by Joanne Csete
Health services for people who use drugs are important on many levels. In addition to the clinical benefits to the individual and the benefit to the community of reducing drug-related harms such as HIV and drug-related crime, they represent an alternative to arrest and detention for some offenses and thus are a possible starting point for developing less repressive drug policies. In spite of a significant body of evidence that drug-related health services are a very good investment for society, they remain woefully underfunded and unavailable.
Summary
• Governments should ensure that health services for people who use drugs (at adequate scale) are a priority for public resource allocation. These services currently have a very low availability relative to need.
• Governments should develop standards and monitoring systems to ensure good-quality health services for people who use drugs in both public and private sector facilities. Further, they should not impede those services.
• Governments should ensure that police do not interfere with health service provision. They should, for example, not use numbers of arrests of drug users as a basis for police compensation or performance review. Police, prosecutors and judges should be trained on the importance of basic health services for people who use drugs.
• Governments may find it useful to invest in benefit-cost studies of these services and should inform the public and legislators in user-friendly ways of their benefits.
• In multilateral bodies, health services for people who use drugs are in dire need of member state champions. United Nations agencies, especially WHO and UNAIDS, have commissioned research and made statements in support of most of these services, but international debates remain dominated by positions based on fear and ideology rather than evidence.
The policy approach to drug control in most countries features heavy spending on policing, interdiction of drugs, judicial processes and incarceration. In the United States, for example, it is estimated that about $50 billion a year from state and federal budgets goes to drug control, of which the majority is devoted to law enforcement and interdiction.1 One estimate of drug-related law enforcement expenses globally puts the figure at about $100 billion per year.2 Drug-related health and social services are nonetheless often underfunded and inadequate to meet the need. Treatment for drug dependence, for example, is frequently inaccessible or unaffordable to people who need it, and this service may not exist without (often grudging) public sector support. Millions of people who need them are without services to protect themselves from injection-related harms, such as provision of sterile injecting equipment and medicines, such as methadone, that stabilise cravings and do not require injection.3
Good-quality treatment for drug dependence and drugrelated harm reduction services have been widely studied and can be life-saving for those fortunate enough to have access to them. The clinical evidence for effectiveness of these measures, particularly with respect to outcomes such as averting HIV or hepatitis C transmission, is very strong. The purpose of this contribution is to review the evidence that they also have a larger economic and social value – that is, to assess their costs and benefits in a broad sense, including with respect to social outcomes such as crime reduction.
Basic ideas: cost of drug use and promise of treatment
Not all drug use is problematic, and thus not all drug use requires a health service response. The most recent annual report of the UN Office on Drugs and Crime (UNODC) uses the rough estimate that globally 167 to 315 million persons aged 15-64 used illicit substances.4 The large range of the estimate reflects the paucity of countries with population-based surveys that would allow more precise estimates and the fact that people who use drugs are highly criminalised in many places and thus may be hidden from surveys. UNODC defines ‘problem drug use’ to include people who inject drugs and people who are diagnosed with drug dependence or other drug-related disorders. It estimated that in 2011 there were 16 to 29 million persons whose drug use was problematic, less than 10 percent of the total of people who use drugs.5 Thus, part of the challenge of drug-related health services is to target those most in need of services and ensure that the services are effective and readily accessible. (A corresponding challenge of economic importance is to ensure that people who use drugs but do not have problematic use are not obliged or otherwise directed into services that they do not need.)
Treatment for drug addiction takes many forms – residential and non-residential, assisted by medications such as methadone or not, ‘12-step’ programmes and other group support approaches, behavioural and cognitive therapies, and many others. It is plain from clinical experience, as noted by the World Health Organization (WHO) and UNODC, that while all of these have some record of success for some people, none is effective 100 percent of the time.6 It is common for people with drug dependence, if they have varied services available to them, to attempt several forms of therapy before finding the one that succeeds for them, whether ‘success’ is judged as complete abstinence or less problematic drug use. There is also evidence from many settings to suggest, not surprisingly, that drug treatment combined with support in the form of stable housing, food assistance and support to family members has the greatest chance of success.7 Based on evidence to date, it is safe to say that drug treatment (combined or not with some form of social support) can reduce problematic drug consumption and thus the costs associated with it, and we take that as a point of departure in this contribution.
