Prevention (Papers)

August 4, 2024

Lifestyle changes—including eating fruits, vegetables, and whole grains—can help patients, especially those with diabetes or hypertension, improve outcomes.

Robert Ostfeld, MD, ScM, director of preventive cardiology at Montefiore Health System and professor of medicine at Albert Einstein College of Medicine in New York sat down with Drug Topics ahead of the American Society for Preventive Cardiology Congress on CVD Prevention to discuss the role that dietary patterns and nutrition decisions play in living a healthful lifestyle.

Drug Topics: What specific nutrients or dietary patterns have been shown to benefit patients with hypertension and diabetes, and how can this information be incorporated into patient counseling?

Robert Ostfeld, MD, ScM: That’s a very important question. A healthful diet, of course, can very positively impact cardiometabolic health—including blood pressure, diabetes, [and] lipids—and cardiovascular health and overall health in general.

Reassuringly, there is broad [alignment] in terms of what defines a healthful dietary pattern. For example, multiple medical societies—like the American Heart Association, the American College of Cardiology, the American Society for Preventive Cardiology, the Canadian Cardiovascular Society, the European Society of Cardiology—are all broadly aligned; consuming more plant-based nutrition, less ultra-processed foods, less red and processed meats, is helpful both cardiometabolically and [for] cardiovascular health overall.

Unfortunately, that recommendation hasn’t necessarily percolated down well, at least into the US. There was an interesting recent analysis where from the NHANES database—the National Health and Nutrition Examination Survey database—published in 2021, where they looked at a little over 11,000 people…where they used 5 elements to define diet. One element was consuming at least 4 and a half servings of fruits and vegetables a day, at least 3 servings of whole grains each day, low sugar or sweetened beverage consumption, low salt consumption, and 2 servings of fatty fish each week. If you had 0 or 1 of those, then they felt you had a poor diet; 2 or 3 an intermediate [diet], and 4 or 5, an ideal dietary pattern. About 75% of the US has a poor, 0 to 1 of those [elements] dietary pattern; 25% [have] intermediate, and 0.7% of the US has an ideal dietary pattern.

There’s a huge gap between where we are and where we could. You could ask, “Does it even really matter?” Of course it does. In this study, they modeled if everyone adopted an ideal dietary pattern—so 4 or 5 of those 5 elements—for 1 year, what would happen? Well, it was estimated that cardiovascular event rates would fall by about 42%. The gap matters. There’s randomized prospective cohort data that eating a healthful dietary pattern, more plant based [and] aligned with American College of Cardiology and American Heart Association recommendations, can also be helpful for high blood pressure, particularly the DASH [Dietary Approaches to Stop Hypertension] dietary pattern for high cholesterol, the dietary portfolio pattern, which is a high fiber plant based diet, and also, similar recommendations broadly for diabetes.

What I should reinforce is, it’s not really that there’s 1 diet for high blood pressure, high cholesterol, and diabetes. They’re really broadly aligned that consuming more healthful, plant-based foods—fruits, vegetables, whole grains, beans, lentils—less ultra-processed foods and less red and processed meats, is helpful for all of the above: cardiovascular health and cardiometabolic health.

Drug Topics: How can patients be supported in overcoming common barriers to healthy eating, such as budget constraints and limited access to nutritious foods, in the management of hypertension and diabetes?

Ostfeld: Helping the individual patient in the office embrace a more healthful diet can be a challenge. Society does not make…it easy for the healthy choice to be the easy choice. And behavior change, getting someone to change how they eat, how they live, can be very, very difficult. These are big hurdles that we face.

As an individual practitioner, it can be overwhelming to overcome some of these things; at least we can try and start. As an individual [health care provider], you’ll have your team around you who can support you and reinforce your message. Nurses, support staff, and registered dietitians can be incredibly helpful to reinforce and educate about this topic.

In the clinic specifically, I will try to find a specific reason that the patient may be interested in living more healthfully. Maybe they want to lose weight or improve their skin complexion, maybe they want to lower their blood pressure, lower their cholesterol, come off a medication… Whatever the case may be, I try to highlight how consistently eating more healthfully can address that particular issue. I will give them some very specific steps—some simple specific steps, because everyone’s busy and there’s so much information to take in—that they can hopefully do when they get home to live more healthily. I have a handout that I give them that I try to keep very simple.

Sometimes in clinic, because we’re all so busy, I’ll just say, “Let’s just start with 222.” [That’s] 2 servings of green leafy vegetables a day, 2 servings of fruit each day, 2 servings of other vegetables each day: 222. I’ll do that a little bit weirdly, deliberately, so they’ll remember it. Then when they go home, depending on where they live, there may be more or [fewer] access or cost issues. [I’ll explain that] for ease, [they] could cook in bulk; we certainly don’t have to buy, you know, organic green juices. You can get frozen vegetables, frozen fruits, big sacks of potatoes, oatmeal, and beans, and those things can be much less expensive and more doable.

Another way to help patients adopt a more healthful lifestyle is—there may be the hurdle of costs here—but there are services that can deliver meals, healthful meals, to patients; they may be able to access registered dieticians, and of course there are multiple online resources that are free for patients. The Physicians Committee for Responsible Medicine has a 21-day kickstart for more plant-based nutrition should, the [health care provider] feel that that’s appropriate for the patient. There are a variety of resources that people can have access to; some may cost a little bit more, but some are also free. The American College of Lifestyle Medicine also has multiple online resources.

Source: https://www.drugtopics.com/view/q-a-examining-the-key-drivers-of-a-healthful-lifestyle

Filed under: Education,Health,Latest News,Prevention (Papers),Prevention and Intervention,USA :

By Zara Abrams Date created: March 1, 2024. 14 min read

For years, students in middle and high schools across the country were urged to “just say no” to drugs and alcohol. But it’s no secret that the Drug Abuse Resistance Education (D.A.R.E.) program, which was typically delivered by police officers who urged total abstinence, didn’t work. A meta-analysis found the program largely ineffective and one study even showed that kids who completed D.A.R.E. were more likely than their peers to take drugs (Ennett, S. T., et al., American Journal of Public Health, Vol. 84, No. 9, 1994; Rosenbaum, D. P., & Hanson, G. S., Journal of Research in Crime and Delinquency, Vol. 35, No. 4, 1998).

“We know that the ‘Just Say No’ campaign doesn’t work. It’s based in pure risks, and that doesn’t resonate with teens,” said developmental psychologist Bonnie Halpern-Felsher, PhD, a professor of pediatrics and founder and executive director of several substance use prevention and intervention curriculums at Stanford University. “There are real and perceived benefits to using drugs, as well as risks, such as coping with stress or liking the ‘high.’ If we only talk about the negatives, we lose our credibility.”

Partially because of the lessons learned from D.A.R.E., many communities are taking a different approach to addressing youth substance use. They’re also responding to very real changes in the drug landscape. Aside from vaping, adolescent use of illicit substances has dropped substantially over the past few decades, but more teens are overdosing than ever—largely because of contamination of the drug supply with fentanyl, as well as the availability of stronger substances (Most reported substance use among adolescents held steady in 2022, National Institute on Drug Abuse).

“The goal is to impress upon youth that far and away the healthiest choice is not to put these substances in your body, while at the same time acknowledging that some kids are still going to try them,” said Aaron Weiner, PhD, ABPP, a licensed clinical psychologist based in Lake Forest, Illinois, and immediate past-president of APA’s Division 50 (Society of Addiction Psychology). “If that’s the case, we want to help them avoid the worst consequences.”

While that approach, which incorporates principles of harm reduction, is not universally accepted, evidence is growing for its ability to protect youth from accidental overdoses and other consequences of substance use, including addiction, justice involvement, and problems at school. Psychologists have been a key part of the effort to create, test, and administer developmentally appropriate, evidence-based programs that approach prevention in a holistic, nonstigmatizing way.

“Drugs cannot be this taboo thing that young people can’t ask about anymore,” said Nina Christie, PhD, a postdoctoral research fellow in the Center on Alcohol, Substance Use, and Addictions at the University of New Mexico. “That’s just a recipe for young people dying, and we can’t continue to allow that.”

Changes in drug use

In 2022, about 1 in 3 high school seniors, 1 in 5 sophomores, and 1 in 10 eighth graders reported using an illicit substance in the past year, according to the National Institute on Drug Abuse’s (NIDA) annual survey (Monitoring the Future: National Survey Results on Drug Use, 1975–2022: Secondary School Students, NIDA, 2023 [PDF, 7.78MB]). Those numbers were down significantly from prepandemic levels and essentially at their lowest point in decades.

Substance use during adolescence is particularly dangerous because psychoactive substances, including nicotine, cannabis, and alcohol, can interfere with healthy brain development (Winters, K. C., & Arria, A., Prevention Research, Vol. 18, No. 2, 2011). Young people who use substances early and frequently also face a higher risk of developing a substance use disorder in adulthood (McCabe, S. E., et al., JAMA Network Open, Vol. 5, No. 4, 2022). Kids who avoid regular substance use are more likely to succeed in school and to avoid problems with the juvenile justice system (Public policy statement on prevention, American Society of Addiction Medicine, 2023).

“The longer we can get kids to go without using substances regularly, the better their chances of having an optimal life trajectory,” Weiner said.

The drugs young people are using—and the way they’re using them—have also changed, and psychologists say this needs to inform educational efforts around substance use. Alcohol and cocaine are less popular than they were in the 1990s; use of cannabis and hallucinogens, which are now more salient and easier to obtain, were higher than ever among young adults in 2021 (Marijuana and hallucinogen use among young adults reached all-time high in 2021, NIDA).

“Gen Z is drinking less alcohol than previous generations, but they seem to be increasingly interested in psychedelics and cannabis,” Christie said. “Those substances have kind of replaced alcohol as the cool thing to be doing.”

Young people are also seeing and sharing content about substance use on social media, with a rise in posts and influencers promoting vaping on TikTok and other platforms (Vassey, J., et al., Nicotine & Tobacco Research, 2023). Research suggests that adolescents and young adults who see tobacco or nicotine content on social media are more likely to later start using it (Donaldson, S. I., et al., JAMA Pediatrics, Vol. 176, No. 9, 2022).

A more holistic view

Concern for youth well-being is what drove the well-intentioned, but ultimately ineffective, “mad rush for abstinence,” as Robert Schwebel, PhD, calls it. Though that approach has been unsuccessful in many settings, a large number of communities still employ it, said Schwebel, a clinical psychologist who created the Seven Challenges Program for treating substance use in youth.

But increasingly, those working to prevent and treat youth substance use are taking a different approach—one that aligns with principles Schwebel helped popularize through Seven Challenges.

A key tenet of modern prevention and treatment programs is empowering youth to make their own decisions around substance use in a developmentally appropriate way. Adolescents are exploring their identities (including how they personally relate to drugs), learning how to weigh the consequences of their actions, and preparing for adulthood, which involves making choices about their future. The Seven Challenges Program, for example, uses supportive journaling exercises, combined with counseling, to help young people practice informed decision-making around substance use with those processes in mind.

“You can insist until you’re blue in the face, but that’s not going to make people abstinent. They ultimately have to make their own decisions,” Schwebel said.

Today’s prevention efforts also tend to be more holistic than their predecessors, accounting for the ways drug use relates to other addictive behaviors, such as gaming and gambling, or risky choices, such as fighting, drag racing, and having unprotected sex. Risk factors for substance use—which include trauma, adverse childhood experiences, parental history of substance misuse, and personality factors such as impulsivity and sensation seeking—overlap with many of those behaviors, so it often makes sense to address them collectively.

“We’ve become more sophisticated in understanding the biopsychosocial determinants of alcohol and drug use and moving beyond this idea that it’s a disease and the only solution is medication,” said James Murphy, PhD, a professor of psychology at the University of Memphis who studies addictive behaviors and how to intervene.

Modern prevention programs also acknowledge that young people use substances to serve a purpose—typically either social or emotional in nature—and if adults expect them not to use, they should help teens learn to fulfill those needs in a different way, Weiner said.

“Youth are generally using substances to gain friends, avoid losing them, or to cope with emotional problems that they’re having,” he said. “Effective prevention efforts need to offer healthy alternatives for achieving those goals.”

Just say “know”

At times, the tenets of harm reduction and substance use prevention seem inherently misaligned. Harm reduction, born out of a response to the AIDS crisis, prioritizes bodily autonomy and meeting people where they are without judgment. For some harm reductionists, actively encouraging teens against using drugs could violate the principle of respecting autonomy, Weiner said.

On the other hand, traditional prevention advocates may feel that teaching adolescents how to use fentanyl test strips or encouraging them not to use drugs alone undermines the idea that they can choose not to use substances. But Weiner says both approaches can be part of the solution.

“It doesn’t have to be either prevention or harm reduction, and we lose really important tools when we say it has to be one or the other,” he said.

In adults, harm reduction approaches save lives, prevent disease transmission, and help people connect with substance use treatment (Harm Reduction, NIDA, 2022). Early evidence shows similar interventions can help adolescents improve their knowledge and decision-making around drug use (Fischer, N. R., Substance Abuse Treatment, Prevention, and Policy, Vol. 17, 2022). Teens are enthusiastic about these programs, which experts often call “Just Say Know” to contrast them with the traditional “Just Say No” approach. In one pilot study, 94% of students said a “Just Say Know” program provided helpful information and 92% said it might influence their approach to substance use (Meredith, L. R., et al., The American Journal of Drug and Alcohol Abuse, Vol. 47, No. 1, 2021).

“Obviously, it’s the healthiest thing if we remove substance use from kids’ lives while their brains are developing. At the same time, my preference is that we do something that will have a positive impact on these kids’ health and behaviors,” said Nora Charles, PhD, an associate professor and head of the Youth Substance Use and Risky Behavior Lab at the University of Southern Mississippi. “If the way to do that is to encourage more sensible and careful engagement with illicit substances, that is still better than not addressing the problem.”

One thing not to do is to overly normalize drug use or to imply that it is widespread, Weiner said. Data show that it’s not accurate to say that most teens have used drugs in the past year or that drugs are “just a part of high school life.” In fact, students tend to overestimate how many of their peers use substances (Dumas, T. M., et al., Addictive Behaviors, Vol. 90, 2019; Helms, S. W., et al., Developmental Psychology, Vol. 50, No. 12, 2014).

A way to incorporate both harm reduction and traditional prevention is to customize solutions to the needs of various communities. For example, in 2022, five Alabama high school students overdosed on a substance laced with fentanyl, suggesting that harm reduction strategies could save lives in that community. Other schools with less reported substance use might benefit more from a primary prevention-style program.

At Stanford, Halpern-Felsher’s Research and Education to Empower Adolescents and Young Adults to Choose Health (REACH) Lab has developed a series of free, evidence-based programs through community-based participatory research that can help populations with different needs. The REACH Lab offers activity-based prevention, intervention, and cessation programs for elementary, middle, and high school students, including curricula on alcohol, vaping, cannabis, fentanyl, and other drugs (Current Problems in Pediatric and Adolescent Health Care, Vol. 52, No. 6, 2022). They’re also working on custom curricula for high-risk groups, including sexual and gender minorities.

The REACH Lab programs, including the comprehensive Safety First curriculum, incorporate honest discussion about the risks and benefits of using substances. For example: Drugs are one way to cope with stress, but exercise, sleep, and eating well can also help. Because many young people care about the environment, one lesson explores how cannabis and tobacco production causes environmental harm.

The programs also dispel myths about how many adolescents are using substances and help them practice skills, such as how to decline an offer to use drugs in a way that resonates with them. They learn about the developing brain in a positive way—whereas teens were long told they can’t make good decisions, Safety First empowers them to choose to protect their brains and bodies by making healthy choices across the board.

“Teens can make good decisions,” Halpern-Felsher said. “The equation is just different because they care more about certain things—peers, relationships—compared to adults.”

Motivating young people

Because substance use and mental health are so intertwined, some programs can do prevention successfully with very little drug-focused content. In one of the PreVenture Program’s workshops for teens, only half a page in a 35-page workbook explicitly mentions substances.

“That’s what’s fascinating about the evidence base for PreVenture,” said clinical psychologist Patricia Conrod, PhD, a professor of psychiatry at the University of Montreal who developed the program. “You can have quite a dramatic effect on young people’s substance use without even talking about it.”

PreVenture offers a series of 90-minute workshops that apply cognitive behavioral insights upstream (addressing the root causes of a potential issue rather than waiting for symptoms to emerge) to help young people explore their personality traits and develop healthy coping strategies to achieve their long-term goals.

Adolescents high in impulsivity, hopelessness, thrill-seeking, or anxiety sensitivity face higher risks of mental health difficulties and substance use, so the personalized material helps them practice healthy coping based on their personality type. For example, the PreVenture workshop that targets anxiety sensitivity helps young people learn to challenge cognitive distortions that can cause stress, then ties that skill back to their own goals.

The intervention can be customized to the needs of a given community (in one trial, drag racing outstripped substance use as the most problematic thrill-seeking behavior). In several randomized controlled trials of PreVenture, adolescents who completed the program started using substances later than peers who did not receive the intervention and faced fewer alcohol-related harms (Newton, N. C., et al., JAMA Network Open, Vol. 5, No. 11, 2022). The program has also been shown to reduce the likelihood that adolescents will experiment with illicit substances, which relates to the current overdose crisis in North America, Conrod said (Archives of General Psychiatry, Vol. 67, No. 1, 2010).

“People shouldn’t shy away from a targeted approach like this,” Conrod said. “Young people report that having the words and skills to manage their traits is actually helpful, and the research shows that at behavioral level, it really does protect them.”

As young people leave secondary school and enter college or adult life, about 30% will binge drink, 8% will engage in heavy alcohol use, and 20% will use illicit drugs (Alcohol and Young Adults Ages 18 to 24, National Institute on Alcohol Abuse and Alcoholism, 2023; SAMHSA announces national survey on drug use and health (NSDUH) results detailing mental illness and substance use levels in 2021). But young people are very unlikely to seek help, even if those activities cause them distress, Murphy said. For that reason, brief interventions that leverage motivational interviewing and can be delivered in a school, work, or medical setting can make a big difference.

In an intervention Murphy and his colleagues are testing, young adults complete a questionnaire about how often they drink or use drugs, how much money they spend on substances, and negative things that have happened as a result of those choices (getting into an argument or having a hangover, for example).

