Novick, D. M., Joseph, H., Croxson, T. S., et al (1990) Absence of antibody to human immunodefeciency virus in long-term, socially rehabilitated methadone maintenance patients. Archives of Internal Medicine, 150, pp. 97-99.

4. Ball, J. C., Lange, W. R., Myers, C. P., & Friedman, S. R. (1988) Reducing the risk of AIDS through methadone maintenance treatment. Journal of Health and Social Behavior, 29, pp. 214-226.

5. Glass, R. (1993) Methadone maintenance: New research on a controversial treatment. Journal of the American Medical Association, 269, pp. 1995-1996.

6. McLellan, A. T., Arndt, I. O., Metzger, D. S., Woody, G. E., & O'Brien, C. P. (1993) The effects of psychosocial services in substance abuse treatment. Journal of the American Medical Association, 269, pp. 1953-1959.

7. Yancovitz, S. R., Des Jarlais, D. C., Peyser, N. P., et al (1991) A randomized trial of an interim methadone maintenance clinic. American Journal of Public Health, 81, pp. 1185-1191.

8. Dole, V. P. (1991) Interim methadone clinics: An undervalued approach. American Journal of Public Health, 81, pp. 1111-1112.

9. Cates, W. Jr., & Hinman, A. R. (1992) AIDS and absolutism: The demand for perfection in perfection. New England Journal of Medicine, 327, pp. 492-494.

10. Anonymous (1993) Interim methadone maintenance treatment. Journal of the American Medical Association, 269, pp. 1361.

References: Finch et al.

Ball, J. C., & Ross, A. (1991) The Effectiveness of Methadone Treatment: Patients, Programs, Services and Outcome (New York, Springer-Verlag).

Capelhorn, J. R. M., & Bell, J. (1991) Methadone dosage and retention of patients in maintenance treatment, Medical Journal of Australia, 154, pp. 195-199.

Hartgers, C., Van Den Hoek, A., Krijnen, P., & Coutinho, R. A. (1992) HIV prevalence and risk behaviour among injecting drug users who participate in "low threshold" methadone programs in Amsterdam, American Journal of Public Health, 82, pp. 547-551.

Institute for the Study of Drug Dependence (1993) National Audit of Drug Misuse in Britain 1992 (London, ISDD).

Joe, G. W., Simpson, D. D., & Hubbard, R. L. (1991) Treatment predictors of tenure in methadone maintenance, Journal of Substance Abuse, 3, pp. 73-84.

Yancovitz, S. R., Des Jarlais, D. C., Peyser, N. P., et al (1991) A randomized trial of an interim methadone maintenance clinic. American Journal of Public Health, 81, pp. 1185-1191.

Ward, J., Mattick, R., & Hall, W. (1991) Key Issues in Methadone Maintenance Treatment (Sydney, New South Wales University Press).