Cost-benefit analysis – comparison of the cost of an intervention or programme to a monetary estimate of its benefit – is an essential tool for evaluation of health interventions. (The technique of cost-benefit analysis produces results usually expressed as benefit-cost ratios – that is, an estimate of the benefits derived divided by the cost incurred. Positive net benefits are indicated by benefit-cost ratios greater than one.) It is important to assess costs and benefits of treatment of drug dependence, not least because many of the people needing this intervention are reliant on publicly supported treatment, thereby making it particularly susceptible to political controversy.8 While many studies demonstrate the clinical benefit to the individual of various forms of treatment for drug dependence, consideration of social and economic costs has generated a smaller literature. Indeed, the multifaceted nature of the costs of drug dependence and benefits of reducing it pose considerable methodological challenges, a full treatment of which is beyond the scope of this contribution. For our purposes, it is useful to note that WHO, recognising these challenges, has established guidelines suggesting that quantifying the economic impact of drug use on society should include assigning monetary value to the following costs:
WHO: ‘Tangible’ elements of economic impact of problematic drug use
• Health, social and welfare services (i.e. reduced drug dependence should result in a lower burden of health and social services related to drug dependence).
• Productivity loss in the workplace and the home.
• Drug-related crime, law enforcement and criminal justice.
• Road accidents.
• Cleaning up the environment (e.g. of unsafely discarded injection equipment).
• Research and prevention activities.9
These are the categories of ‘tangible’ cost; loss of life, pain and suffering are noted by WHO as intangible costs. WHO’s guidelines then seek to consider the various measurement challenges, necessary simplifying assumptions and other elements of putting cost figures on the tangible items in an effort to enable national governments to make estimates that will be comparable to some degree.
For some of these items, methodological debates will possibly never be completely settled. Quantifying crime-related costs, for example, includes obvious criminal justice activities, including incarceration (though drug-related activities may not always be distinguished); costs of drug-related crime to individuals, including material loss and loss of time and productivity; and the ‘esoteric and ephemeral’ costs to the legitimate economy of the human resources represented by people who are involved with drug trafficking or other drug-related crimes.10 It is recognised that for many of these elements, there will not be good data in even the best-organised jurisdictions, and simplifying assumptions will be necessary. In addition, WHO experts note that many drug-related crimes, particularly assaults and thefts, are habitually under-reported by victims and thus not captured in official data.11 Ideally, moreover, these factors should be studied over a long period, which is rarely possible in practice.
METHODS
This contribution benefits from a number of careful reviews of cost-benefit and cost-effectiveness studies of health services for people who use drugs, particularly of treatment for drug dependence, which were complemented with an updated search of cost-benefit and cost-effectiveness studies of drug-related health services.12
COSTS AND BENEFITS OF TREATMENT OF DRUG DEPENDENCE
An important review of 11 cost-benefit analyses published before 2003, all of them conducted in the United States, included only published peer-reviewed studies that attempted cost-benefit analyses of one of more of these factors: crime, health services utilisation, employment earnings and expenditure on illicit drugs and alcohol.13 The authors note, in sum:
• The average total net benefit accruing from all categories of cost reductions estimated over the 12-month period was $42,905. The average benefit-cost ratio for studies in which it was calculated was 8.9, ranging from 1.33 to 23.33.
• The greatest economic benefit was in reduced criminal activity, over half of the total.