In an hour-long counseling session, they then have a nonjudgmental conversation about their substance use, where the counselor gently amplifies any statements the young person makes about negative outcomes or a desire to change their behavior. Participants also see charts that quantify how much money and time they spend on substances, including recovering from being intoxicated, and how that stacks up against other things they value, such as exercise, family time, and hobbies.

“For many young people, when they look at what they allocate to drinking and drug use, relative to these other things that they view as much more important, it’s often very motivating,” Murphy said.

A meta-analysis of brief alcohol interventions shows that they can reduce the average amount participants drink for at least 6 months (Mun, E.Y., et al., Prevention Science, Vol. 24, No. 8, 2023). Even a small reduction in alcohol use can be life-altering, Murphy said. The fourth or fifth drink on a night out, for example, could be the one that leads to negative consequences—so reducing intake to just three drinks may make a big difference for young people.

Conrod and her colleagues have also adapted the PreVenture Program for university students; they are currently testing its efficacy in a randomized trial across multiple institutions.

Christie is also focused on the young adult population. As a policy intern with Students for Sensible Drug Policy, she created a handbook of evidence-based policies that college campuses can use to reduce harm among students but still remain compliant with federal law. For example, the Drug Free Schools and Communities Act mandates that higher education institutions formally state that illegal drug use is not allowed on campus but does not bar universities from taking an educational or harm reduction-based approach if students violate that policy.

“One low-hanging fruit is for universities to implement a Good Samaritan policy, where students can call for help during a medical emergency and won’t get in trouble, even if illegal substance use is underway,” she said.

Ultimately, taking a step back to keep the larger goals in focus—as well as staying dedicated to prevention and intervention approaches backed by science—is what will help keep young people healthy and safe, Weiner said.

“What everyone can agree on is that we want kids to have the best life they can,” he said. “If we can start there, what tools do we have available to help?”

Filed under: Drug use-various effects,Education Sector,Mental Health,Prevention (Papers),Prevention and Intervention,Social Affairs,USA :

July 2017 Revised January 2018

Injury Prevention Centre: Who we are

The Injury Prevention Centre (IPC) is a provincial organization that focuses on reducing catastrophic injury and death in Alberta. We act as a catalyst for action by supporting communities and decision-makers with knowledge and tools. We raise awareness about preventable injuries as an important component of lifelong health and wellness. We are funded by an operating grant from Alberta Health and we are housed at the School of Public Health, University of Alberta.

Injury in Alberta

Injuries are the leading cause of death for Albertans aged 1 to 44 years. In 2014, injuries resulted in 2,118 deaths, 63,913 hospital admissions and 572,653 emergency department visits. Of all age groups, young adults, 20 to 24 years old had the highest percentage of injury deaths with 84.9%. Youth, 15 to 19 years of age had the second highest percentage of injury deaths with 76.4%.

1. Alberta is spending an estimated $4 billion annually on injury – that amounts to $1,083.00 for every Albertan.

2. Potential impact of cannabis legalization on injury in Alberta In 2018, the Government of Canada will legalize the use of cannabis for recreational purposes. In the United States, some jurisdictions have similarly legalized cannabis for recreational use and have collected data on the changes in injuries due to cannabis use. Jurisdictions that have legalized the use of recreational as well as medical cannabis have experienced increases in injuries due to burns (100%), pediatric ingestion of cannabis (48%), drivers testing positive for cannabis and/or alcohol and drugs (9%), drivers testing positive for THC (6%) and drivers testing positive for the metabolite caboxy-THC (12%) when comparing pre- and post-legalization numbers.

3. (pg. 149) Of greatest concern are the traffic outcomes. “Fatalities substantially increased after legislation in Colorado and Washington, from 49 (in 2010) to 94 (in 2015) in Colorado, and from 40 to 85 in Washington. These outcomes suggest that after legislation, more people are driving while impaired by cannabis.”

4. (pg.155) Alberta can expect to see similar changes in injuries when the new laws take effect. The objective of this document is to recommend policies for inclusion in the Alberta Cannabis Framework that will minimize negative impacts of cannabis legalization on injuries to Albertans. Our focus is on:

* Preventing Cannabis-Impaired Driving

* Preventing Poisoning of Children by Cannabis

* Preventing Burns due to Combustible Solvent Hash Oil Extraction

* Preventing Other Injuries due to Cannabis Impairment

* Developing Surveillance to Identify Trends in Cannabis-Related injury

* Implementing a Comprehensive Public Education Plan

Injuries due to cannabis impairment in Alberta can be expected to rise following the legalization of recreational cannabis use. To mitigate the negative effects of legalization on injuries in Alberta, the Injury Prevention Centre recommends the Government of Alberta take the following actions for:

Preventing Cannabis-Impaired Driving

Impose administrative sanctions at a lower limit than Criminal Code impairment

Mandate a lower per se levels for THC/alcohol co-use

Increase sanctions for co-use of alcohol and cannabis

Separate cannabis and alcohol outlets by the creation of a public retail system for the distribution of cannabis products

Support Research to Improve Enforcement Tools

Apply sufficient resources to training and enforcement

Conduct public education regarding cannabis-impaired driving .

Preventing Poisoning of Children by Cannabis

Uphold federal legislation regarding packaging

Support public education on cannabis poisoning’

Preventing Burns due to Combustible Solvent Hash Oil Extraction

Prohibit the production of cannabis products using combustible solvents if it fails to appear in federal Bill C45.

Implement public education regarding the dangers of producing cannabis products using combustible solvents

Preventing Other Injuries due to Cannabis-Impairment

Inform the public about the risks of other activities when impaired

Develop Surveillance to Identify Trends in Cannabis-Related injury

Collect and analyze emergency department, hospital admission and death data for injuries involving cannabis impairment

Develop and implement a comprehensive public education campaign about the safe use of cannabis

Source: https://injurypreventioncentre.ca/downloads/positions/IPC%20-%20Cannabis%20Legalization Jan. 2018

Filed under: Canada,Global Drug Legalisation Efforts,Political Sector,Prevention (Papers) :

Drug education is the only part of the middle school curriculum I remember — perhaps because it backfired so spectacularly. Before reaching today’s legal drinking age, I was shooting cocaine and heroin.

I’ve since recovered from my addiction, and researchers now are trying to develop innovative prevention programs to help children at risk take a different road than I did.

Developing a public antidrug program that really works has not been easy. Many of us grew up with antidrug programs like D.A.R.E. or the Nancy Reagan-inspired antidrug campaign “Just Say No.” But research shows those programs and others like them that depend on education and scare tactics were largely ineffective and did little to curb drug use by children at highest risk.

But now a new antidrug program tested in Europe, Australia and Canada is showing promise. Called Preventure, the program, developed by Patricia Conrod, a professor of psychiatry at the University of Montreal, recognizes how a child’s temperament drives his or her risk for drug use — and that different traits create different pathways to addiction. Early trials show that personality testing can identify 90 percent of the highest risk children, targeting risky traits before they cause problems.

Recognizing that most teenagers who try alcohol, cocaine, opioids or methamphetamine do not become addicted, they focus on what’s different about the minority who do.

The traits that put kids at the highest risk for addiction aren’t all what you might expect. In my case, I seemed an unlikely candidate for addiction. I excelled academically, behaved well in class and participated in numerous extracurricular activities.

Inside, though, I was suffering from loneliness, anxiety and sensory overload. The same traits that made me “gifted” in academics left me clueless with people.

That’s why, when my health teacher said that peer pressure could push you to take drugs, what I heard instead was: “Drugs will make you cool.” As someone who felt like an outcast, this made psychoactive substances catnip.

Preventure’s personality testing programs go deeper.

They focus on four risky traits: sensation-seeking, impulsiveness, anxiety sensitivity and hopelessness.

Importantly, most at-risk kids can be spotted early. For example, in preschool I was given a diagnosis of attention deficit/hyperactivity disorder (A.D.H.D.), which increases illegal drug addiction risk by a factor of three. My difficulty regulating emotions and oversensitivity attracted bullies. Then, isolation led to despair.

A child who begins using drugs out of a sense of hopelessness — like me, for instance — has a quite different goal than one who seeks thrills.

Three of the four personality traits identified by Preventure are linked to mental health issues, a critical risk factor for addiction. Impulsiveness, for instance, is common among people with A.D.H.D., while hopelessness is often a precursor to depression. Anxiety sensitivity, which means being overly aware and frightened of physical signs of anxiety, is linked to panic disorder.

While sensation-seeking is not connected to other diagnoses, it raises addiction risk for the obvious reason that people drawn to intense experience will probably like drugs.

Preventure starts with an intensive two- to three-day training for teachers, who are given a crash course in therapy techniques proven to fight psychological problems. The idea is to prevent people with outlying personalities from becoming entrenched in disordered thinking that can lead to a diagnosis, or, in the case of sensation-seeking, to dangerous behavior.

When the school year starts, middle schoolers take a personality test to identify the outliers. Months later, two 90-minute workshops — framed as a way to channel your personality toward success — are offered to the whole school, with only a limited number of slots. Overwhelmingly, most students sign up, Dr. Conrod says.

Although selection appears random, only those with extreme scores on the test — which has been shown to pick up 90 percent of those at risk — actually get to attend. They are given the workshop targeted to their most troublesome trait.

But the reason for selection is not initially disclosed. If students ask, they are given honest information; however, most do not and they typically report finding the workshops relevant and useful.

“There’s no labeling,” Dr. Conrod explains. This reduces the chances that kids will make a label like “high risk” into a self-fulfilling prophecy.

The workshops teach students cognitive behavioral techniques to address specific emotional and behavioral problems and encourage them to use these tools.

Preventure has been tested in eight randomized trials in Britain, Australia, the Netherlands and Canada, which found reductions in binge drinking, frequent drug use and alcohol-related problems. A 2013 study published in JAMA Psychiatry included over 2,600 13- and 14-year-olds in 21 British schools, half of whom were randomized to the program. Overall, Preventure cut drinking in selected schools by 29 percent — even among those who didn’t attend workshops. Among the high-risk kids who did attend, binge drinking fell by 43 percent.

Dr. Conrod says that Preventure probably affected non-participants by reducing peer pressure from high-risk students. She also suspects that the teacher training made instructors more empathetic to high-risk students, which can increase school connection, a known factor in cutting drug use. Studies in 2009 and in 2013 also showed that Preventure reduced symptoms of depression, panic attacks and impulsive behavior.

For kids with personality traits that put them at risk, learning how to manage traits that make us different and often difficult could change a trajectory that can lead to tragedy.

Source: http://www.nytimes.com/2016/10/04/well/family/the-4-traits-that-put-kids-at-risk-for-addiction

Filed under: Addiction (Papers),Education Sector (Papers),Prevention (Papers) :

In Illinois in the USA, randomly allocating towns to enforce laws against youth smoking in public led not just to fewer youth smoking but also fewer drinking or using and being offered illegal drugs – did anti-tobacco policing spill-over to create an environment unfriendly to drinking and illegal drug use?

Summary The featured report drew its data from a study which randomly assigned 24 towns in the US state of in Illinois to either more vigorously enforce laws prohibiting under-age possession and use of tobacco, or to continue with existing low-level enforcement practices, a study which showed the intended effects on youth smoking. The issue addressed by the featured report was whether this spilled over to affect other forms of substance use and availability.

The towns selected for and which (via their officials) agreed to participate in the study were also all engaged in a state-sponsored programme intensifying enforcement of the ban on commercial tobacco sales to youngsters under the age of 18. The difference in the 12 towns allocated to enhanced enforcement was that this was supplemented by intensified enforcement of laws against young people having or using tobacco, in particular by levying civic fines against minors caught using or possessing tobacco in public. By design, at the start of the study all the towns only infrequently enforced these laws, a situation continued in the 12 control towns not allocated to enhanced enforcement.

Assignment had the intended effect; over the four years of the study, the average yearly number of anti-tobacco citations issued to minors was significantly higher (17 v. 6) in towns assigned to enhanced enforcement than in control towns.

Earlier reports on the study also showed the intended impact on youth smoking, which increased at a significantly slower rate for adolescents in towns where enforcement was extended. The researcher-administered, confidential surveys of school pupils which established this also asked about current (past 30 days) and ever use of substances other than tobacco. The key statistics for the study were the total number of different types of drugs the student had recently or ever used, averaged over pupils in the same town to assess the impacts on youth in the town as a whole. Pupils were also asked how many times over the past year someone had tried to give or sell them illegal drugs. These surveys were administered in four succeeding years to students from grade seven (age 12–13) up to grade ten in 2002, 11 in 2003, and 12 in 2004 and 2005, meaning that in each year some of the same pupils but also many new ones were sampled.

Across the four waves of data collection 52,550 pupils were eligible to be surveyed of whom 29,851 (57%) completed at least one survey. From these were selected only the 25,404 pupils (who completed 50,725 surveys) living in the 24 towns in the study.

Main findings

At the start of the study towns in the two sets of 12 did not differ in the number of substances currently or ever used by their pupils. As the different tobacco enforcement policies were implemented, over the succeeding three years the number of different drugs that a pupil currently or had ever used increased significantly less steeply in towns assigned to enhanced tobacco enforcement. There was a similar and also statistically significant result for offers of illicit drugs.

Use of substances other than tobacco was dominated by alcohol, so a further analysis focused on this substance alone. Again, increases in the average proportions of pupils who had recently or ever drank alcohol were significantly less steep in towns assigned to enhanced tobacco enforcement.

Though differences between the two sets of towns were statistically significant they were modest, and in both sets most substances had or were being used by few pupils.

The authors’ conclusions

In this study, towns allocated to heightened enforcement of laws prohibiting youth possession and use of tobacco experienced relatively lower increases in the probability that their young people had or were using a number of different substances or had been exposed to an offer of illicit drugs, providing preliminary evidence that police efforts to reduce specific substance use behaviours might have a positive spill-over effect on other high-risk activities. Given the co-occurrence of different forms of substance use, strategies that strengthen community norms against youth tobacco use might work synergistically to help reduce youth drug use and illicit drug offers.

How did an enforcement effort focused exclusively on tobacco affect use and availability of other substances? There are several possible explanations. Being punished for tobacco-related crimes might deter individual children from possessing and using other drugs, and the knowledge that police in enforcement towns approach youngsters to enforce anti-tobacco laws may deter young people and even adults from selling drugs in these communities. Possibly relevant too is the ‘broken window’ approach to enforcement, supported by studies which have shown that enforcement of laws against lower-level crimes can deter more serious offences. According to this theory, creating an environment where youth cigarette use is not tolerated might create an unfavourable environment for drug use. More directly, greater contact between young people and police enforcing underage tobacco laws might give police more chances to search for and confiscate illegal drugs.

Police believe that publicly smoking cigarettes acts as a signal to drug dealers that a young person might also be in the market for drugs. If so, making youth smoking less visible in a town may also make that town less attractive to dealers. Reduced visibility may also minimise the perception that illegal behaviour is normal and acceptable in that community. The effect could be to reduce sales attempts by make potential young customers less obvious and by making the entire town seem an undesirable dealing location. Alternatively, the findings might reflect reduced offers of alcohol or other drugs from friends rather than drug dealers, because reductions in use of tobacco spread to other substances, especially alcohol.

However, alcohol not illegal drugs might account for the bulk of the findings. Use of tobacco and alcohol tend to go together, so if police crack down on tobacco, they might also discourage drinking.

Source: Journal of Community Psychology: 2010, 38(1), p. 1–15.

Filed under: Prevention (Papers),Social Affairs,USA,Youth :

Teens can’t control impulses and make rapid, smart decisions like adults can — but why?

Research into how the human brain develops helps explain. In a teenager, the frontal lobe of the brain, which controls decision-making, is built but not fully insulated — so signals move slowly. “Teenagers are not as readily able to access their frontal lobe to say, ‘Oh, I better not do this,’ ” Dr. Frances Jensen tells Fresh Air’s Terry Gross.

Jensen, who’s a neuroscientist and was a single mother of two boys who are now in their 20s, wrote The Teenage Brain to explore the science of how the brain grows — and why teenagers can be especially impulsive, moody and not very good at responsible decision-making. “We have a natural insulation … called myelin,” she says. “It’s a fat, and it takes time. Cells have to build myelin, and they grow it around the outside of these tracks, and that takes years.” This insulation process starts in the back of the brain and heads toward the front. Brains aren’t fully mature until people are in their early 20s, possibly late 20s and maybe even beyond, Jensen says.

“The last place to be connected — to be fully myelinated — is the front of your brain,” Jensen says. “And what’s in the front? Your prefrontal cortex and your frontal cortex. These are areas where we have insight, empathy, these executive functions such as impulse control, risk-taking behavior.” This research also explains why teenagers can be especially susceptible to addictions — including drugs, alcohol, smoking and digital devices.

Interview Highlights

On why teenagers are more prone to addiction

Addiction is actually a form of learning. … What happens in addiction is there’s also repeated exposure, except it’s to a substance and it’s not in the part of the brain we use for learning — it’s in the reward-seeking area of your brain. … It’s happening in the same way that learning stimulates and enhances a synapse. Substances do the same thing. They build a reward circuit around that substance to a much stronger, harder, longer addiction.

Just like learning a fact is more efficient, sadly, addiction is more efficient in the adolescent brain. That is an important fact for an adolescent to know about themselves — that they can get addicted faster.

It also is a way to debunk the myth, by the way, that, “Oh, teens are resilient, they’ll be fine. He can just go off and drink or do this or that. They’ll bounce back.” Actually, it’s quite the contrary. The effects of substances are more permanent on the teen brain. They have more deleterious effects and can be more toxic to the teen than the adult.

On the effects of binge drinking and marijuana on the teenage brain

Binge drinking can actually kill brain cells in the adolescent brain where it does not to the same extent in the adult brain. So for the same amount of alcohol, you can actually have brain damage — permanent brain damage — in an adolescent for the same blood alcohol level that may cause bad sedation in the adult, but not actual brain damage. …

Because they have more plasticity, more substrate, a lot of these drugs of abuse are going to lock onto more targets in [adolescents’] brains than in an adult, for instance.

We have natural cannabinoids, they’re called, in the brain. We have kind of a natural substance that actually locks onto receptors on brain cells. It has, for the most part, a more dampening sedative effect. So when you actually ingest or smoke or get cannabis into your bloodstream, it does get into the brain and it goes to these same targets.

It turns out that these targets actually block the process of learning and memory so that you have an impairment of being able to lay down new memories. What’s interesting is not only does the teen brain have more space for the cannabis to actually land, if you will, it actually stays there longer. It locks on longer than in the adult brain. … For instance, if they were to get high over a weekend, the effects may be still there on Thursday and Friday later that week. An adult wouldn’t have that same long-term effect.

On marijuana’s effect on IQ

People who are chronic marijuana users between 13 and 17, people who [use daily or frequently] for a period of time, like a year plus, have shown to have decreased verbal IQ, and their functional MRIs look different when they’re imaged during a task. There’s been a permanent change in their brains as a result of this that they may not ever be able to recover.

It is a fascinating fact that I uncovered going through the literature around adolescence is our IQs are still malleable into the teen years. I know that I remember thinking and being brought up with, “Well, you have that IQ test that was done in grade school with some standardized process, and that’s your number, you’ve got it for life — whatever that number is, that’s who you are.”

It turns out that’s not true at all. During the teen years, approximately a third of the people stayed the same, a third actually increased their IQ, and a third decreased their IQ. We don’t know a lot about exactly what makes your IQ go up and down — the study is still ongoing — but we do know some things that make your IQ go down, and that is chronic pot-smoking.

On teenagers’ access to constant stimuli

We, as humans, are very novelty-seeking. We are built to seek novelty and want to acquire new stimuli. So, when you think about it, our social media is just a wealth of new stimuli that you can access at all times. The problem with the adolescent is that they may not have the insider judgment, because their frontal lobes aren’t completely online yet, to know when to stop. To know when to say, “This is not a safe piece of information for me to look at. If I go and look at this atrocious violent video, it may stick with me for the rest of my life — this image — and this may not be a good thing to be carrying with me.” They are unaware of when to gate themselves.

On not allowing teenagers to have their cellphones at night

It may or may not be enforceable. I think the point is that when they’re trying to go to sleep — to have this incredibly alluring opportunity to network socially or be stimulated by a computer or a cellphone really disrupts sleep patterns. Again, it’s also not great to have multiple channels of stimulation while you’re trying to memorize for a test the next day, for instance.

So I think I would restate that and say, especially when they’re trying to go to sleep, to really try to suggest that they don’t go under the sheets and have their cellphone on and be tweeting people. First of all, the artificial light can affect your brain; it decreases some chemicals in your brain that help promote sleep, such as melatonin, so we know that artificial light is not good for the brain. That’s why I think there have been studies that show that reading books with a regular warm light doesn’t disrupt sleep to the extent that using a Kindle does.

Source: http://www.mprnews.org/story/2015/01/28/npr-teen-brains

Filed under: Addiction (Papers),Effects of Drugs (Papers),Prevention (Papers),Social Affairs (Papers) :

An early onset of drinking is a risk factor for subsequent heavy drinking and negative outcomes among high school students, finds a new study.

Researchers asked 295 adolescent drinkers (163 females, 132 males) with an average age of 16 years to complete an anonymous survey about their substance use. These self-report questions assessed age at first intoxication – for example, “How old were you the first time you tried alcohol/got drunk?” They also took stock of the previous month’s consumption of alcohol, including an assessment of the frequency of engaging in binge drinking.

“Teenagers who have their first drink at an early age drink more heavily, on average, than those who start drinking later on,” said Meghan E. Morean, an assistant professor of psychology at the Oberlin College, Ohio and adjunct assistant professor of psychiatry at Yale School of Medicine. The findings also suggest that how quickly teenagers move from having their first drink to getting drunk for the first time is an important piece of the puzzle.

“In total, having your first drink at a young age and quickly moving to drinking to the point of getting drunk are associated with underage alcohol use and binge drinking, which we defined as five or more drinks on an occasion in this study,” Morean noted. We would expect a teenager who had his first drink at age 14, and who got drunk at 15, to be a heavier drinker than a teenager who had his first drink at age 14, and waited to get drunk until age 18, researchers emphasised.

“The key finding here is that both age of first use and delay from first use to first intoxication serve as risk factors for heavy drinking in adolescence,” said William R. Corbin, associate professor and director of clinical training in the department of psychology at Arizona State University

The study is scheduled to be published in the journal Alcoholism: Clinical and Experimental Research.

Source: www.business-standrd.com 20th Sept 2014

Filed under: Addiction,Addiction (Papers),Alcohol,Drug use-various effects on foetus, babies, children and youth,Education Sector (Papers),Prevention (Papers),Prevention and Intervention,Youth :

CND 52^ND Session – Vienna International Centre

Side Event – 18^th March 2009

Effective Programmes for Drug Prevention in Youth

by Peter Stoker – Director, National Drug Prevention Alliance, UK.

This paper is written in the context of education for Universal Prevention, rather than for Indicated or Selective Prevention processes.

Drug education, as we on the prevention side of the house understand it, is part of the process of producing drug-free lifestyles for all. But our opponents characterise and condemn this as part of a so-called ‘war on drugs’.

Well, if what we have here is indeed a ‘war’, should Obama pull the troops out? More realistically, this is a ‘war’ that has never been fought for real. And sadly those whom you might think of as ‘our’ troops too often turn out to be collaborators. With the benefit of hindsight we can see that the term ‘war on drugs’ is a finely conceived and executed meme (Ref 1 – a paper by my NDPA colleague Brian Heywood – will tell you more about what a meme is) – this particular meme engenders a feeling that we who are opposed to drug abuse are aggressors, whilst our opponents, the libertarians, are cast as peace-seekers. Their high priests, such as Arnold Trebach, exploit this meme by pleading that ‘… we have had enough ‘drug war’ – what we want now is a little ‘drug peace’’. As Mel Brooks might have put it:

“A little piece of heroin, a little piece of dope,

A little piece of cocaine, brings us peace – we hope.”

Whether you seek a drug-free society, or the kind of drug-laden ‘peace’ Arnold Trebach proposes, both camps see a key role for drug education. Surely this means that if we serve up more education than they do, we will reach our goal – right? Wrong. This is the kind of over-simplifying that has typified too much of what has been done in the name of drug education in the past – it is like serving yourself chicken soup at home – it gives you a warm feeling, but nobody else notices.

After nearly twenty years of PRIDE conferences I can recall several drug education programmes which would have ‘warmed the soup’ for the teacher – but done little else.

Taking the title of this paper – ‘Effective Drug Education for Youth’ – let me start by de-constructing the title – in reverse order:

‘Youth …’

There are not a few people around – present company excepted – who see drug education with youth as the Silver Bullet. Get this youthful generation ‘educated’ and we are home and dry (and clean and sober). I take issue with this – youth are not an island, even though they are as vulnerable as any, and more vulnerable than many, to external influences – what the professionals call ‘mediating variables’. And youth have an inexhaustible knack of grabbing the wrong end of the stick; I still relish the words of one American mentor, several years ago:

‘There’s nothing wrong with a teenager that reasoning with him

won’t aggravate’.

Just to remind us all that youth are not the be-all and end-all, I draw your attention to a report on evidence-based prevention with ‘older adults’ – published under the auspices of SAMHSA (Substance Abuse and Mental Health Services Administration) by the ‘Older Americans Substance Abuse and Mental Health Technical Assistance Center’. The problem of substance abuse amongst senior citizens is recognised to be such as to require prevention to be ‘a national priority’. (Ref 2)

‘Drug Education …’

I am astonished to note that there are still teachers around who think the transfer of factual knowledge is the key to drug prevention success. One may comfort oneself on the excellence of one’s knowledge transfer, and be warmed by a few positive feedbacks; the acid test is ‘have you influenced the majority?’ – the acid answer is ‘probably not’. Of course facts on their own will be seminal for a few receiving them – we have all, in our time, been touched by a single fact – but one cannot in all seriousness extend this to a generality.

We need to recognise that drug education is not an end in itself, it is a tool of prevention, and as such it must help must mediate behaviour. You can deliver a programme of education which satisfies process criteria within itself – but it has long been known that transmitting knowledge does not automatically change behaviour.

A valuable and occasionally seminal tool, maybe, but unless it is delivered skilfully, and in the right setting, unless it is properly sharpened, it won’t cut it.

‘Effective …’

My contention, from the review above, is that concentrating on ‘youth’ and ‘drug education’ in isolation cannot (for most recipients) be effective in terms of drug prevention. If we are looking for effective lifestyle change, then we have to look much wider and more rationally.

The current US-based point of reference for effective processes of prevention is NIDA. (National Institute on Drug Abuse). Their most recent summary on the subject is ‘Preventing Drug Use – A Research Based Guide – second edition’ – 2003. (Ref 3) It is interesting to note that this reference work is now more than six years old. Does this mean it cannot yet be improved upon? Have fashions changed? Or is it simply a shortage of funding for prevention research?

The Guide starts by setting out the Principles of Prevention, under sixteen main headings. Of these, Principles 7 and 8 – reproduced here as Table 1 – focus on education, saying:

Principle 7- Elementary Schools – ‘… programs should target improving academic and social-emotional learning’.

Principle 8 – Middle, Junior and High schools – ‘…programs should increase academic and social competence’

The Guide does give a useful reference list of the components of effective preventive education, but this does not seem to take us much further than the earlier work (Ref 3) by Bonnie Benard, when she was a specialist with Illinois Teen Institute in the 1980s. Benards’ recommendations are shown in Table 2.

What neither NIDA nor Benard do not mention is the single factor which can be said to encompass all other factors in influencing (mediating) behaviour. That factor is culture.

This means the culture in which decisions about drugs are made; the culture in which teachers, police, media, legislators, governments, medics, youth workers, parents, partners (and many more besides) operate in this society of ours. The culture impinging on the decision-making person and their interaction with the culture of all other people around them is a major part of this. The age of all concerned is also relevant – as is the ‘education’ they have received. We sometimes forget that teachers in drug education have often received little or no education on the subject themselves, or in some cases, may have been exposed to influence from teacher trainers who have a drug education axe to grind. (Indeed some of these teachers may be current or past users of drugs themselves).

So, what influences the culture around decisions? Ii includes, in no particular order:

– Peer Group Influence

– Personal perceptions

– Income v Cost of any action

– Health Issues

– Moral Structure

– Spiritual structure

– Family values

– The attraction of risk-taking

– The media, music, movies, tv, fashion, humour etc.

– Mental condition, – depressed, elated, in-between, and

– Legislation, including Conventions

This primacy of culture resonates with the work of one of my earliest mentors, Bill Lofquist, (Ref 5) who hails from Tucson, Arizona and who said:

“We need to get beyond the notion that prevention is stopping

something happening, to a more positive approach which

creates conditions which promote the well-being of people.”

Addressing culture through education is ‘creating conditions’ – no more and no less.

If you are going to tackle the culture in a community, you would do well to first measure whether your seeds will fall on stony ground, or will bear fruit. The NIDA Guide usefully assists this by giving a check list ‘Nine Stages of Readiness in a Community’ – reproduced here in Table 3.

Specifics of Effective Drug Education for Youth

Too often, it seems, the approach to drug education takes for granted that the educators understand and buy into the intended goals, know what they are doing, and will operate a Systems Approach – such as that described in another invaluable reference tool – ‘The Future by Design’. Published by the USDHHS, Department of Health and Human Services, in 1991. The core of a systemised approach is a ‘spiral’ of revisiting process stages – plan/implement/evaluate/decide/then plan again.

Another gem from this valuable reference work is a table showing a ‘Contrast of Paradigms’ in empowering a community – whether this be an education community or some other part of society. Reproduced herein as Table 4, it will almost certainly have a salutary effect on all of us, whatever our professional discipline !

As a very recent example of effective prevention programmes. I cite the ‘Good Behavior Game’ developed and tested in Baltimore City Public Schools, and reported in 2008 ( Ref 7 and Ref 8). Addressing multiple targets – anti-social disorders, violent and criminal behaviour, disruptiveness, as well as drug abuse and other factors, the ‘GBG’ program applied classroom management techniques with more than 2300 pupils, and helped them to significantly adjust to the role of successful student. A positive impact on drug/alcohol abuse was but one of the measured positive outcomes.

How Does Effective Education Fit In?

America’s CSAP (Centre for Substance Abuse Prevention) – was excited as long ago as 1991 (Ref 6 – see Chapter 1, Overview) by the finding that the best prevention results come through ‘….co-ordinated prevention efforts that offer multiple strategies, provide multiple points of access, and coordinate and expand citizen participation in community activity.’

Such an approach , whether in drug prevention or drug education, requires a certain relinquishing of self-authority; to get the best out of a wide range of disciplines and sectors, it is expedient to get on to their level – whatever that is. Prevention expert Bill Lofquist spells this out clearly by defining a spectrum of approaches – you can treat youth as dumb ‘Objects’, as ‘Recipients’ – albeit under your control, or as ‘Resources’ sharing the policy and practice. Hard way or easy way – your choice. It is also important to recognise that you cannot ‘do’ prevention ‘to’ people, you must rather engender a condition in which prevention will be the obvious choice for people.

This is also to a significant extent true of drug education – and certainly of affective education.

Equally important is an understanding of how the drug education which you are delivering interacts and harmonises with the whole societal system, and the goals of each sector. An example of this is given in Table 5 herein, which was presented by NDPA to the UK Shadow Home Secretary’s Office last November (2008) as part of a dialogue on national drug policy.

Specific examples of Effective Prevention

The technical references called up in this paper give several specific examples, covering various approaches. NDPA can give extended details (on request) on its own Peer-led drug education and prevention process – Teenex ( Ref 9 )– which was successfully adopted by other countries.

If you are looking for support for prevention, your first place to look would probably not be The Economist, and yet their issue on 5^th March this year gave just that. Their Article entitled ‘In America, lessons learned’ ( Ref 10) says:

‘By far the best way of reducing the harm that drugs do is to convince

people not to use them’

The Economist article gives several further encouragements to preventive drug education. It takes the usual swipes at the DARE (Drug Abuse Resistance Education) programme, and does so on the usual incorrect and outdated basis, but it finds itself compelled to move to a more complimentary stance when it describes the latest remodelling, including DARE’s much wider scope of linked subjects – from drugs to internet bullying.

As the Economist observes, DARE (Drug Abuse Resistance Education) programme has learnt this lesson the hard way. DARE’s current strapline is ‘Dare to resist drugs, and violence’ and despite the hostile attitude of some on both sides of the drug education house towards it, DARE continues to succeed, witness the fact that it has been taken up by another 220 communities in the three years to its latest published report (2007).

Another project lauded by the Economist for a multi-topic motivational approach started in Montana and other western states in tackling the resurgent problem of methamphetamine abuse. Instead of trotting out the usual array of medical harm facts, the organisers elected to highlight that meth users often get rotten teeth. This turned out to be a very telling message.

The Economist concludes its article by referring to the anti-tobacco campaigns, which have made big inroads into prevalence. They suggest several reasons for this success; I would suggest they can all be grouped under the heading of culture change.

Elsewhere, an interestingly different example is given in the NIDA research-based guide. It is called PATHS – Promoting Alternative Thinking Strategies, and it is a programme for ‘promoting emotional, health and social competencies, and reducing aggression and behaviour problems in elementary school children, while enhancing the educational process in the classroom’. Although primarily targeted at school classrooms, it also includes information and activities for parents. I draw your attention to this programme not so much for its particular excellence as much as its example of how diverse one’s drug education approach can and should be. Diversity in a programme may produce vital dividends in this time of scarce funding. If the programme you intend using has other benefits over and above drug education, then this could open the door to other funding sources. Diverse outcomes equals diverse incomes!

Conclusions

With the aim of ‘Effective Drug Education for Youth’ we need to understand that what makes a programme effective will range well beyond the programme itself. Taking an extreme example, if , as has been asserted, drug abuse is a reaction to an unsatisfactory society, then the solution is simple – improve society!

This paper has attempted to take drug education out of its comfort zone, and in the process, to identify ways of improving effectiveness.

One way to concentrate one’s thinking about drug education is to consider it as a business venture. Metaphorically speaking, what are the parameters we should address in this business?

– What is our product, our USP?

– What can we sell it for, and to whom?

– What can the competition sell theirs for and to whom?

– Where can we best sell it?

– Who, besides us, can influence the market?

– Who has the best toys? And can we partner with them?

– What is the shelf life of our product?

– What is our human resource? and

– How are we going to measure sales?

I wish you every good fortune, as you draw up your Business Plan!

**********

REFERENCES

1. Heywood, B. ‘Assaying Information in the Substance Misuse World’ Published NDPA, 2004

2. Blow, C. F. et al ‘Evidence-Based Practices for Preventing Substance Abuse and Mental Health Problems in Older Adults’ Published: Older American Substance Abuse & Mental Health Technical Assistance Center, 2005.

3. National Institute on Drug Abuse. ‘Preventing Drug Use Among Children and Adolescents – A Research- Based Guide’ Published NIDA, Second Edition 2003.

4. Benard, B. ‘Characteristics of Effective Prevention’ Published Project Snowball training manuals, Illinois Teen Institutes, 1987.

5. Lofquist, W.A. ‘Discovering the Meaning of Prevention – A Practical Approach to Positive Change’, Published: AYD Publications, Tucson, Arizona l983. Fifth Printing, 1991.

6. OSAP, DHHS. ‘The Future by Design – A Community Framework for Preventing Alcohol and Other Drug Problems Through a Systems Approach. Published: DHSS No. (ADM) 91-1760; l991

7. Petras, H. et al. ‘Developmental Epidemiological Courses Leading to Antisocial Personality Disorder and Violent and Criminal Behavior; Effects by Young Adulthood of a Universal Preventive Intervention in first-and second-grade Classrooms’ Published: Drug and Alcohol Dependency, 95S1 – pp.S45-S59, 2008

8. Poduska, J. et al. ‘Impact of the Good Behavior Game, A Universal Classroom-based Behavior Intervention, on Young Adult Service Users for Problems with Emotions, Behavior, or Drugs or Alcohol. Published: Drug and Alcohol Dependency, 95S1 – pp.S29-S44, 2008

9. Stoker, S. A. ‘Teenex – ‘A Peer Education and Drug Prevention Programme’ Published National Drug Prevention Alliance, 1988 and subsequent editions.