• The economic benefit of savings on health services averted was about 15 percent of the total, and of increased employment earnings was about 13 percent. The authors note that the latter, measured only as actual in-pocket earnings, probably underestimates the importance of having any kind of stable employment as a determinant of long-term ‘success’.14
Since that review, there have been a number of interesting attempts to estimate social costs and benefits of treatment. Using data from 43 treatment facilities in the state of California supplemented by surveys, Ettner and colleagues used WHO guidelines to assess the benefits of treatment with respect to medical care, criminal activity, earnings of people treated and welfare programme (government transfer) payments.15 Their finding was that treatment cost an average $1,583 per person but benefited society at the level of $11,487, a 7:1 ratio.16 As in the earlier review, the authors estimate that the greatest savings – 65 percent – were in lower crime-related costs, with 29 percent attributable to increased earnings and six percent due to reduced medical costs. They suggest that the actual benefit-cost ratio is probably closer to 9:1 because of the use of arrests as a proxy for crime, given that many crimes do not ever result in an arrest.17
A study that focused narrowly on costs related only to robbery looked at several forms of treatment for drug dependence in the United States.18 Across all forms of treatment, being in treatment was associated with a reduction in robbery incidence of at least 0.4 robberies per patient per year. The authors conclude: ‘Given reasonable valuations associated with averting, at the margin, a single armed robbery, this one component of benefit may be large enough to offset the economic costs’ of drug treatment.19 They further note that while residential treatment is generally considerably more expensive than outpatient care, the greater benefit of residential programmes in averting crime may ‘more than offset’ the added cost.20 Policymakers and service providers alike may tend to favour support for drug treatment programmes that admit older, more educated patients with no criminal record and no psychiatric disorders, but the results of this study suggest that much greater social benefits would derive from expanding treatment access for those patients with a propensity to commit crimes.21
Opioid Substitution Therapy (OST)
In part because of its link to HIV prevention and its long clinical track record, one of the most widely studied forms of treatment for drug dependence is medication-assisted therapy for opiate addiction, also called opioid maintenance treatment or opioid substitution treatment (OST hereinafter). Opiumderived medicines, especially methadone and buprenorphine, can be administered daily by mouth – thus obviating injection – and can stabilise cravings of people with opiate dependence. As UN agencies have noted, this therapy can enable people to hold jobs and eliminate the need to commit crimes to obtain illicit opiates, as well as reducing heroin use, heroin overdose, overdose mortality and reducing other injection-related harms.22 UN agencies have promoted OST as a central element of HIV prevention where illicit opiate use is significant because OST ‘can decrease the high cost of opioid dependence to individuals, their families and society at large by reducing heroin use, associated deaths, HIV risk behaviours and criminal activity’.23 They also note that it may be optimal for some patients to continue OST indefinitely,24 a response to the misinformed but still widely held view that methadone therapy should always be of limited duration as a bridge to abstinence from all opiates.25
OST is limited and stigmatised in many countries and banned outright in a few (notably the Russian Federation).26 In spite of OST’s track record of successful treatment of heroin addiction that dates from the late 1960s, some practitioners and policymakers deride it as substituting one addiction for another. The potential for diversion of methadone and buprenorphine to illicit markets also means that their medical use must be carefully controlled and the costs of that control figured into assessments. In many countries, including the US, the administration of methadone must be directly observed – that is, patients must come to a health facility every day and take their medicine in front of a health professional – an enormous inconvenience to the patient and a practice with considerable other costs. Buprenorphine, particularly in a formulation in which it is combined with the opioid antagonist naloxone, is considered to have a lower potential for diversion to illicit use, and in many places it is possible to receive take-home doses rather than requiring daily direct observation.
...for every one dollar invested in NSPs (2000-2009), $27 is returned in cost savings. This return increases considerably over a longer time horizon.
Because drug injection is associated with high risk of transmission of HIV, a very expensive disease to treat, some cost-benefit studies of OST count benefits mainly in savings from HIV cases averted. In spite of hard-won victories in lowering the cost of HIV treatment, HIV remains quite expensive to treat.27 In addition, HIV transmission through injection with contaminated equipment is much more efficient than sexual transmission; even a very small number of injections poses a high risk.28 Given the high cost of HIV treatment, as some experts have noted, OST expansion carries a benefit so substantial as to be self-justifying ‘regardless of what assumptions are made about the effect of opiate dependence or methadone prescription on the quality of life’.29 Reviewing the research on OST in 2004, WHO, UNAIDS and UNODC summarised it as follows:
According to several conservative estimates, every dollar invested in opioid dependence treatment programmes may yield a return of between $4 and $7 in reduced drug-related crime, criminal justice costs and theft alone. When savings related to health care are included, total savings can exceed costs by a ratio of 12:1.30
Most studies of the cost and benefit of OST have been undertaken in countries of the global North. Recently, however, a number of studies from Asia have made cost-benefit calculations of OST, though generally only of benefits related to averting cases of HIV. A 2012 study in Dehong (Yunnan), China estimated that against a per-patient cost of OST of $9.10-16.70 per month over the 30-month period followed, methadone programmes averted HIV cases of which the cost would have been a net $4600 per case to treat.31 A similar study over a five-year period estimated that OST programmes in the Xinjiang, China averted over 5600 HIV infections that would have incurred a cost to the health system of over $4.4 million in the same period.32 These studies obviously rely on assumptions about risks of HIV transmission faced by people who inject drugs, mostly extrapolations from previous periods. They notably did not calculate the costs of sexual transmission of HIV to people who do not inject drugs and so probably underestimate the benefits accrued.