10. Economist,print edition. ‘In America, lessons learned – but efforts to warn people off drugs are still too timid’. – March 5^th 2009

Table 1.

NIDA: ‘Preventing Drug Use, Research-based Guide’ – 2^nd Edition, 2003.

Prevention Principles – Extract for Education

Principle 7:

Prevention programs for elementary school children should target improving academic and social-emotional learning to address risk factors for drug abuse, such as early aggression, academic failure, and school dropout. Education should focus on the following skills (Ialongo et al. 2001; Conduct Problems Prevention Work Group 2002b):

Self-control
Emotional awareness
Communication
Social problem-solving; and
Academic support, especially in reading.

Principle 8:

Prevention programs for middle or junior high and high school students should increase academic and social competence with the following skills (Botvin et al. 1995; Scheier et al. 1999):

Study habits and academic support;
Communication;
Peer relationships;
Self-efficacy and assertiveness;
Drug resistance skills;
Reinforcement of anti-drug attitudes; and
Strengthening of personal commitments against drug abuse.

NOTE: Principle 9 is also relevant, in encouraging programs aimed at transition points, such as the transition to middle school; these “…can produce beneficial effects even among high-risk families and children”.

(Botvin et al. 1995; Dishion et al. 2002).

————————————————————————————————

Source document full title:

‘Preventing Drug Abuse among Children and Adolescents – A Research-Based Guide for Parents, Educators, and Community Leaders’. Second Edition 2003.

National Institute on Drug Abuse/ US Department of Health and Human Services.

Available on line throughwww.drugabuse.gov

Table 2

Characteristics Of Effective Prevention

Written by Bonnie Benard, NIDA, USA.(Originally in training manuals for Project Snowball, Illinois Teen Institutes, 1987)

Published in Britain in ‘Drug Prevention – Just say Now’ by Peter Stoker, pub. David Fulton Publishers, London, 1992.

Programme comprehensiveness/intensity

A. Multiplicity: the causes of drug/alcohol abuse are multiple: personality, environmental, behavioural (Kandel, Logan, 1984; Hawkins et al, 1951). Programmes tackling only one area usually fail. You should target multiple systems (youth, families, schools, community, workplace, media, etc). Also use multiple strategies (information, lifestyles, positive alternatives, community policies) (Botvin, 1982).

B. Target whole community. School-based programmes achieve less than community-based approaches.

C. Target all youth for prevention – not just “high risk”. Adolescence is seen to be a high-risk time for all youth in terms of health-compromising behaviour. Labelling “high risk” youth can provoke stigmatisation and lead to self-fulfilling prophecies. There is however an argument for defining “high risk” communities where an additional resource over and above the general prevention effort could be justified.

D. Build drug prevention into general health promotion. Drug abuse has been found by several (Lofquist, 1993) to be part of a complex pattern of interrelated factors – e.g. delinquency, truancy, school failure, precocious sexuality, which share common antecedents.

E. Start at an early age and keep going! Even in infancy there are influences in later behaviour. Developmental difficulties by age 3 are difficult to overcome (Burton, White). Here, it is of course relevant to mention Trevor Williams, Noreen Wetton and Alysoun Moon of the Southampton University team who have demonstrated so graphically in their “Jugs and Herrings” research papers that primary age children are not blissfully ignorant of drugs and alcohol. Prevention programmes starting from what children actually know are essential. Many secondary schools still seem to regard years 11 and 12 as the age at which discussion of drugs (or indeed sexuality) should be facilitated. Don’t wait until the horse has run away before you lock the stable doors!

F. Adequate quantity. ‘One-shot prevention efforts do not work” (Kumpfer, 1988) there must be a substantial number of interventions, each of a substantial duration. Project D.A.R.E. (Drug Abuse Resistance Education) initiated by Los Angeles Police and now in several countries, delivers no less than seventeen one-hour lessons to any given year and this is only part of the school programme.

G. Integrate family/classroom/school/community life. This is easier to say than do, but where it has happened results have been enhanced.

H. Supportive environment, empowerment. Where young people are encouraged to participate and take responsibility their behavioural outcomes are improved. In Britain now peer-education methods which have been proven elsewhere have been applied to good effect.

Programme strategies

J. ‘KAB’ – Knowledge/Attitudes/Behaviour. Address these as a set, i.e. each must be directly tackled rather than assuming one will flow from another. The behavioural component is in part addressed by social skills development, but also supported by positive reinforcement activities – drug free social/sporting events, commendations (preferably with something for everyone), media coverage, etc. Research suggests that social learning theory (Bandura, 1977) produces some of the most profound improvements.

K. Drug specific curriculum. Affective education programmes that had not specifically covered drugs (including alcohol) were found unsuccessful, even though they addressed knowledge, attitudes and lifeskills.

L. Gateway drugs. So-called because people now using heavy-end drugs almost always started on these. Gateway drugs can be tobacco, alcohol and cannabis or, these days in Britain, even heroin! Concentration on prevention of these is therefore likely to prevent all substances. British research by PaT (Parents against Tobacco, 1990), showed that of youth who smoked tobacco 50% had also tried an illegal drug compared with only 2% of those who did not smoke tobacco. It should be particularly noted that cannabis is far from harmless; physical, mental and social damage is now being increasingly accepted as a reality.

M. Salient material. Whatever is used needs to identify with the audience, including:

• ethnic/cultural sensitivity

• appeal to youth’s interests

• short term outcomes to be emphasised as important to youth as well as long term

• appropriate language, readability

• appealing graphics

• appropriate to real age/reading age – a key factor

In a survey of 3, 700, 000 young American children, 25% of 9 year olds felt “some” to “a lot” of peer pressure to try drugs or alcohol (Weekly Reader, 1987).

N. Alternatives. Activities have to be plausible, be more highly valued than the health-compromising behaviour. Too often these alternatives are poorly thought through. ( ‘Ping-pong = prevention’? No!)

P. Lifeskills. Development of these will be of wider benefit than drug prevention. Included will be

communication, problem solving, decision-making, critical thinking, assertiveness, peer pressure reversal, peer selection, low-risk choice making, self-improvement, stress reduction and consumer awareness (Botvin, 1985).

Choosing your friends has been found in some research to be more effective than resisting the peer pressure of said friends. Consumer awareness is a “companion” to resisting peer pressure, i.e. resisting media pressure.

Q. Training prevention workers. For the school setting the greater emphasis on experiential and interactive work requires teacher training to extend into youth work skills. Community development skills are valuable in taking school initiatives into the community. Imported “prestige” role models are all very well, but good results have been achieved with parents, peers, teachers, or outside agency workers.

R. Community norms. Consistency of policies throughout schools, families and communities can greatly enhance impact.

S. Alcohol norms. Because of its dual status as a beverage and as a culturally accepted drug, alcohol is problematic for prevention. However, heart disease and tobacco prevention programmes have shown that societal norms can be changed.

T. Improve schooling! Listed here as a target because of its important correlation with healthy lifestyle. Within the current British economic and academic climate one realistic hope may lie with co-operative learning, see the ‘Tribes’ programme, for example.

U. Change society. Don’t just stop with improving schools; add your voices to pressure for improvement in employment, housing, recreation and self-development; it is naïve to suppose that prevention can take place in a political vacuum. Jessor recognises that failing to acknowledge the need for macro-environmental improvement while at the same time placing the responsibility for health solely with the individual is tantamount to “blaming the victim”.

The planning process

V. Design, implementation, evaluation. Evaluations have generally concentrated on outcomes rather than the quality of design. However, implementation is as much dependent on engaging all sectors of the community (be it a school, a workplace, or a town) as it is on quality of design. Evaluation should therefore measure process as well as outcome.

W. Goal-setting. Unrealistic or immeasurable goals help no-one. It is important to set not only long-term outcome goals (for prevention is long-term) but also “process goals” such as increased involvement of parents and community, academic success, increased student-teacher interaction, and so on.

X. Evaluation and amendment. Prevention workers have been criticized for giving too little attention to this area, the crushing shortage of funds has much to do with it (in America the ratio of funding between interdiction-policy and prevention is about 200:1). This lack of emphasis on evaluation has been the Achilles heel that pro-drug campaigners have gleefully attacked. Effective evaluations have been those including longitudinal design, multiple measures of process as well as outcome (Tobler, 1986), and cost-benefit analysis (CBA). CBA is perhaps the greatest marketing tool prevention has; where CBA has been applied substantial cost effectiveness has been demonstrated.

Table 3

NIDA ‘Preventing Drug Use’ – A research-based guide

Measuring Community Readiness for Prevention

AS SIMPLE AS A,B,C.

(A) ASSESSING READINESS

(B) COMMUNITY RESPONSE

(C) IDEAS

1. (A)No Awareness. (B) Relative tolerance of drug abuse. (C) Create motivation. Meet with community leaders involved with drug abuse Prevention.

2. (A) Denial. (B) “Not happening here – can’t do anything about it”. (C) Use the media to identify and talk about the problem.

3. (A) Vague Awareness. (B) Awareness but no motivation. (C) Encourage the community to see how it relates to community issues.

4. (A) Pre-planning. (B) Leadership aware, some motivation. (C) Begin pre-planning.

5. (A) Preparation. (B) Active, energetic leadership and decision-making. (C) Work together. Develop plans for Prevention planning through coalitions and other community groups.

6. (A) Initiation. (B) Data used to support Prevention actions. (C) Identify and implement research-based programs.

7. (A) Stabilisation. Community generally supports existing program. (C) Evaluate and improve ongoing programs.

8. (A) Confirmation/expansion. (B) Decision makers support improving or expanding programs. (C) Insitutionalise and expand programs to reach more populations.

9. (A) Professionalisation. (B) Knowledgeable of community drug problem; expect effective solutions (C) Put multl-component programs in place for all audiences.

Source: Plested et al, 1999.

Table 4

DHHS – OSAP (CSAP) – ‘The Future by Design’

Community Action Alternatives

Community Empowerment System:

a Contrast in Paradigms

How do you want this project or program to run ? You can choose either the paradigm of (A) Agency delivery of Services OR the paradigm of (B) Community Empowerment – Which is it to be ?

Here are the results you could encounter:

1. (A) Professionals are responsible (doing for the community) OR (B) Responsibility is shared (doing with the community)

2. (A) Power is vested in agencies OR (B) Power resides with the community

3. (A) Professionals are seen as experts OR (B) The community is the expert.

4. (A) Planning and services are responsive to each agency’s mission OR (B)Services and activities are planned and implemented on the basis of community needs and priorities

5. Planning and service delivery are fragmented OR Planning and service delivery are interdependent and integrated.

6. Leadership is external and based on authority, position and title OR Leadership is from within the community, based on ability to develop a shared vision, maintain a broad base of support, and manage community problem solving.

7. Ethnic and cultural differences are denied OR Ethnic diversity and special populations are valued.

8. External linkages are limited to networking and co-ordination OR Co-operation and collaboration are emphasized.

9. The decision making process is closed OR Decision making is inclusive.

10. Accountability is to the agency OR Accountability is to the community.

11. The primary purpose of evaluation is to determine funding OR Evaluation is used to check program development and decision making.

12. Funding is categorical OR Funding is based on critical health issues.

13. Community participation is limited to providing input and feedback OR Community is maximally involved at all levels.

Table 5

Submission to UK Shadow Home Office Drugs Minister

by NDPA

An Idealised UK Drug Strategy should contain:

Culture change: – Cross-society measures coordinated to produce a

result, as has been done with tobacco.

Information: – Improve quality, age-appropriateness, root out hidden messages.

Prevention: – Few know what it is, fewer practice it. Study it. Apply it.

Show its cost-benefit to society as a whole.

Education: – Abstinence goal. Check materials before allowing them into schools. Develop random drug testing

Intervention, Treatment, Rehab, After-care, All should be abstinence-oriented

Justice system: – Apply proven systems such as Drug Courts. Work towards drug-free prisons. Apply mandatory education courses to any person cautioned or convicted.

Policing: – Should include referral to education courses

Customs:- Address serious concerns about SOCA

NICE – Should embrace an abstinence focus

Harm Reduction: – Should apply to whole society, not just users

Human Rights: – Should apply to whole society, not just users

Policy reviews: – Should proceed in line with the above goals.

———————————————————————————————-

Guide to acronyms:

NICE National Institute on Clinical Excellence

SOCA Serious and Organised Crime Authority

Filed under: Prevention (Papers) :

Author: Mr. S.W.Varcoe May 2012 www.dalgarnoinstitute.org.au

drug in the past 30 days has decreased 38% from its peak in 1979 (14.1%) to 2009 (8.7%). Equally impressive are statistics from the United Nations Office on Drugs and Crime (UNODC), which has documented a greater than 80% reduction in annual opioid use over the past century!”8,9,10

Yet, there is more to professional health management strategies than economic rationalism. Disease control is a primary goal of good health management policy/strategies. Eradication of any disease is the ultimate goal, but in the interim, management practices can be used with an attempt to alleviate symptoms and to improve health status, enabling best opportunities to work toward recovery and wellness. When there is any option for recovery/wholeness then that becomes the goal.

No good health professional will refuse or omit such options when they are available.

For instance, when it comes to the epidemiology of a disease, treating physicians look to a number of factors, including the agent of contagion. They look to manage, negate and prevent these agents from spreading.

Illicit drug use dependency has now been widely touted as a ‘disease’ and as such the term ‘disease’ has an ever morphing definition in various diagnostic manuals. Regardless of the definition, treatment principles still remain the same – the containment, cessation and future prevention of this disease. Two key factors must be addressed if any sort of positive health outcome is going to be achieved…

a) Susceptibility factors of the patient

b) Exposure factors to the patient

So in treating the disease of drug dependency/addiction one must address both of these factors to have best hope of the drug user becoming healthy again – The health that a) saves money b) keeps you from harm c) enables your full productive potential d) adds to your and the communities general well-being.

The question we now have to ask of any measure that will increase accessibility, permissibility and availability of illicit drugs is, will it exacerbate or alleviate a) susceptibility factors and b) exposure factors? If it does the former, then we have breached good, professional and fiscally responsible health care practice. Any action/method/process that enables the increase or worsening of these two factors is at best reprehensible and at worse culpable and worthy of malpractice suites and license revocation.

When it comes to the mental, physical and emotional health of society’s citizens and particularly its children, any measure that increases the exposure or susceptibility to a disease must be, if not eradicated, utterly contained. To do less is to collapse the very core of what good governance and good health care strategy is for a nation.

When the already available, well managed and effectively deployed ‘exposure’ preventing tool of criminality is employed, we are half way to achieving best potential for full recovery. Removing this proactively used mechanism will only see the opposite be true in a community.

Filed under: Prevention (Papers) :

It seems like everyone — informed by the science or not — has an opinion on marijuana research these days. And while I may disagree with their conclusions, many editors’ pro-legalization opinion columns are smartly formulated and backed by some credible research. But this past week’s opinion article by a member of the Chicago Tribune’s editorial board, Steven Chapman, was neither. Mr. Chapman makes eight particularly incorrect and misleading assertions that deserve a correction:

1.”Existing laws aren’t keeping kids away from pot.”

Fact: It’s true that many kids smoke marijuana. About half of high school seniors have done so at least once. But many more kids drink alcohol — a legal, addictive, commercialized drug. And while tobacco has been decreasing among kids and is now used slightly less than pot among high schoolers, we can thank a societal shift on attitudes and also 80 years of learning the hard way for that. Overall, still, alcohol and cigarettes are used far greater than marijuana.

We also have had a relatively recent societal shift in attitudes about marijuana. As our country increasingly shuns tobacco, it also has made marijuana more accessible and socially acceptable — and youth are reporting easier access to weed at the same time.

But are they really getting marijuana more easily than beer? The 2009 survey Mr. Chapman referenced has been debunked. A recent by the University of Maryland showed that kids alcohol and cigarettes were the most readily accessible substances, with 50% and 44% respectively, of youth reporting that they could obtain them within a day. Youth were least likely to report that they could get marijuana within a day (31%); 45% report that they would be unable to get marijuana at all.

2. “The sale and use of a substance does not necessarily mean more people will use it.”

Fact: Of course it does. Tobacco and alcohol are legal and readily accessible — and our nation’s use of those substances reflect this. According to the National Survey on Drug Use and Health, past-month use of tobacco stands at about 27%t, and past-month use of alcohol is about 52%. Meanwhile, past-month use of marijuana stands at about 8%of Americans. When RAND researchers analyzed California’s 2010 effort to legalize marijuana, they concluded that the price of the drug could plummet and therefore marijuana consumption could increase. When something is legal, it is very likely that more people use it.

3. “No one, after all, is talking about putting pot in vending machines.” Fact: Yes, as a matter of fact, they are. And it’s not just vending machines. It’s the “Starbucks of marijuana,” too. American society loves commercialization and Big Business has proven time and time again that they just can’t control themselves. A volunteer ban on liquor ads is completely ignored, as are bans on gambling advertising.

And remember what we have learned about Big Tobacco? Here’s evidence presented during the 1990s tobacco settlements to jog your memory:

The Liggett Group: “If you are really and truly not going to sell [cigarettes] to children, you are going to be out of business in 30 years.”

R. J. Reynolds: “Realistically, if our company is to survive and prosper over the long-term, we must get our share of the youth market.”

Lorillard: “The base of our business is the high school student.”

Phillip Morris: “Today’s teenager is tomorrow’s potential regular customer… Because of our high share of the market among the youngest smokers, Philip Morris will suffer more than the other companies from the decline in the number of teenage smokers.” Philip Morris (now Altria) just bought the domain names “altriacannabis.com” and “altriamarijuana.com.”

We are incredibly naive to think a commercial marijuana industry wouldn’t employ all of the same strategies to convince people — especially young people — to use marijuana.

4. “The tolerance-fuels-use theory is thunderously lacking in real-world support. In the Netherlands, where ‘coffee shops’ are allowed to sell pot, teenagers are far less likely to use it than their American peers.”

Fact: The Netherlands experience is far more complicated than Mr. Chapman would care to discuss. Yes, the Netherlands has always had drug use rates below or at around the same rate as the U.S. Frankly, American drug use rates have far exceeded most of the world’s for a few hundred years now. But when the Netherlands started advertising pot – something we in America would be extremely susceptible to — they witnessed a tripling in youth use marijuana use rates, according to independent researchers. Their citizens now have a higher likelihood of needing treatment for marijuana than most of Europe. And they are closing many of their “coffee shops” after years of tolerance because of very potent pot that is saturating the market.