A special category of treatment of drug dependence is the legal administration of medicinal heroin available in a few countries, generally only for small numbers of people with long-standing addictions who, for various reasons, have not benefited from other therapies. A review of evaluations of heroin-assisted treatment in Switzerland, Germany, the Netherlands, Spain, Canada and the UK concluded that these programmes have generally demonstrated considerable benefits through the reduction of criminal activities among these patients, decline in use of illicitly obtained drugs and decline in risky injection.33 One study of the Swiss experience indicated that the incidence of the crimes of burglary, muggings and drug trafficking declined between 50 to 90 percent among people in the prescription heroin programme, depending on the crime, but did not attempt to assign costs to this reduction.34 It is not expected that this intervention would ever be offered on a mass scale, but it illustrates the principle of achieving significant benefits by reaching those associated with the most problematic use.
OTHER SERVICES FOR PEOPLE WHO USE DRUGS
Needle and Syringe Programmes (NSPs)
Programmes that furnish clean injection equipment to people who inject drugs are proven to be extremely effective with respect to prevention of HIV. The review commissioned by WHO of the extensive research on this subject shows, in fact, that these programmes, most often established as needle exchanges (whereby used injection equipment can be exchanged for sterile equipment), are among the most effective and cost-effective programmes in the HIV prevention arsenal.35 These programmes should not be expected to have the range of potential social benefits that are associated with treatment of drug dependence since they do not necessarily reduce drug use or addiction, though they may present important opportunities for referral to treatment services and other social support – an element that has not been extensively evaluated economically in the published literature.
As of 2012, there were about 500 overdose episodes that occurred among people using Insite but no deaths, whereas the neighbourhood of Insite was previously known for frequent overdose-related incidents and deaths on the street.
A 2010 review of cost studies – mostly cost-effectiveness rather than cost-benefit – concluded that if averting HIV cases could be demonstrated, as they were convincingly in a number of studies, the benefit-cost ratio of these programmes should be expected to be very high because the programmes tend to cost little, and HIV care is expensive.36 A widely cited study by the government of Australia drew the following conclusion about these programmes across the country:
For every one dollar invested in NSPs, more than four dollars were returned (additional to the investment) in healthcare cost-savings in the short term (10 years) if only direct costs are included; greater returns are expected over longer time horizons….If patient/client costs and productivity gains and losses are included in the analysis, then…for every one dollar invested in NSPs (2000-2009), $27 is returned in cost savings. This return increases considerably over a longer time horizon.37
As noted above, NSP programmes reach people who are actively injecting and who are more likely than non-injectors to have drug-related health problems, and NSP staff can provide a link to other health services and counselling. A 2010 review in The Lancet concluded that if the desired outcome is HIV control, the greatest cost-effectiveness and benefit-cost will be achieved by high coverage of both these interventions in combination with high coverage of HIV treatment, even though the last element is very costly in most places.38 The authors bemoan the low availability of all these services for many people who use drugs, which is linked to the stigma they face and their fear of using services that may result in their drug use being brought to the attention of the police.39
Needle and syringe programmes may yield particularly high returns in prison settings. Countries including Germany, Switzerland, Spain, Moldova, Belarus, Luxembourg, Romania and Kyrgyzstan have programmes that furnish clean injection equipment in prison,40 an intervention that requires the politically courageous recognition that in spite of even the best efforts to stop it, drug injection occurs in prisons. All of those programmes studied have had dramatic results in reducing transmission of HIV and in some cases hepatitis C, though benefit-cost ratios have not been calculated.41 Since treating HIV among prisoners is the responsibility of the state and could be a long-term responsibility, the cost savings from HIV and hepatitis cases averted are likely to be considerable. OST is offered in prison in some countries, where it has an excellent track record (directly observed administration is facilitated by the prison environment), but many countries that offer OST in the broader community still do not offer it in prisons.42
Supervised Injection Facilities
Some countries committed to comprehensive HIV services for people who use drugs also authorise so-called supervised or safe injection facilities, places where people can inject illicit drugs with clean equipment in the presence of health professionals. These facilities exist in many western European countries – Germany, the Netherlands and Switzerland were pioneers – as well as Canada and Australia.43 The facility in Vancouver, Canada, called Insite, has been extensively studied by public health and social science researchers. As of 2012, there were about 500 overdose episodes that occurred among people using Insite but no deaths,44 whereas the neighbourhood of Insite was previously known for frequent overdose-related incidents and deaths on the street. In addition, a 2011 study found that not only was overdose mortality averted in the facility itself, but in a 500-metre radius of Insite, overdose episodes dropped by 35 percent in the first years of the facility’s operation, compared to a nine percent decline in the rest of the city.45 In benefit-cost terms, a 2010 study that made conservative assumptions about overdose mortality, other overdose complications and HIV cases averted estimated a benefit-cost ratio for Insite of about 5:1 or in monetary terms about $6 million a year.46
Drug Treatment Courts
A number of countries, particularly the US and Canada, have invested in specialised drug courts or drug treatment courts in which some alleged offenders can be diverted to court-supervised treatment programmes as an alternative to incarceration. Drug courts in the US have been extensively evaluated, mostly on the criterion of criminal recidivism. The US model of courts raises a number of questions, including the due process issue of requiring people to plead guilty to whatever charge is before them as a condition of being diverted to treatment, the question of whether treatment should ever be coercive in any sense, and the fact that many courts refuse OST as a treatment option in spite of great need for it.47 An extensive drug court evaluation supported by the US Department of Justice included a cost-benefit calculation that assigned monetary values to components of a broad definition of benefits, including social and economic productivity of drug court participants, welfare programme savings, and criminal justice and health service savings and compared them to drug court costs, which are generally well documented.48 Their sophisticated analysis, involving many well-specified assumptions, concluded that drug courts in the US carry a benefit-cost ratio of 1.92:1.49 At this writing, the US is promoting drug courts heavily as part of its international drug control programmes.
Drug treatment courts have potentially large economic benefits in theory from incarceration costs averted, but not if their rules are so onerous or their protection of due process so flawed as to make them unattractive to a significant percentage of those who might benefit from them. In places where opiate addiction is a public health problem, drug courts should follow the recommendation of the board of the US National Association of Drug Court Professionals and allow OST as a treatment alternative likely to be essential for many participants.50
CONCLUSION
In spite of methodological challenges, a significant body of evidence shows that health services for people who use drugs have significant social and economic benefits, including reduction of crime and increasing the ability of people who have lived with addiction to be economically productive. This evidence has figured insufficiently in policy and resource allocation decision-making on drugs, apparently frequently overshadowed by political factors. These services should be a high priority for fiscally-minded governments, which should especially ensure that they are not undermined, for example, by policing that targets health or needle exchange facilities to find drug users to fill arrest quotas, or by undue ‘not in my backyard’ neighbourhood opposition to the placement of drug treatment clinics. Moreover, drug-related health services derive the greatest benefits when they target marginalised people with a propensity to commit crime, in spite of the obvious political challenges posed by directing funding toward these individuals.
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Notes:
1 See US Office of National Drug Control Policy, ‘The National Drug Control Budget FY 2103 Funding Highlights’ and Drug Policy Alliance, ‘The Federal Drug Control Budget: New Rhetoric, Same Failed Drug War,’ 2013, http://www.drugpolicy.org/sites/default ... Budget.pdf
2 Count the Costs, ‘The war on drugs: Wasting billions and undermining economies,’ http://www.countthecosts.org/sites/defa ... iefing.pdf.
3 Bradley Mathers, Louisa Degenhardt, Hammad Ali, Lucas Wiessing et al., ‘HIV prevention, treatment and care services for people who inject drugs: a systematic review of global, regional and national coverage,’ Lancet 375 (2010): 1014-1028.
4 UN Office on Drugs and Crime, World Drug Report 2013 (Vienna: United Nations, 2013), appended fact sheet, http://www.unodc.org/doc/wdr/Fact_Sheet_Chp1_2013.pdf
5 Ibid.
6 WHO and UNODC, ‘Principles of drug dependence treatment: discussion paper.’ (Vienna: United Nations, 2008), https://www.unodc.org/documents/drug-tr ... arch08.pdf.