5. “‘In the states that have passed medical-marijuana laws, youth marijuana use has decreased,’

Amanda Reiman, policy manager for the Drug Policy Alliance, told me. In California, “the number of seventh, ninth and 11th graders reporting marijuana use in the last six months and in their lifetimes all declined” after 1996, when the state passed its medical marijuana law.”

Fact: Rule number one in journalism: Check your facts. Informal rule #2: Make sure the facts you do use come from scientists, not advocates. There are two major problems with this statement:

(a) First, it does not come from a respected source, peer-reviewed journal, or anything of the like. The truth is that we are only beginning to learn about what happens to youth marijuana use when marijuana is “medicalized.” The only two peer-reviewed studies that I’ve seen on this shows that marijuana use is higher in medical marijuana states than non-medical marijuana states. And we have seen rapid increases in marijuana use since medical marijuana has been more widely accepted, since about 2007 or so. But we’re still learning. At the very least, the jury is out. But ask kids what they think about marijuana and you’ll probably get the answer that “if it’s medicine, it must be okay.” We know, for example, that the diversion of medical marijuana is common among adolescents in substance treatment. (b) Second, even if we were to look at the overall use statistics and make a wide generalization about the link between medical marijuana and youth use, we would not look at 1996 as a starting point. Medical marijuana outlets were not implemented en masse until about 2006 or so. So while the law passed in 1996, it’s fair to say it was not fully implemented until 10 years later. And what has happened since 2006 in California and nationwide? Use rates have rapidly increased. But as I said before, we still need more research on the topic.

6. “The alleged harms of cannabis on the teen mind and body are exaggerated.”

Fact: By whom? The producers of the 1936 film Reefer Madness? Maybe so. But today’s science has moved beyond scare tactics and there are some general beliefs scientists hold about marijuana and its effect on teens: Addiction: 1 in 6 kids who ever smoke marijuana will become addicted, according to independent research. Mental Health: Marijuana use is significantly linked with mental illness, especially schizophrenia and psychosis, but also depression and anxiety. Learning: Heavy, persistent marijuana use in adolescence is linked to a strong decline in IQ. A new analysis of this study has raised doubts among some, but the original study authors redid their analysis and are sticking to their findings. Also researchers unconnected to both studies have concluded that the new analysis does not overturn the original study. The Director of the National Institute on Drug Abuse summed it up nicely:

…observational studies in humans cannot account for all potentially confounding variables. In contrast, animal studies — though limited in their application to the complex human brain — can more definitively assess the relationship between drug exposure and various outcomes. They have shown that exposure to cannabinoids during adolescent development can cause long-lasting changes in the brain’s reward system as well as the hippocampus, a brain area critical for learning and memory. The message inherent in these and in multiple supporting studies is clear. Regular marijuana use in adolescence is known to be part of a cluster of behaviors that can produce enduring detrimental effects and alter the trajectory of a young person’s life — thwarting his or her potential. Beyond potentially lowering IQ, teen marijuana use is linked to school dropout, other drug use, mental health problems, etc. Given the current number of regular marijuana users (about 1 in 15 high school seniors) and the possibility of this number increasing with marijuana legalization, we cannot afford to divert our focus from the central point: regular marijuana use stands to jeopardize a young person’s chances of success–in school and in life.

7. “A kid who gets his hands on beer doesn’t have to worry about getting toxic chemicals or nasty fillers. Buying pot in illicit markets may also expose users of all ages to violence, robbery or extortion. But you don’t see innocent bystanders getting killed in shootouts among liquor store owners.”

Fact: Marijuana legalization would do little to curb the black market, especially because that market could easily undercut the new, taxed price of legal marijuana . And let’s be clear: Most kids get their pot from a friend or family member indoors, not from some shady character on a street corner. Don’t believe everything you see in the movies.

8. “The alternative to legalization is sticking with a policy that has produced millions of arrests, squandered hundreds of billions of dollars and turned many harmless people into criminals in the eyes of the law — all while failing to stem the popularity of pot. For kids or adults, there is nothing healthy in that.”

Fact: This is probably my biggest beef with this piece. And it is not because the facts about marijuana use trends over the past 30 years are dead wrong (in fact, marijuana use is much lower than it was in the late 1970s).

To say that the only alternative to current policy is legalization is like saying the only alternative to current gun policy is the repeal of the Second Amendment. Actually, there are myriad of things short of legalization we can do to lessen the harms of current policy while improving upon it. That is why I launched Project: SAM (Smart Approaches to Marijuana) with Patrick Kennedy last week. And many public health professionals have joined us already, including Harvard’s Sharon Levy; University of Kansas’ famed tobacco treatment pioneer, Kim Richter; Denver’s Paula Riggs, a leader in drug treatment in the US, and many others.

So if neither legalization nor prohibition, then what?

Science-based drug education for parents and kids needs to become a top national priority. Community coalitions that engage in multiple community sectors, and drug courts that leverage the criminal justice system with treatment must be brought to scale. Strategies that implement job and stable housing programs should also be more widespread. We do not need to stigmatize people whose only crime is smoking marijuana, of course. But while “lock ’em up” or “legalize” may both fit neatly on a bumper sticker, they are not thoughtful ways to implement drug policy. There exists an approach that neither legalizes, nor demonizes, marijuana. We reject dichotomies — such as “incarceration versus legalization” — that offer only simplistic solutions to the highly complex problems stemming from marijuana use and the policies surrounding it. We champion smart policies that decrease marijuana use — and do not harm marijuana users and low-level dealers with arrest records that stigmatize them for life and in ways that make it even harder for them to break free from cycles of addiction.

People can disagree about whether or not legalization would result in a net benefit or net harm to society. But making up facts or revealing only half-truths gets us nowhere near the reasoned debate on this issue that we all crave.

Source: http://www.huffingtonpost.com/kevin-a-sabet-phd/a-response-to-stevenchap_b_2530530.html 24th January 2013

Filed under: Cannabis/Marijuana,Prevention (Papers),Social Affairs (Papers),USA :

July 30, 2012

Physicians should take lead against efforts in Colorado, Washington and Oregon.

The American Society of Addiction Medicine (ASAM) opposes proposals to legalize marijuana anywhere in the United States, including three state measures on November 2012 ballots.

Legalization initiatives in Colorado, Washington and Oregon create unacceptable risks to public health, according to a white paper approved by the ASAM Board of Directors at its July 25 meeting. Physicians and other health professionals must learn more about the real health threats posed by marijuana use, all of which are made worse by legalization. Physicians should encourage public education about these facts and lead efforts against ballot initiatives to legalize marijuana, the report said.

ASAM is the nation’s foremost association of physicians dedicated to the diagnosis and treatment of the disease of addiction.

“ASAM has brought to bear its commitment to science and public health in taking a strong position against marijuana legalization,” said Robert DuPont, M.D., the report co-author, who is a former White House Drug Czar and former director of the National Institute on Drug Abuse (NIDA). “ASAM can provide leadership to all physicians and all medical associations about the dangerous and seductive mirage of drug legalization, including marijuana legalization, as a so-called solution to serious health problems resulting from drug use.”

ASAM asserts that the significant public health problems and costs related to marijuana legalization are not well-understood by the public or policymakers. ASAM’s conclusion that marijuana legalization would threaten public health is based on the following:
•Marijuana use is neither safe nor harmless. Marijuana contains psychoactive cannabinoids which can produce a sense of discomfort and even paranoid thoughts in some users. Cannabinoids interact with brain circuits in comparable ways to opioids, cocaine and other addictive drugs. Marijuana use is associated with damage to specific organs and tissues and impairments to behavioral and brain functioning.
•Of greatest concern is marijuana use during adolescence—a time of ongoing brain development and heightened vulnerability to addiction. Research shows that heavy marijuana use decreases neurocognitive performance, with worse neurocognitive effects seen among those who begin marijuana use early.
•Marijuana is addictive. Repeated marijuana use is reinforcing because the drug increases activation of reward circuitry in the brain. Approximately 9% of people who try marijuana become dependent. For those who begin using the drug in their teens, approximately 17% become dependent. These figures are similar to alcohol dependence.
•Legalization would promote the public perception that marijuana is harmless at the same time that availability of the drug would grow exponentially. The rate of marijuana use and marijuana-related substance use disorders, including addiction, would increase.
•Increased marijuana addiction would heighten demand for substance use disorder treatment services, which already are inadequate for current needs.
•Marijuana use is associated with increased rates, and worsening symptoms, of psychosis. Increased marijuana use caused by legalization and increased access to high-potency marijuana could result in rising rates of psychotic illnesses.
•Marijuana-related crashes are major traffic safety threats; marijuana use doubles the risk of a crash. Research in Washington State showed that 12% of drivers killed in car crashes were positive for marijuana. Legalization would increase drugged driving.

Marijuana legalization will increase its availability to young people, who are the most at risk from this drug. Research shows that marijuana leads to a host of significant health, social, learning and behavioral problems in young users.

“Children who use marijuana are more likely to struggle in school, because it impairs their ability to concentrate and retain information during their peak learning years when their brains are developing,” said Andrea Barthwell, M.D., the report co-author who is a former ASAM president and former Deputy Director for Demand Reduction in the Office of National Drug Control Policy. “Even short-term use can cause problems with memory, learning, cognitive development and problem solving. Research shows a clear link between adolescent marijuana use and a decrease in academic achievement.”

ASAM has previously issued policy statements urging that people addicted to marijuana, like those addicted to any drug, should receive treatment rather than punishment for their illness. That position, however, makes no reference to the question of legalization, the report stated.

“ASAM believes that addiction should be primarily treated as a health issue rather than a criminal justice issue,” said Stuart Gitlow, M.D., ASAM Acting President. “But that does not mean we would support a social experiment dramatically changing the legal status of marijuana and resulting in an upsurge in marijuana use. Health problems caused by marijuana would grow with increased use; marijuana addiction rates would undoubtedly rise. ASAM must oppose any public policy changes that would cause a significant increase in addictive substance use.”

Source: ASAM White Paper 26th July 2012

Filed under: Addiction (Papers),Prevention (Papers) :

Written by Bonnie Benard, NIDA, USA.(Originally in training manuals for Project Snowball, Illinois Teen Institutes, 1987)

Published in Britain in ‘Drug Prevention – Just say Now’ by Peter Stoker, pub. David Fulton Publishers,London, 1992.

Programme comprehensiveness/intensity

B. Target whole community. School-based programmes achieve less than community-based approaches.

G. Integrate family/classroom/school/community life. This is easier to say than do, but where it has happened results have been enhanced.

Programme strategies

L. Gateway drugs. So-called because people now using heavy-end drugs almost always started on these. Gateway drugs can be tobacco, alcohol and cannabis or, these days inBritain, even heroin! Concentration on prevention of these is therefore likely to prevent all substances. British research by PaT (Parents against Tobacco, 1990), showed that of youth who smoked tobacco 50% had also tried an illegal drug compared with only 2% of those who did not smoke tobacco. It should be particularly noted that cannabis is far from harmless; physical, mental and social damage is now being increasingly accepted as a reality.

M. Salient material. Whatever is used needs to identify with the audience, including:

• ethnic/cultural sensitivity

• appeal to youth’s interests

• short term outcomes to be emphasised as important to youth as well as long term

• appropriate language, readability

• appealing graphics

• appropriate to real age/reading age – a key factor

In a survey of 3, 700, 000 young American children, 25% of 9 year olds felt “some” to “a lot” of peer pressure to try drugs or alcohol (Weekly Reader, 1987).

P. Lifeskills. Development of these will be of wider benefit than drug prevention. Included will be

R. Community norms. Consistency of policies throughout schools, families and communities can greatly enhance impact.

The planning process

X. Evaluation and amendment. Prevention workers have been criticized for giving too little attention to this area, the crushing shortage of funds has much to do with it (inAmerica the ratio of funding between interdiction-policy and prevention is about 200:1). This lack of emphasis on evaluation has been the Achilles heel that pro-drug campaigners have gleefully attacked. Effective evaluations have been those including longitudinal design, multiple measures of process as well as outcome (Tobler, 1986), and cost-benefit analysis (CBA). CBA is perhaps the greatest marketing tool prevention has; where CBA has been applied substantial cost effectiveness has been demonstrated.

Source: Quoted in book Drug Prevention Just Say Now (1992) by Peter Stoker. Contact NDPA

Filed under: Education Sector (Papers),Prevention (Papers),Social Affairs (Papers) :

Several jurisdictions in the U.S. have taken steps toward decriminalizing marijuana possession for personal use or when prescribed by a physician for medicinal purposes. Other jurisdictions have pending ballot initiatives or legislative bills proposing such changes in the law.
The Board of Directors of the National Association of Drug Court Professionals (NADCP) has determined that it is essential for drug court practitioners to be fully and objectively informed about the effects of marijuana on their participants and the public at-large. This document briefly reviews the scientific evidence concerning the effects of marijuana.

Incarceration for Marijuana Possession

It is exceedingly rare to be incarcerated in the U.S. for the use or possession of marijuana. According to the National Center on Addiction & Substance Abuse at Columbia University (CASA, 2010), less than 1 percent (0.9%) of jail and prison inmates in the U.S. were incarcerated for marijuana possession as their sole offense.
Excluding jail detainees who may be held pending booking or release on bond, the rates are even lower. Prison inmates sentenced for marijuana possession account for 0.7 percent of state prisoners and 0.8 percent of federal prisoners (see Table). And, considering that many of those prisoners pled down from more serious charges, the true incarceration rate for marijuana possession can only be described as negligible.
State Prisoners Federal Prisoners
Marijuana offense only 1.6% N.R.
Marijuana possession only 0.7% 0.8%
First-time marijuana possession 0.3% N.R.

Source: Office of National Drug Control Policy, Who’s Really in Prison for Marijuana? [NCJ #204299] (citing BJS, 1999, Substance abuse and treatment, state and federal prisoners, 1997 [NCJ #172871]; U.S. Sentencing Commission, 2001 Sourcebook of Federal Sentencing Statistics). N.R. = not reported. 2

Addiction Potential

By the early 1990’s, the scientific community had concluded from rigorous laboratory and epidemiological studies that marijuana is physiologically and psychologically addictive. Every drug of abuse has what is called a dependence liability, which refers to the statistical probability that a person who uses that drug for nonmedical purposes will develop a compulsive addiction. Based upon several nationwide epidemiological studies, marijuana’s dependence liability has been reliably determined to be 8 to 10 percent (Anthony et al., 1994; Brook et al., 2008; Budney & Moore, 2002; Kandel et al., 1997; Munsey, 2010; Wagner & Anthony, 2002). This means that one out of every 10 to 12 people who use marijuana will become addicted to the drug.
Importantly, the dependence liability of any drug increases with more frequent usage. Individuals who have used marijuana at least five times have a 20 to 30 percent likelihood of becoming addicted to the drug, and those who use it regularly have a 40 percent likelihood of becoming addicted (Budney & Moore, 2002).
The hallmark feature of physical addiction is the experience of uncomfortable or painful withdrawal symptoms whenever levels of the substance decline in the bloodstream. This is, in part, what drives addicts to continue abusing drugs or alcohol despite suffering severe negative medical, legal and interpersonal consequences. Carefully controlled, rigorous laboratory studies have proven beyond further dispute that marijuana addiction is associated with a clinically significant withdrawal syndrome. When marijuana-addicted individuals stop using the drug, they experience symptoms of irritability, anger, cravings, decreased appetite, insomnia, interpersonal hypersensitivity, yawning and/or fatigue (Budney et al., 2001; Preuss et al., 2010). In fact, the features and severity of the marijuana withdrawal syndrome are virtually indistinguishable from those of nicotine (cigarette) withdrawal.
A second hallmark feature of addiction is psychosocial dysfunction resulting from repeated use of the substance. The most commonly diagnosed symptoms of psychosocial dysfunction among marijuana addicts include persistent procrastination, bad or guilty feelings, low productivity, low self-confidence, interpersonal or family conflicts, memory problems and financial difficulties (Budney & Moore, 2002; NIDA, 2005). This constellation of symptoms has been collectively referred to as an “amotivational syndrome” (e.g., Hubbard et al., 1999) because marijuana abusers tend to be characteristically languid and often achieve considerably below their true intellectual potentials.
Based on this substantial body of empirical research, the American Psychiatric Association (APA) has long recognized cannabis dependence as a valid and reliable psychiatric disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is the official psychiatric diagnostic classification system in the U.S. A diagnosis of cannabis dependence has been continuously included in the 3rd and 4th editions of the DSM since 1980 (APA, 1980, 1987, 1994, 2000). In the soon-to-be published 5th edition of the DSM, a cannabis withdrawal syndrome will now also be officially recognized as part of the diagnostic criteria for cannabis dependence.