7 Ibid.
8 Susan L. Ettner, David Huang, Elizabeth Evans, Danielle Rose Ash et al., ‘Cost-benefit in the California Treatment Outcome Project: does substance abuse treatment ‘pay for itself?,’ Health Research and Educational Trust 41 (2005):193-194.
9 Eric Single et al., International guidelines for estimating the costs of substance abuse, 2nd ed. (Geneva: World Health Organization, 2004).
10 Single et al., 59-62.
11 Ibid., 60-61.
12 Kathryn E. McCollister and Michael T. French. ‘The relative contribution of outcome domains in the total economic benefit of addiction interventions: a review of first findings,’ Addiction 98 (2003): 1647-1659; Louisa Degenhardt, Bradley Mathers, Peter Vickerman, Tim Rhodes et al. ‘Prevention of HIV infection for people who inject drugs: why individual, structural and combination approaches are needed,’ Lancet DOI:10.1016/S0140-6736(10)60742-8; Daniel Wolfe, M. Patrizia Carrieri and Donald Shepard, ‘Treatment and care for injecting drug users with HIV infection: a review of barriers and ways forward,’ Lancet DOI:10.1016/S0140-6736(10)60832-X; Center for Health Program Development and Management, ‘Review of cost-benefit and cost-effectiveness literature for methadone or buprenorphine as a treatment for opiate addiction,’ Baltimore, 9 May, 2007.
13 McCollister and French, op. cit.
14 Ibid., 1655.
15 Ettner et al., 196.
16 Ibid., 205.
17 Ibid., 204, 206.
18 Anirban Basu, A. David Paltiel and Harold A. Pollack, ‘Social costs of robbery and the cost-effectiveness of substance abuse treatment,’ Health Economics (2008): 927-946.
19 Ibid., 939.
20 Ibid., 939-940.
21 Ibid., 940.
22 World Health Organization, UN Office on Drugs and Crime and UNAIDS (UN Joint Programme on HIV/AIDS), ‘WHO/UNODC/UNAIDS position paper: Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention,’ Geneva, 2004, http://www.unodc.org/documents/hiv-aids ... herapy.pdf
23 Ibid., 1.
24 Ibid.
25 See, for example, Charles Winick, ‘A mandatory short-term methadone-to-abstinence program in New York City,’ Mount Sinai Journal of Medicine 68(2001): 41-45; the Manhattan and Brooklyn drug treatment courts in New York City as of 2013 require participants to use methadone only as a short-term bridge to abstinence.
26 Mathers et al., op.cit.
27 HIV treatment costs vary considerably based on the percentage of patients who may have developed resistance or intolerable side effects to generic first-line medicines, as well as whether countries have access to generic forms of some medicines. The cost of a WHO-recommended first-line regimen was about $112 per patient per year in 2012. Second-line regimens cost on average about $450 per person per year in 2012, but much more in the US and other high-income countries. The cost of third-line treatments was $13,225 per person per year in Georgia, $7,782 in Paraguay, $8,468 in Armenia, and $4,760 in Thailand. See World Health Organization, ‘Global update on HIV treatment 2013: results, impacts and opportunities,’ Geneva, United Nations, 99-100, http://apps.who.int/iris/bitstream/1066 ... 34_eng.pdf.
28 One review of the research indicates that HIV risk from one episode of vaginal (male-female) sex is as low as 0.05 percent (or 1 in 2000) while injection with contaminated equipment carries a risk of about 0.7 percent or 0.8 percent. Government of Canada, Public Health Agency, ‘HIV transmission risk: a summary of evidence,’ Ottawa, 2013, http://www.phac-aspc.gc.ca/aids-sida/pu ... ih-eng.php.
29 Paul G. Barnett and Sally S. Hui, ‘The cost-effectiveness of methadone maintenance,’ Mount Sinai Journal of Medicine 67 (2000): 371.
30 World Health Organization, Joint UN Programme on HIV/AIDS (UNAIDS) and UN Office on Drugs and Crime. ‘Position Paper: Substitution Maintenance Therapy in the Management of Opioid Dependence and HIV Prevention,’ Geneva, United Nations, 2004.