Medical Harm

In many respects, smoked marijuana has the potential to be as, or more, harmful than cigarettes. Although marijuana does not contain nicotine, it does contain 50 to 70 percent more carcinogenic compounds, including tar, than cigarettes (NIDA, 2005; Hubbard et al., 1999). Marijuana also produces high levels of a particular enzyme which converts certain hydrocarbons into their carcinogenic or malignant forms (NIDA, 2005).
Although gram for gram, marijuana smoke is clearly more carcinogenic than cigarette smoke, it is difficult to predict whether actual incidence rates of induced cancers are likely to be as high as they are for cigarettes. On one hand, cannabis smokers tend to use the drug on fewer occasions than cigarette smokers. On the other hand, they typically inhale larger amounts of the drug per occasion, hold the smoke in their lungs for longer intervals of time, and are unlikely to employ filters. This makes it difficult to compare the predicted magnitudes of the harms. The best estimate from the National Institutes of Health (NIH) is that a person who smokes five marijuana cigarettes per week is likely to be inhaling as many cancer-causing chemicals as one who smokes a full pack of cigarettes every day.1
See U.S. Dept. of Justice, Drug Enforcement Administration, Exposing the myth of medical marijuana: The facts. Available at http://www.justice.gov/dea/ongoing/marijuanap.html.
Like nicotine, cannabis increases heart rate, alters blood pressure, can induce tachycardia (rapid or irregular heartbeat), increases myocardial (heart) stress, decreases oxygen levels in the circulatory system, and exacerbates angina (Hubbard et al., 1999). As a result, a person’s risk of a heart attack is increased four-fold during the first hour after smoking marijuana (NIDA, 2005).
There is no question that regular marijuana use is associated with a wide spectrum of chronic respiratory ailments. A nationally representative study of 6,728 adults found heavy marijuana use to be substantially associated with chronic bronchitis, coughing on most days, wheezing, abnormal chest sounds and increased phlegm (Moore et al., 2005).
Marijuana has undisputed negative effects on cognitive functioning, including memory, learning and motor coordination. These negative effects persist long after the period of acute intoxication, averaging approximately 30 days of residual cognitive impairment (Bolla et al., 2002; NIDA, 2005; Pope et al., 2001). This means that individuals are apt to wrongly believe they are capable of performing critical tasks, such as driving a car, operating heavy machinery, caring for children or solving work-related intellectual problems, when in fact they may be performing in the mildly to moderately impaired range of functioning.
Like any drug, marijuana’s negative effects tend to be most pronounced in elderly persons, individuals with chronic medical illnesses, and those with compromised immune systems. This is of particular concern given that marijuana is being specifically touted for “medicinal” use by elderly patients, cancer patients, and those with immunodeficiency syndromes such as HIV/AIDS (e.g., Munsey, 2010). Rather than benefiting such individuals, marijuana has the serious potential to further suppress or compromise their immune systems and exacerbate the disease process (NIDA, 2005).

Medicinal Effects

Marijuana is a “Schedule I” drug according to the Drug Enforcement Administration (DEA), meaning it has a high abuse potential and no recognized medical indication. However, the Food and Drug Administration (FDA) has approved a particular ingredient within marijuana (THC) in a non-smoked form for certain medical indications, such as for treatment of nausea, vomiting and poor appetite. Recent studies have also supported its use in treating chronic neuropathic pain (e.g., Munsey, 2010).
To date, research indicates that oral THC (when administered at adequate doses) is as effective as smoked marijuana in achieving these therapeutic effects (e.g., Munsey, 2010). Anecdotal testimonials are the only evidence favoring smoked marijuana over oral THC for therapeutic purposes. Further research is called for to determine whether other compounds within marijuana might have medicinal properties as well, but at this juncture any such indications are purely experimental and speculative.
Regardless, smoked marijuana could no more be considered a “medication” than cigarettes or alcohol. Although cigarettes and alcohol have undeniable effects that many people may find palliative (such as alleviating short-term stress), they are very “dirty” drugs. This means they contain dozens, if not hundreds, of other physiologically active compounds which are irrelevant to their palliative effects and may actually work at cross-purposes against those effects. For example, many people believe alcohol and nicotine lower their stress level, but in fact these drugs are proven to increase anxiety, lower stress tolerance and exacerbate insomnia over the longer term. These drugs are also associated with a host of serious medical conditions, including cancer, heart disease, liver disease and respiratory illnesses. For these reasons, physicians would rarely, if ever, “prescribe” these drugs to treat a medical condition.
More research is needed to isolate the potential therapeutic effects of specific compounds within marijuana, and to determine how to administer those compounds in a manner that is medically safe and does not threaten to cause heart, lung and other diseases. Administering the “dirty” form of the drug would never be a legitimate medical end-goal.

Impact on Crime

Two recent meta-analyses (advanced statistical procedures) have concluded that marijuana use during adolescence or young adulthood significantly predicts later involvement in criminal activity and criminal arrests (Bennett et al., 2008; Pedersen & Skardhamar, 2010). The risk of criminal involvement was determined to be between 1.5 and 3.0 times greater for cannabis users than for non-users. 5 The results suggest that, all else being equal, cannabis users are at a statistically increased risk for associating with antisocial individuals, engaging in illegal conduct, and eventually getting a criminal record.

Conclusion

Marijuana is an intoxicating and addictive drug that poses serious medical risks akin to those of nicotine and alcohol. Although some physicians may consider it to have palliative indications, no national or regional medical or scientific organization recognizes marijuana as a medicine in its raw or smoked form.
If marijuana becomes decriminalized or legalized in a given jurisdiction, this does not necessarily require drug court practitioners to abide its usage by their participants. The courts have long recognized restrictions on the use of a legal intoxicating substance (i.e., alcohol) to be a reasonable condition of bond or probation where the offender has a history of illicit drug involvement. If there is a rational basis for believing cannabis use could threaten public safety or prevent the offender from returning to court for adjudication, appellate courts are likely to uphold such restrictions in the drug court context.
Individuals who have a valid medical prescription for marijuana present a more challenging issue, but one that is probably also not insurmountable. Under such circumstances, the judge might subpoena the prescribing physician to testify or respond to written inquiries about the medical justification for the prescription. In addition, the court may be authorized by the rules of evidence or rules of criminal procedure to engage an independent medical expert to review the case and offer a medical recommendation or opinion. Having a Board-certified addiction psychiatrist on hand to advise the drug court judge may provide probative evidence about whether a particular marijuana prescription is medically necessary or indicated.
It remains an open question what degree of deference appellate courts are likely to give to the conclusions of a treating physician. In the absence of clear precedent, the best course of action is to develop a factual record and make a particularized decision in each case about the medical necessity for the prescription and the rationale for restricting marijuana usage during the term of criminal justice supervision.
If judges make these decisions based on a reasonable interpretation of medical evidence presented by qualified experts, it seems unlikely that drug courts — which were specifically designed to treat seriously addicted individuals — could not restrict access to an intoxicating and addictive drug as a condition of criminal justice supervision.

About NADCP

It takes innovation, teamwork and strong judicial leadership to achieve success when addressing drug-using offenders in a community. That’s why since 1994 the National Association of Drug Court Professionals (NADCP) has worked tirelessly at the national, state and local level to create and enhance Drug Courts, which use a combination of accountability and treatment to compel and support drug-using offenders to change their lives.
Now an international movement, Drug Courts are the shining example of what works in the justice system. Today, there are over 2,400 Drug Courts operating in the U.S., and another thirteen countries have implemented the model. Drug Courts are widely applied to adult criminal cases, juvenile delinquency and truancy cases, and family court cases involving parents at risk of losing custody of their children due to substance abuse.
Drug Court improves communities by successfully getting offenders clean and sober and stopping drug-related crime, reuniting broken families, intervening with juveniles before they embark on a debilitating life of addiction and crime, and reducing impaired driving.
In the 20 years since the first Drug Court was founded in Miami/Dade County, Florida, more research has been published on the effects of Drug Courts than on virtually all other criminal justice programs combined. The scientific community has put Drug Courts under a microscope and concluded that Drug Courts significantly reduce drug abuse and crime and do so at far less expense than any other justice strategy.
Such success has empowered NADCP to champion new generations of the Drug Court model. These include Veterans Treatment Courts, Reentry Courts, and Mental Health Courts, among others. Veterans Treatment Courts, for example, link critical services and provide the structure needed for veterans who are involved in the justice system due to substance abuse or mental illness to resume life after combat. Reentry Courts assist individuals leaving our nation’s jails and prisons to succeed on probation or parole and avoid a recurrence of drug abuse and
Today, the award-winning NADCP is the premier national membership, training, and advocacy organization for the Drug Court model, representing over 27,000 multi-disciplinary justice professionals and community leaders. NADCP hosts the largest annual training conference on drugs and crime in the nation and provides 130 training and technical assistance events each year through its professional service branches, the National Drug Court Institute, the National Center for DWI Courts and the National Veterans Treatment Court Clearinghouse.

NADCP publishes numerous scholastic and practical publications critical to the growth and fidelity of the Drug Court model and works tirelessly in the media, on Capitol Hill, and in state legislatures to improve the response of the American justice system to substance-abusing and mentally ill offenders through policy, legislation, and appropriations.
For more information please visit us on the web at www.AllRise.org.

Source: National Association of Drug Court Professionals. Sept. 2010

Filed under: Effects of Drugs (Papers),Medicine and Marijuana,Prevention (Papers) :

COLUMBUS, Ohio – The federal anti-drug campaign “Above the Influence” appears to have effectively reduced marijuana use by teenagers, new research shows. A study of more than 3,000 students in 20 communities nationwide found that by the end of 8th grade, 12 percent of those who had not reported having seen the campaign took up marijuana use compared to only 8 percent among students who had reported familiarity with the campaign.

Evidence for the success of “Above the Influence” is especially heartening because the primary independent evaluation of its predecessor campaign, “My Anti-Drug”, showed no evidence for success, said Michael Slater, principal investigator of the new study and professor of communication at Ohio State University. “The ‘Above the Influence’ campaign appears to be successful because it taps into the desire by teenagers to be independent and self-sufficient,” Slater said. For example, one television ad in the campaign ends with the line “Getting messed up is just another way of leaving yourself behind.”
Campaigns that only emphasize the risk of drug use may not be effective with many teens.
“We know that many teenagers are not risk avoidant, and consider the risks of marijuana to be modest. A campaign that merely emphasizes already-familiar risks of marijuana probably won’t reach the teens who are most likely to experiment with drugs,” he said.
The study appears in the March 2011 issue of the journal Prevention Science.
Slater said this study was not originally designed to study the effectiveness of the “Above the Influence” campaign, which is sponsored by the federal Office of National Drug Control Policy (ONDCP). Instead, the study was going to examine the effectiveness of a very similar, but more localized anti-drug campaign called “Be Under Your Own Influence.” This theme was developed years before the “Above the Influence” campaign by study co-author Kathleen Kelly, professor of marketing at Colorado State University.
It involved in-school media and promotional materials combined with community-based efforts. Like the “Above the Influence” campaign, it emphasized that drug use undermines the ability of teens to achieve their goals and act independently. Slater said that members of his research team presented preliminary results supporting the effectiveness of “Be Under Your Own Influence” to the ONDCP and to Partnership for Drug Free America, which oversees creative efforts for the national campaign, in 2003, about two years before “Above the Influence” was launched. However, the researchers did not have any direct input into the development of the “Above the Influence” campaign.
Slater said the approaches are very similar. ‘Above the Influence’ uses the same approach — focusing on the inconsistency of substance use with teens’ aspirations and autonomy — that we developed,” he said.
A study published in 2006 of “Be Under Your Own Influence” showed that it reduced by about half the number of students who began using marijuana and alcohol during the two years of the project, compared to students in communities without the program. This new study was designed to replicate and extend the previous research, Slater said. In the 20 communities involved in the study, schools received some combination of some, all or none of the “Be Under Your Own Influence” materials.
The researchers surveyed 3,236 students who were about 12 years old when the study began in 2005. They were surveyed four times beginning in 7th grade and ending about a year and a half later. The researchers didn’t know that the ONDCP would be launching its “Above the Influence” campaign about the same time this new study began. As a result, though, the researchers asked students about their exposure to the national campaign during the second through fourth surveys.
The results of this study showed that the ONDCP campaign appeared to be very successful at reaching students: up to 79 percent of students surveyed said they had seen the ads. “There was wide exposure to the national campaign, and it really swamped the effects of our local effort,” Slater said. “It took over, and we didn’t see any independent effects for the ‘Be Under Your Own Influence’ campaign.”
But it was really the message of “Above the Influence” that mattered in reducing marijuana use – not the fact that it was a national campaign, he said. In their previous study, the researchers found that “Be Under Your Own Influence” showed strong local anti-drug effects, even though the national “My Anti-Drug” campaign was going on. “‘Above the Influence’ has succeeded more than its predecessor attempt to influence teens,” Slater said.
The effectiveness of the ONDCP campaign can be seen in the way it appeared to influence attitudes of teens who viewed the ads. Results showed that teens who had seen the “Above the Influence” ads were more likely than others to say that marijuana use was inconsistent with being autonomous and independent and that it would interfere with their goals and aspirations. “The teens seemed to pick up on the messages that the campaign promoted,” Slater said. “The campaign really works to honor teens’ interest in becoming autonomous and achieving goals and stays away from messages that don’t really reach the teens who are most likely to use marijuana.”
Slater says study limitations include the fact that findings regarding the ONDCP campaign were based on survey results and not a randomized, experimental design in which some youth saw the ONDCP campaign and others did not. Another limitation was that the study, while taking place in 20 communities around the U.S., did not use a random sample of U.S. youth.
Other co-authors of the study were Frank Lawrence of Penn State University; Linda Stanley of Colorado State University; and Maria Leonora G. Comello of the University of North Carolina.
The research was supported by a grant from the National Institute on Drug Abuse.

Source: http://researchnews.osu.edu/archive/aboveinfluence.htm March 2011

Filed under: Prevention (Papers) :

Caria M.P., Faggiano F., Bellocco R. et al.
Journal of Adolescent Health: 2011, 48, p. 182–188.

The largest European drug education trial ever conducted tested whether US-style social influence programmes would prove effective in Europe. Among the successes were the reductions in problem drinking documented in this report.
Summary This account is partly based on an earlier Findings analysis of the same study.
Funded at European level by the European Commission, the European Drug Addiction Prevention trial (EU-Dap) aimed to test whether ‘social influence’ school-based drug prevention programmes of the kind developed in the USA will prove effective in Europe. Across seven countries and 170 schools it recruited 7079 12–14-year-old pupils, the largest sample ever in a European drug education trial.
Developed by the EU-Dap project team, the 12-lesson curriculum they tested is known in English as Unplugged. Materials are available on the EU-Dap web site and the programme’s development and approach has been extensively documented. As well as informing pupils about substances and their use, such curricula aim to affect substance use by training pupils how to resist pressure to use, reinforcing attitudes which sustain commitment to continued non-use, and enhancing decision-making, social and life skills. Unplugged particularly emphasised correcting pupils’ beliefs about the pervasiveness of substance use (‘normative beliefs’) by contrasting these with data from surveys of pupils of the same age which typically reveal that average use levels are lower. To make the programme more feasible for schools, it was limited to 12 lessons which can be completed within a school year. The schools’ own teachers taught the lessons after two and a half days’ training in the lessons and materials, and in how to teach them using methods which encourage interaction between pupils and between pupils and teachers, such as role-play and giving and receiving feedback in small groups.
This basic curriculum was supplemented either by meetings led by pupils selected by their classmates, or by workshops for the pupils’ parents. While the curriculum was moderately well implemented, peer-led activities were rarely conducted, few parents attended the workshops, and an important element – role-play – was generally omitted.
Schools were randomly allocated to one of these three variants of the Unplugged intervention or to act as ‘control’ schools which simply carried on with their normal lessons. Taken singly, none of the three variants significantly improved substance outcomes compared to the controls, so reports to date have concentrated on comparing outcomes for all 3547 pupils in the 78 Unplugged schools, to the 3532 pupils in 65 control schools. Excluded from this total were the 27 schools which dropped out of the study after being randomised to the interventions but before their students could be surveyed. Among these were nearly a quarter of the schools allocated to Unplugged. Another five did not conduct the latest follow-up surveys. Of the 7079 pupils surveyed before the lessons, 18 months later (15 months after the Unplugged lessons had ended) 5541 provided usable data at the latest follow-up. In between a a further survey had assessed pupils’ reactions three months after the lessons.
Main findings
At the final follow-up, pupils in Unplugged schools were not significantly less likely to have been drinking or drinking at least weekly (25% v. 30% in control schools) over the past month. However, they were significantly less likely (7% v. 9%) to report having experienced problems related to their drinking over the past year. When the sample was divided up in various ways, this effect remained statistically significant only among pupils not already drinking before the lessons, among those who thought their parents would allow them to drink, and among girls aged 12 or less at the baseline survey.
These results could not include data from the 22% of pupils who did not complete the latest follow-up survey, or who could not be identified as the same individual who completed a baseline survey. On the assumption that they did not change their behaviour or were all non-users, the results remained substantially the same. When instead ‘worst case’ assumptions were applied to each outcome, none were significantly different to those in control schools.
Because (via an anonymous code) individuals could be linked back to their baseline responses, the researchers could identify transitions in substance use patterns and problems. Of the nine possible drinking transitions, just one – non-drinkers becoming frequent (at least weekly) drinkers – was significantly less likely in Unplugged schools, though there was also a tendency for these pupils to more often stay non-drinkers and for occasional drinkers to progress less often to frequent drinking. In respect of drink-related problems, the great majority of pupils had not experienced these before the baseline survey; in Unplugged schools, these pupils were significantly more likely to stay this way and less likely to progress to frequent problems.
The authors’ conclusions
Findings on alcohol-related problems from the featured study together with earlier findings that Unplugged retarded growth in episodes of drunkenness indicate that the curriculum’s preventive effects are limited to problematic drinking rather than the frequency of consumption. Possibly this is because in these European countries, drinking at least to a moderate degree is deeply rooted in and largely determined by culture and society. In contrast, very heavy and problematic drinking is determined more by the individual and their circumstances so is more amenable to educational influences. Based on other findings from the 18-month follow-up, earlier the research team had also concluded that comprehensive social influence curricula can effectively be delivered in the European school setting and help delay onset of substance use, hinder progression to higher levels of use, and facilitate reversion to less intensive patterns of use.
Taking earlier reports together with the current report, it is now clear that the curriculum generally had no significant impacts on substance use, though there were fairly consistent tendencies suggestive of reductions. Specifically, there were no significant impacts on the prevalence of smoking, drinking, or using cannabis or other drugs. Regular use too was generally unaffected, the only significant finding being a short-lived reduction in regular smoking. At a more microscopic level, of 45 possible transitions between use or problem levels, just eight were significantly more or less likely in Unplugged schools, all in a favourable direction. Of these, all but two concerned alcohol. How much these findings can be relied on is questionable. The favourable direction of most other transitions attenuates but does not eliminate concern that among so many tests, some would have thrown up statistically significant differences purely by chance.
The pattern of findings on problem drinking in this report and on drunkenness in an earlier report suggests that the lessons did retard the age-related growth in problem drinking. At the 18-month follow-up, significantly more Unplugged pupils (87% v. 85%) continued to say they had not been drunk in past month, fewer who had been drunk once or twice in the past month at baseline progressed to more frequent drunkenness (16% v. 33%), and more reverted to not being drunk at all (59% v. 39%).
The fact that Unplugged did not significantly reduce alcohol-related problems among pupils who had already drunk or experienced drink-related problems before the lessons may have been due to the small numbers involved. The same cannot be said of the lack of impact among boys or among pupils who thought their parents would not allow them to drink. The latter finding was perhaps indicative of the lessons’ inability to improve on the impact of an anti-drinking culture in the home. However, not too much should be read in to these results. When a sample is subdivided in multiple ways, there is a heightened risk that some differences will be statistically significant purely by chance.
These generally unconvincing results were achieved against a comparator which should have allowed Unplugged to shine. By design, at entry to the study none of the schools were implementing specific drug prevention interventions with strong packages targeted at the relevant school years, a situation which presumably persisted in most control schools. In contrast, Unplugged was intended to be a strong package which could display its advantages in a study large enough to detect these. It seems probable that Unplugged was indeed preferable to doing nothing very much specifically to prevent substance use. However, if this was the case, the benefits were quite limited. Moreover the findings can only be considered applicable to the roughly half of schools prepared to take on the burden of the research and interventions, and to the minority of the entire pupil population taught in such schools who complete the surveys required by research projects. Among schools which did take on the intervention, the parental and peer-leader supplements did not prove feasible and implementation of the core curriculum itself was “just moderate”.
Overall, the findings are not strong enough to alter the view that drug education in secondary schools makes little contribution to the prevention of problems related to drinking and illegal drug use though the evidence in respect of smoking is stronger.
Mixed and generally inconclusive findings of a prevention impact from school programmes targeting substance use do not negate the possibility that general attempts to create schools conducive to healthy development will affect substance use along with other behaviours, nor do they relieve schools of the obligation to educate their pupils on this important aspect of our society. Arguably too, while less or safer substance use may be a desirable side-effect, drug education should be assessed against educational and youth development criteria to do with being relevant and useful as assessed by the young people themselves, rather than pre-set behaviour change objectives.
This draft entry is subject to consultation and correction by the study authors and other experts.

Source: Caria M.P., Faggiano F., Bellocco R. et al.
Journal of Adolescent Health: 2011, 48, p. 182–188.

Filed under: Prevention (Papers) :

The power of an attractive fallacy

Manuel Pinto Coelho*Dr, Chairman of Association for a Drug Free Portugal – member of World Family Organization; Member of International Task Force on Strategic Drug Policy; Member of Drug Watch International

We grew up believing that no matter how many times affirmed, no matter how insistently repeated, a lie, as convenient as it could be, would never become the truth. Does that principle still apply today? We wonder…

Last year, Mr. Glenn Greenwald an American lawyer and writer, fluent in Portuguese, was invited and sponsored by Cato Institute – Washington think-tank committed to libertarianism that has been a long-time advocate of drug legalization – to come to our home country Portugal, with a certain task at hand. He was to develop a study concerning the results of the Portuguese drug decriminalization policy. After 3 weeks he went back to the United States and wrote a book. And on that book he characterized the Portuguese drug policy as being a huge success. An example. A lesson to the world. A model worth being replicated.

Those 33 pages do look appealing. The book was a tremendous sensation. So many attractive indicators and positive statistics really pleased a lot of minds, including the media, which boosted the proliferation of the “good news”. The TIME magazine published an article commending the book and its content.
It had a record number of viewing hits that day. “The Moderate Voice”, “The Kansas City Star”, the “Pittsburgh Tribune-Review”, “The Examiner”, the “Scientific American”, are just a few of the publications that mimicked the phenomena. In Portugal, the magazine “Visão” dedicated two articles in two consecutive numbers to this “happening” with the flashy title “Portugal inspires Obama”. “The Economist” was next in line and many others followed. And so the book was flying around the world and speeding through the internet,
inflaming people all over the globe.

But…
Was the book truthful? Was the information in it reliable? Was it worth all that credit? Is that the truth?
Let’s take a look at some statements that might have helped trigger the libertarian euphoria.

It says:
–“The total number of drug-related deaths has actually decreased from the pre-decriminalization year of 1999 (when the total was close to 400) to 2006 (when the total was 290)”.

And regarding consumption, it gives the general notion of decreasing tendencies
affirming that:
-“Prevalence rates for the 15 to 19 age group have actually decreased in absolute terms since decriminalization.” -“Most significantly, the number of newly reported cases of HIV and AIDS among drug addicts has declined substantially every year since 2001.”

It looks rather good doesn’t it?

Unfortunately it does not comply with the truth. So lets abandon the artefacts and move to the real facts.

Consumption
Looking closer at the data regarding prevalence, it’s curious that the only 3 graphics presented in Mr. Greenwald’s book, mainly focus on an age span population comprised between 13 and 19 years old. Only a brief reference is made to the adjacent 20 to 24 age group, that already doesn’t show any mild decrease, but rather a boosted 50% increase. +50%

And still concerning the 13 to 15 age group in school environments, if we want to look at the same data in a different perspective, we can attest to an increase in every drug category from 1998 to 2002, with cannabis sky-rocketing the charts with its 150% raise.

Only to have a mild decrease on to 2006, with the exception of heroin, and although numbers are still not available regarding subsequent years, there is a general sense that the numbers are ascending yet again.

If we look below the age of 34 it’s nearly a 50% escalation. If one glances at the numbers related to prevalence in the total Portuguese population, there isn’t a single drug category, not one, that has decreased since 2001.

Between 2001 and 2007, the drug consumption in Portugal increased by 4.2% in absolute terms – the percentage of people who have experimented with drugs at least once in their lifetime, climbed from 7.8% in 2001 to 12%.in 2007.

The following statistics are reported:
• Cannabis: from 12.4% to 17% (15-34 years old)
• Cocaine: from 1.3% to 2.8% (15-34 years old)
• Heroin: from 0.7% to 1.1% (15-64 years old)
• Ecstasy: from 1.4% to 2.6 (15-34 years old)
(Portuguese IDT – November 2008) +40%

Cannabis
It is difficult to assess trends in intensive cannabis use in Europe, but among the countries that participated in both field trials between 2004 and 2007 (France, Spain, Ireland, Greece, Italy, Netherlands and Portugal), there was an average increase of approximately 20%. (EMCDDA – November 2008)

Cocaine
“There remains a notorious growing consumption of cocaine in Portugal, although not as severe as that which is verifiable in Spain. The increase in consumption of cocaine is extremely problematic.”
(EMCDDA´s Executive Director, Wolfgang Gotz, Lisbon – May 2009)

In the chapter “Trends” of cocaine use, the new data (Surveys from 2005-2007) confirms the escalating trend during the last year in France, Ireland, Spain, United Kingdom, Italy, Denmark and Portugal. (EMCDDA – November 2008)

While amphetamines and cocaine consumption rates doubled in Portugal, cocaine drug seizures have increased sevenfold between 2001 and 2006, rating us the sixth highest in the world in that matter. (WDR – June 2009)

Heroin and drug related Deaths and Homicides
In Portugal, heroin is the most responsible for internments in drug rehabilitation facilities and for overdose deaths.
Behind Luxembourg, Portugal has the highest rate of consistent drug users and IV heroin dependents. (Portuguese Drug Situation Annual Report – 2006)

Concerning drug-related deaths, in 2005 Portugal had 219 deaths, representing an increase of 40% relative to 2004 (156). (Portuguese Drug Situation Annual Report – 2006)
In 2006, the total number of deaths as a consequence of overdose did not diminish radically compared to 2000. In fact, the opposite occurred.

“With 219 deaths by drug ‘overdose’ a year, Portugal has one of the worst records, reporting more than one death every two days. Along with Greece, Austria and Finland, Portugal is one of the countries that recorded an increase in drug overdose by over 30% in 2005”. (EMCDDA – November 2007)

The number of deceased individuals that tested positive results for drugs (314) at the Portuguese Institute of Forensic Medicine in 2007, registered a 45% raise, climbing fiercely after 2006 (216). This represents the highest numbers since 2001 – roughly one death per day – therefore reinforcing the growth of the drug trend since 2005. (Portuguese IDT – November 2008)

In Portugal, since decriminalization has been implemented, the number of drug related homicides has increased by 40%. “It was the only European country with a significant increase in (drug-related) murders between 2001 and 2006” (WDR – June 2009).

HIV and AIDS
On to the HIV and AIDS issue, by no means have the numbers declined substantially. Again, the exact opposite takes place. Portugal remains the country with the highest incidence of IDU-related AIDS and it is the only country recording a recent increase. 703 newly diagnosed infections, followed from a distance by Estonia with 191 and Latvia with 108 reported cases. We’re top of the list, with a shameful 268% aggravation from the next worst case. (EMCDDA – November 2007)

The number of new cases of HIV / AIDS and Hepatitis C in Portugal recorded among drug users is eight times the average found in other member states of the European Union. “Portugal keeps on being the country with the most cases of injected drug related AIDS (85 new cases per one million of citizens in 2005, while the majority of other EU countries do not exceed 5 cases per million) and the only one registering a recent increase. 36 more cases per one million of citizens were estimated in 2005 comparatively to 2004, when only 30 were referred ” (EMCDDA – November 2007).

It’s rather simple and easy to grasp the reality of the facts, with one look at the real figures, the official figures. Still Mr. Glenn Greenwald managed to picture it otherwise, and most of the world press bought it, and subsequently some governments disgracefully did too.

That’s the power of an attractive fallacy.

In the same line of thought as Mr. Greenwald’s misleading book, there were recently published on the foreign press, two articles that deserved our attention. The first one by Danny Kushlik of the Transform Drug Policy Foundation entitled “Portuguese style decriminalization and legal regulation”. And a second one published in Oxford Journals – British Journal of Criminology with the partial funding of Beckley Foundation (usually very active in criticizing the United Nations drug Conventions) signed by Caitlin E.

Hughes and Alex Stevens: “What Can We Learn From The Portuguese Decriminalization of Illicit Drugs?”
Both , underestimating the readers understanding, suggest the contrary to what the numbers show clearly and unequivocally. In this last one, the authors are peremptory in their “Conclusion”: “ …since decriminalization in July 2001, the following changes have occurred:

• reduced illicit drug use among problematic drug users and adolescents, at least since 2003;
• reduced burden of drug offenders on the criminal justice system;
• reduction in opiate-related deaths and infectious diseases;

… and continues:
• “It is also an ethical and political choice of how the state should respond to drug use. Internationally, Portugal has gone furthest in emphasizing treatment as an alternative to prosecution. Portuguese political leaders and professionals have by and large determined that they have made the right policy choice and that this is an experiment worth continuing.”… “As this paper has shown, decriminalization of illicit drug use and possession does not appear to lead automatically to an increase in drug related harms. Nor does it eliminate all drug-related problems. But it may offer a model for other nations that wish to provide less punitive, more integrated and effective responses to drug use”.

Articles like these ones were so effective, that, as we mentioned before, already the Czech Republic, Mexico and Argentina copied the model and adopted the famous Portuguese drug decriminalization model.

Decriminalization and CDT’s

Let’s recede in time back to 2001. In early summer July 1st a law takes effect that decriminalizes every single drug, provided that it is for personal use only. This means that yet illegally sold, purchased or consumed, you will never be criminally charged for any of it, unless you possess a quantity superior to an estimated 10 day supply, then transforming yourself into a drug dealing criminal.

Compared with this law, the Dutch famous permissiveness is a strict dictatorship! So what did the mentors of this new law have in mind when they idealized it? Their belief was that by eliminating the social stigma of guilt associated with criminalized drug consumption, users would be more willing to enrol in drug dissuasion programs. This is based on the conception that most addicts avoid treatment for the fear of criminal charges.

In a article dedicated to Portugal´ s drug policy “The Economist” in it’s printed edition (August 27th 2009) says:
“Officials believe that, by lifting fears of prosecution, the policy has encouraged addicts to seek treatment. This bears out their view that – sanctions are not the best answer. ´Before decriminalization, addicts were afraid to seek treatment because they feared they would be denounced to the police and arrested,´ says Manuel Cardoso, deputy director of the Institute for Drugs and Drug Addiction, Portugal´ s main drugs-prevention and drugs-policy agency. ´Now they know they will be treated as patients with a problem and not stigmatised as criminals´.”

So the current Portuguese reality, that one reality the world has recently been invited to follow, is that anyone who’s drug dependent and commits a crime is not a criminal, because drug dependents are sick poor people.

In almost 20 years of experience – we directed the first private Portuguese drug
dependency rehabilitation clinic (Health Ministry Licence 1/1996) – neither ourselves nor any of our several collaborators, have ever heard or even slightly sensed this supposed fear of seeking treatment over the risk of criminal indictment.

Not even 1 of the 14.000 addicts that went through our clinics has ever showed any kind of fear concerning the authorities. Even in long sessions with psychologists, never was that a topic of conversation.This conception is a seriously distorted projection of reality. It is an unfounded lame argument.
This statement is also a serious and painful attempt against all the crowd of medical doctors, followers by obligation of the Hippocratic oath that ensures professional secrecy.

These doctors, although without proper conditions to do their job, as a consequence of a total absurd drug dependency policy, are giving their best to help drug dependents and their families.

As to the differentiation of dealers from users, official reports from the National Institute of Administration state that since 2001 is very hard to distinguish between dealer and consumer, since it is fairly easy for a dealer to organize his distributing method through smaller, below the line quantities.

As matter of fact that important document reports on Chapter XIV – The Future of the National Strategy: Main Questions – How to distinguish the consumer from the Traficant? ”Doubts rises in what concerns the main criteria explicated on the Decreto- Lei n.º 130-A/2001 of 23 de April, in which is considered a consumer everyone that does not carry drug quantity superior to10 days of use. So, it is possible to exert drug traffic with more distributed logistics avoiding the possession of quantities superior to that limit. How can we ameliorate this criterion?”

Since this neutral (INA) report was published – November 2003 – until today, nothing was done to improve the situation. Absolutely nothing was changed, and despite the disappointing results, the Portuguese strategy was renewed up until 2012. In fact, nowadays, in this country that some people insist on preaching as a role-model to the world, if you walk alone through any crowded street in Lisbon’s Bairro Alto or in certain populated spots of historical downtown, you are likely to be approached by individuals sneakily alluring with hashish, cocaine and others on their swift hands, even in broad daylight. Such daring characters were inexistent 5 years ago in places like these. There is a growing sense of fearlessness in the selling of small quantity drugs, since most police officers find it unworthy of their attention and
effort.

According to this ideology, a beneficial distinction is created when putting this law to practice: on one hand we would have dealers and traffickers sent to prison and on the other, we would have more dependents sent into treatment facilities. Furthering this notion, was the creation of the CDT´ s (Commissions for the Dissuasion of Drug Addiction) where users caught in the act, would be sent for evaluation, and if so justified, they would be persuaded to follow treatment in order to avoid Administrative fines and other light penalizations. Better explaining the CDT’s: there is no better way to illustrate how these new facilities, created as a form of diversion from imprisonment, truly work, than to present the reader the desperate appeal from the director of one of the most significant units.
The letter that follows was posted on IDT’s intranet services:

“The Portuguese CDT’s were created one for each district under the entry into force of Law 30/2000, which decriminalized the consumption of narcotic drugs and psychotropic substances. Becoming, then, the institutions or authorities with the responsibility to take knowledge of the offenses which began to be originated by the situations of consumption, leaving the realm of the courts: they began by depending on the Presidency of the Council of Ministers and subsequently by the Ministry of Health. Usually the cases that reach the CDT’s are sent by the PSP (Portuguese Public Police Force), GNR (Portuguese Military Guard) Courts and Prisons. Hence the law itself specifies in particular the existence of a multidisciplinary team in each CDT, covering the fields of psychology, sociology, social service, law and administrative and directive part. The same law provides and requires different processing in each case, since the hearing, the technical evaluation, measures of deterrence, any work of motivation for treatment, monitoring process in its different moments (suspension, sanction if any, etc.). Similarly, the law requires that the hearing and the taking of any decision must be made only with a quorum, is to say, with at least two of the three members set out in the Board of Directors the Commission. The same law also recommends that any decision is adequately supported by a report of the technical team, observing this team the monitoring of cases in stage of suspension, creating networks and linking with support institutions or treatment.

Accordingly – and taking into account the different stages of the process (from receipt of the case, sealing of seized drugs and its transmission to the State safe deposit, the service of police officers and defendants, hearing, evaluation, decisions, reports, minutes, quotas and several information to attach to each case, the statement of measures taken and the corresponding bureaucratic processing,

correspondence sending, creation of maps and databases in constant update, ordering of the destruction of drugs after each archiving process, meetings, etc..) the law provides for eight persons employed by each Committee,
being one President, two vowels, two elements in the technical support team (psychology and social work) and three elements in the administrative support team.

What happens, however, is that despite many statements giving notice of the longstanding lack of resources to the minimum requirement: the CDT Braga as always seen increased the volume of work and decreased the number of staff to do it. In the first year, in December 2001, the Social Service Technician left, as she lived in Vila do Conde and was admitted on Welfare Services of that city. She has never been replaced.

In January 2003, a member of the Board of Directors, the one specialized in the field of psychology, left to engage in private practice. In May of that year it was the time for one of the administrative employees, because she lived in Esposende and was able to be placed at the local Health Centre. Also in October of the same year, the psychologist of the technical support team leaves the service, being this team, since then, without any of the two members
provided by law. In February 2004, the second administrative official leaves, as she lived in Guimarães and managed to be employed in a private company in this city.
At that time, the CDT Braga was left with only one administrative employee, on top of all in nursing license which reduced in two hours her daily work schedule. Only later, in November 2007, after much insistence, another administrative employee was placed in system of mobility from the IRS of Braga. The situation deteriorated again in August 2009, when the oldest administrative employee moves to Lisbon at her request, to accompany her husband who had been placed in a company at the capital city. In November of this year, the IRS requires the employee who is in mobility in this service but belongs to their staff.

Thus, of the three elements of the administrative team provided by law, this team – which was often short of staff and with board members assisting the many secretarial work – is now also without anyone. Like this, the CDT with one of the largest work volume in the country has currently two members of the Board (President and Juridical Vowel), totally depleted, for more than five years, of any element in the technical support team and also completely lacking, up to the moment, administrative support. Of the eight elements that the law provides, there are only two resistant ones.