31 Yan Xing, Jiangping Sun, Weihua Cao, Liming Lee et al., ‘Economic evaluation of methadone maintenance treatment in HIV/AIDS control among injection drug users in Dehong, China,’ AIDS Care 24 (2012): 756-762.
32 Mingjian J. Ni, Li Ping Fu, Xue Ling Chen et al., ‘Net financial benefits of averting HIV infections among people who inject drugs in Urumqi, Xinjiang, People’s Republic of China (2005-2010),’ BMC Public Health 2012, 12:572, http://www.biomedcentral.com/1471-2458/12/572.
33 Benedikt Fischer, Eugenia Oviedo-Joekes, Peter Blanken, Christian Haasen et al., ‘Heroin-assisted treatment (HAT) a decade later: a brief update on science and politics,’ Journal of Urban Health 84 (2007): 552-562.
34 Martin Killias, Marcel F. Aebi and Denis Ribeaud, ‘Key findings concerning the effects of heroin prescription on crime,’ in Heroin-assisted treatment: work in progress eds. Margret Rihs-Middel, Robert Hämmig and Nina Jacobshagen (Bern: Verlag Hans Huber, 2005).
35 Alex Wodak and Annie Cooney, ‘Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among injection drug users – Evidence for Action Technical Paper,’ Geneva, World Health Organization, 2004, http://whqlibdoc.who.int/publications/2 ... 591641.pdf
36 Degenhardt et al., 35-36.
37 Government of Australia, National Centre in HIV Epidemiology and Clinical Research’ ‘Return on investment 2: evaluating the costeffectiveness of needle and syringe programs in Australia,’ 2009, http://www.health.gov.au/internet/main/ ... retexe.pdf.
38 Degenhardt et al., 30.
39 Ibid.
40 See Rick Lines, Ralf Jürgens, Glenn Betteridge et al., ‘Prison needle exchange: lessons from a comprehensive review of international evidence and experience,’ (Toronto: Canadian HIV/AIDS Legal Network, 2006), http://www.aidslaw.ca/publications/inte ... wnloadFile. php?ref=1173; and Ingo Ilya Michels and Heino Stöver, ‘Harm reduction – from a conceptual framework to practical experience: the example of Germany’. Substance Use and Misuse 47 (2012): 910-922.
41 Lines et al., ibid.
42 Kate Dolan, Ben Kite, Emma Black et al., ‘HIV in prison in low-income and middle-income countries,’ Lancet Infectious Diseases 7 (2007): 32–41.
43 Harm Reduction International, Global state of harm reduction 2012: toward an integrated response, London, 2012, http://www.ihra.net/files/2012/07/24/Gl ... 12_Web.pdf.
44 Vancouver Coastal Health, ‘Supervised Injection Site – User Statistics,’ http://supervisedinjection.vch.ca/resea ... statistics
45 Brandon D.L. Marshall, M-J Milloy, Evan Wood, Julio Montaner and Thomas Kerr, ‘Reduction in overdose mortality after the opening of North America’s first medically supervised safer injection facility: a retrospective population-based study,’ Lancet 377 (2011): 1429-1437.
46 Martin A. Andresen and Neil Boyd, ‘A cost-benefit and cost-effectiveness analysis of Vancouver’s supervised injection facility,’ International Journal of Drug Policy 21 (2010): 70-76.
47 Ryan S. King and Jill Pasquarella, ‘Drug courts: a review of the evidence,’ (Washington, DC: The Sentencing Project, 2009), http://www.sentencingproject.org/doc/dp_drugcourts.pdf; and Drug Policy Alliance, ‘Drug courts are not the answer: toward a health-centered approach to drug use,’ New York, 2011, http://www.drugpolicy.org/sites/default ... Final2.pdf.
48 P. Mitchell Downey and John K. Roman, ‘Chapter 9 – Cost-benefit analyses,’ in Shelli B. Rossman, John K. Roman, Janine M. Zweig et al., eds. The multi-site adult drug court evaluation: the impact of drug courts. (Washington, DC: Urban Institute, 2011), 228-250.
49 Ibid., 247.
50 National Association of Drug Court Professionals: Resolution of the Board of Directors on the availability of medically assisted treatment (M.A.T.) for addiction in drug courts, 17 July 2011, http://www.nadcp.org/sites/default/file ... %20MAT.pdf