These problems have often been reported by different ways, at different times and for various departments. It is even reported that in the present context, it is almost impossible to open the doors of this service in good conditions of functionality and safety. It was further added that, given the holiday season where there will be only one person present at the service and that, even if there are two, they will have to unfold to the main administrative services and to assist to the basic office tasks: it is not possible under law to carry out hearings or to take decisions in the many cases that will be piling up, some on the verge of expiry. It should be understood that everything was always done and the effort always ensured to give the best prestige to a public service with internationally recognized merit. And everything was always reassured even at times when the situation had become uncomfortable and suffocating. We are proud of it and feel duty done and with a clear conscience. I also believe that people who I address to could and can in many contexts be somewhat hamstrung to resolve these serious and urgent issues, denoting intention to solve… The difference is that now it became impossible to this service to give a minimally satisfactory response and with dignity – even at the level of assuring the existence of conditions to open doors… Considering this situation, we would appreciate to whom it might consider the possibility of eventually working for the CDT of Braga or had knowledge of someone available to perform duties here, either in the technical team of psychology and social work, either in the technical and administrative staff. Thanking you in advance for the attention that you could dedicate in order to a better cooperation or easing to overcome this major constraint, we remain at your disposal.
The Chairman of the CDT Braga Jorge Tinoco”.

Note: the underlined parts are APLD’s responsibility.
For a better understanding of this new Portuguese reality let us give some more statistical insight on these entities – the CDT´s:

From a total number of 7.346 processes instated to caught users, 2.816 were classified has being non dependents 2.075 are pending evaluation and 783 were considered to be dependents.

Of these 783, 661 voluntarily accepted to be treated in order to temporarily suspend the legal process. From this group of 661 people, 166 had never had any prior contact with treatment facilities. 127 resumed abandoned treatment and 368 were already following treatment when they got caught practising the illegal offense.
So we can attest that the CDT units, one for every district, with a total of 99 technicians working in them, only managed to conduct towards treatment 166 addicts. Since the remaining (127 + 368) were already referenced and being followed in the CAT facilities.

This means that those supposed indicators of statistical success, come from referencing the dependents that are already referenced, once again misleading everyone into factual misinterpretation. Plus, the 2.816 referenced as not constituting risk cases, in other words, yet not having a drug dependency, were dismissed from any kind of intervention. This is equivalent to saying that they wait for users to get hooked on drugs, before they grant them any support. This is disastrous.

As well confirmed by the IDT 2008 Report that says that there is evident lack of response upon this population. Five of these CDT units don’t even have any technical element on their staff, and many others lack professionals too.

Health
On the very recent 2010 World Drug Report released last June 26th, the Executive Director of the United Nations Office on Drugs and Crime (UNODC), Mr. Antonio Maria Costa (Executive Director) signed an extremely preoccupant Forward ED was peremptory:
“…Most importantly, we have returned to the roots of drug control, placing health at the core of drug policy. By recognizing that drug addiction is a treatable health condition, we have developed scientific, yet compassionate, new ways to help those affected. Slowly, people are starting to realize that drug addicts should be sent to treatment, not to jail.”… …

“While the pendulum of drug control is swinging back towards the right to health and human rights, we must not neglect development.”

…“Above all, we must move human rights into the mainstream of drug control.” …“Just because people take drugs, or are behind bars, this doesn’t abolish their right to be a person protected by law – domestic and international.”

What a strange world this we are living in, where it’s becoming increasingly difficult to distinguish right from wrong, even for good willed people sharing the same moral and ethical values. Surprisingly the United Nations still most representative official, in applying in his speech the two favorite arguments, the two “jewels of the crown” of the well known economic-social-political group that insistently and restlessly wishes to legalize drugs – “health” and “human rights” – indicates eventually that, he too was influenced by the “resounding success” of the Portuguese experience, and maybe did not find the strength to resist the pressure, dropped the towel and capitulated!

Amazingly UNODC’s Forward speech is coincident with pro-legalization organizations like Drug Policy Alliance, Cato Institute, Transnational Institute, Beckley Foundation, Encod, among many others who claim that the War on Drugs cannot be won and that drug use and dependency should be treated as a health problem and not as a criminal one.
By joining his voice to others who consider prohibition a violation of human rights, giving the idea that drugs are not the vehicle responsible for violence and crime but instead the war against drugs is, as that pledged group usually says. The ED’s Forward doesn’t invite as it should the drug dependent to live without drugs, considering instead, between the lines, a “responsible use” and not less surprisingly attracts the world to follow the so original as promptly condemned example of Portugal and, likewise, decriminalize drugs too!

Who could have imagined this some years ago? After the ED’s speech, the model of society (in what concerns narcotic dependence), that always used to address the phenomenon in a winning optimistic and positive way, a society that would not allow drugs to be part of it, that used to carry the message that narcotic dependent behavior should always be considered unacceptable and marginal (the drug addicts used to feel uneasy on the streets), and would adopt regulation that makes life more difficult for those who decide to take drugs, surprisingly and unfortunately gave place to another model. A pessimistic, negative and ineffective one which considers utopian a society free from drugs, that doesn’t follow necessarily the goal of abstinence (in the name of compassion…), pretends above all to make the use of drugs less dangerous by making them more acceptable in society (narcotic dependents feel protected, not to say stimulated) and bases itself essentially on the concept of taking care of and supporting rather than reaching a cure – the unfortunately famous Portuguese one.

It is our understanding that contrary to what it is suggested on the last UNODC’s Forward, by the Executive Director Antonio Maria Costa (ED) we should not place health but welfare at the core of drug policy. As a matter of fact these are two completely different situations: if the key word for “health” is disease, the key word for welfare is discomfort.

Considering drug dependency a “treatable health condition” like Portuguese officials and the ED do, is another way to call it a disease – the ED labeled it countless times…”drug addicts need treatment as much as patients of chronic diseases such as cancer, diabetes and tuberculosis” (UNODC Annual Report – 2008). This opens the door to medical treatment and other harm reduction strategies, hiding that before the (un)health conditions are installed, before diseases like AIDS and other co-morbid situations are installed, there is an important panoply of other conditions much more related with psychological and social discomfort – personal and societal factors that drive the drug dependent into drug dependency.

Health problems are essentially consequences of a prior uneasiness felt by the individual. The disease model linked to “mainstream healthcare” prevents the correct scientific research of all these situations, a crucial research which could evolve into effective treatment.

Talking about “health problems” is to the public opinion the same than talking about”disease”-that-must-be-dealt-naturally-by-doctors.

But what is treatment? What can we interpret treatment to be? – This is the heart of the matter, the mother of all questions.
• Can the perpetuity of a called chemical dependency be considered a treatment?
• Can we interpret the massive 70% majority of dependents in substitute drug programs in Portugal to be an indicator of success, or are they just a deluding form of social control?
• Can dependents aspire to a life free of drugs?
• Can drug-free treatments do the job?

Deep underneath all these questions lies the fundamental one: Is the drug dependent a condemned victim of his own biology or can he work himself around that issue through the process of discovering himself and his will power?In other words, is drug dependency an incurable disease or is essentially a cognitive behavioral entanglement? This is the fundamental question and the answer to it is determinant in the choice of treatment to be approached and the politics to be drawn. As we can see in further detail later on, the society as a whole feeling dismissed of its obligations, keeps itself away from the scene, so perpetuating the discomfort, sorry, the “illness” of the drug addict!
“Harm reduction” strategies are used in Portugal – a country where drug dependency is officially considered a disease – as the main tool to fight drug dependency, as can be confirmed by such a high percentage of drug dependents in substitution programs. This means that those strategies are prioritized, much to the detriment of prevention and treatment. In political terms, this also means that, surely well intentioned, Portuguese officials understand that to treat the drug dependent is indeed a very difficult task and that the majority of them relapse one time after another when they try to stop using drugs.

So to the Portuguese people, drugs are awful and they are (poorly) persuaded to stayaway from them. But if someone is already using them, then… that’s OK, because they are “sick” and they don’t have any power to change that for the rest of their lives. A letter we received some years ago from the Portuguese Prime Minister portrays
eloquently the situation and the Portuguese reality:
“…substitution treatment (methadone) that in the beginning were considered as just a means to achieve abstinence,have now been accepted as therapeutic maintenance programs, eventually definite in character, but that can in some cases work as a starting point for dependency liberation.”

UNODC’s 2008 slogan “use music, use sports, do not allow drugs to come into your life” had been in Portugal, in a symbolic way, replaced since 2001 by “use methadone, use buprenorphine, don’t allow drugs to abandon your life…!”
With a policy like the Portuguese one, Portuguese narcotic dependents feel more and more protected not to say stimulated. When they listen to their “drug czar” – Portuguese IDT and EMCDDA President’s thoughts: – “as a diabetic needs insulin, some people need an opiate”…”the demonization of drugs and the message that drugs kill is outdated”…”I am not a fundamentalist with drugs since people can live in balance with them”… “cannabis is not already seen as a gateway to other drugs” their soul disposition is not hard to guess – jumps of joy! More or less unconscientiously, policies like the these, give up helping drug dependent in their changing process on the way to abstinence and prefer to take care and support them.

Drug dependence as a chronic disease arises from this desistance process. It is pessimistic, negative and inadequate, and all in the name of “compassionate humanism”, and as we said before, does not lead to abstinence.

But does abstinence work? Even if the regular citizen and drug therapists experience did not tell us that abstinence and spontaneous remission are familiar realities, a well known study revealed that people who completed successfully a treatment program (even if one year only after the beginning of the abstinence) reduced 60% illicit activities. The sALE of drugs fell close to 80%, imprisonment decreased more than 60%, drug dependents without a roof decreased to numbers close to 43%, dependence to Social Institutions fell 11% and finally the employment increased 20%. (National Institute on Drug Abuse, Drug Abuse Treatment Outcome Study (1997); Department of Health and Human Services, National Treatment Improvement and Evaluation Study (1996).

“Health at the core of drug policy” like has been done with an excused rigor since 2001 in Portugal is now also stated by the ED? False medical therapies have been used by successive governments not only in Portugal as a smoke curtain behind which have been hidden some of the most pressing problems that sicken our societies.
By transferring it to the authority of medical profession, they have successfully managed, so far, to transform political problems (that can not be resolved in a commission time…) into medical problems requiring specialized medical intervention, depriving us as society of the responsibility of an accurate and correct research of the true causes of entering and exiting drug dependency.

But is “drug addiction a treatable health condition”? It is very sad and worrying when the noble science of Medicine is emphasized as the solution for drug dependency. People must understand that what drug addicts really need is psychological help, not medical (while medical doctors can prescribe medicines, psychologists “prescribe” psychotherapy). To send away the indispensable psychologists with their fundamental emotional control strategies and skills to avoid the situations that lead to drug abuse, is to open perversely the door to the fantastic paraphernalia with which doctors usually feed (the Government calls it “treating”) the “disease” – syringes, needles, methadone, buprenorphine, condoms, etc. – with the aid of large staff on the street, ingloriously and willingly doing their best to care drug abusers.

This is the case happening in Portugal. If instead the world understands the phenomenon less like a disease (of the will or whatever) and more like a psychological state, a way of dealing with life, if people understand that what those unfortunate people need is a reason to live and for this purpose doctors (as ourselves) can offer nothing, a decisive step forward will be performed.

When the ED states that “we have developed scientific, yet compassionate, new ways to help those affected” we agree that we must go on searching new ways of scientific research but as we stated previously, oriented in a different direction. In a direction that can help us better understand the discomfort or the privation of well-being induced by the unhappy situations that are mostly responsible for drug users to fall into the drug dependency.

Not the current research that tries to find out (with the disguised enthusiasm of pharmaceutical industrials) biomedical/bio-chemical reasons for one essentially cognitive-behavioral phenomenon. Betting on this “treatable health condition” betting on this conveniently shy disease conception of drug dependency, Governments like the Portuguese do not understand that on dependence people “get in”, while on the disease people “fall”. As a result, drug dependents go on pretending they are sick and the government goes on pretending they are treating them! That is the very thing.

This is turning political problems into medical ones, like sweeping dust under the carpet, pretending to recover people by patting them on the back and allowing them to maintain the same addictive pattern… This is neither humanization nor compassion.

What is indeed human and compassionate is the urgent creation of a new paradigm to the drug dependency phenomenon – the creation of a culture of observation, the creation of a new culture where one would look at the drug dependent instead the drug dependency. Attentions should be directed to individual´s health, social, familiar, economic and psychological idiosyncrasies thus leaving the “one size fits all” model and returning to tailor-made hand giving that makes him or her finally feel… like a human being. That would be the real work, the decisive one on the way to the drug dependents and their families welfare. That would be the real work, the decisive one to cure the drug dependent of his “disease”.

We can resume by saying that in philosophical terms, to confuse the concept of “treatment” with the concept of “social control” as nowadays is done in Portugal is an incorrect attitude. In psychological terms, to convince drug dependents that their metabolism is unbalanced and that they have to maintain it dependent of anopiate as methadone, buprenorphine or any another, instead of fighting for their autonomy, is distorting and deluding. Any policy that drives a significant fringe of its society to a situation of defeat or inability to fight for its growth and personal development is unethical.

Jail
“Slowly, people are starting to realize that drug addicts should be sent to treatment, not to jail” expressed the ED on the UNODC’s Forward. Most respectfully, this is another unhappy statement by the ED, that if adopted by the international community as it was already in Portugal, can be very harmful as well.

Firstly, as we said before, this opens a precedent as it clearly invites other countries to do the same that Portugal did, to decriminalize the consumption, the possession and acquisition of drugs. And what is more extraordinary, is that it sounds like a prize to a country that did it with very bad results against the rest of the world and against UN Conventions that the ED represents…!

The APLD can imagine everyone who is wishing to legalize drugs clapping their hands vibrantly – Mr. Soros, Mr. Nadelmann, Mr. Trebach and relatives must feel very happy indeed, with their abstruse goal getting a little closer…

By the way, we remember when that happened in our country Portugal in July 2001, United Nations INCB was fast, as it should, to condemn our original attitude – we were the only country in the whole world to do it! Secondly, it is a nonsense and an incongruity. Who wins by weakening drug laws?

Is it not true that like the ED several times stressed out, “the rule of law” is one (the main one?) of the three pillars where any winner drug addiction policy, and not only, should sustain on? “We are slaves of the law in order to be free” said Cicero (106 aC-43 aC). He did not mention any exceptions!

Don’t send drug addicts to jail? To legalize crime committed by drug dependents (or by “patients” – sic) doesn’t seem to be the most effective way to fight it. As a matter of fact (and as we’ve mentioned before) in our country, since decriminalization has been implemented in July 2001, the number of homicides related to drugs has increased 40%. It was the only European country with a significant increase in (drug-related) homicides between 2001 and 2006. (WDR- June 2009).

Confirming national and international official data, a recent report commissioned by the IDT, the Center for Studies and Opinion Polls (CESOP) of the Portuguese Catholic University, based on direct interviews regarding the attitudes of the Portuguese towards drug addiction revealed that 83.7% of respondents indicated that the number of drug users in Portugal has increased in the last four years, 66.8% believed that the accessibility of drugs in their neighborhoods was easy or very easy and 77,3% stated that crime related to drugs had also increased.(IDT “Toxicodependências” No. 3, 2007).

What is happening in Portugal is very peculiar; drug dependents, with the support of the government since 2001, rely on their status as “sick people” to not be punished for their crimes. The same is to say that they do crimes but they are not criminals because they are drug dependents… But then afterwards, these addicts forget that they are “sick” and are assumed as free and responsible people who are able to decide whether they want treatment or not!

After the decriminalization in Portugal, the law punishes only when another illicit act is added to the effect of use, which works almost every time as attenuation. The example of Portugal shows clearly that facilitating access to drugs, will not be the way to reduce the use, the decrease of drug dependencies or related crime.
In considering, through decriminalization, the drug dependent as a patient and not as a delinquent, the State cannot then choose, through a policy which prioritizes “harm reduction” measures, to feed the “disease” instead of healing it.

But people may wonder; must drug dependents be sent to prison? Of course, if they commit a crime within a certain penal frame, a crime that deserves that type of punishment, yes they must go to prison like any other citizen. Is the prison the right answer to the drug dependent problem? Although it might seem strange, yes it can be. First of all, if the drug dependent is not only a user but is also someone who carries drugs to deliver/sell to others, then yes, he deserves and he must go to the jail. What happens in Portugal – the most liberal country in the world where any citizen, as we’ve said before, is allowed to carry drugs up to a ten day supply, so being considered for personal use only, thus not being considered a dealer, and punished only with a fine – is a perfect absurdity. No one in a civilized society should have the “human right” to harm his neighbor.

Secondly, it all depends on the prison policy system. if, as is the case in Sweden where one has a nearly perfect system that really treats the criminal drug dependent in a drug free program, with a wilful multidisciplinary team taking advantage of possessing the most important tool to help someone in his recovering process – Time, they have it in a large amount – and using it properly, then yes, it can be good. We can even go farther and say, that it can be a blessing to be arrested, to stop the dependency and to rehabilitate oneself.

In Sweden they do not feed drugs to drug dependent prisoners as it happens in Portugal, Spain – where needle machines and shooting rooms are available (in Portugal the Government has been trying every year without success – much to officials surprise and anger, for the last two years, although a nurse has been patiently available 24 hours a day, not even one prisoner has required it ever…) and a few more ingenuous countries. In Swedish prisons, drug needle machines and shooting rooms are not available and hopefully, they never will be. There’s the understanding that if you cannot make a prison a drug free place, how on earth can someone even imagine that would succeed anywhere else?!

By using drug detection dogs, searching visitors as well as staff working, the Swedish system gives the first step to clearly indicate that drugs are not welcome. Drug detection dogs are available at almost every prison in Sweden.
There are drugs in Swedish prisons as it happens in the rest of the world but at least there are very serious efforts in order to get rid of them. In Sweden, when drug dependent prison inmates leave the prison, they have less chances
to return back by drug dependency reasons. They do their best to care and rehabilitate the human being and they do not use drugs to treat drug problems.

Human rights
”Above all we must move human rights into the mainstream of drug control.”
(UNODC’s Forward) Before starting to discuss the problem of human rights, the first question we should point out is; from what point of view are we interested to discuss this so controversial subject? The economic? The political?
The legal?

Or are we going to discuss above all the drug dependents and their families’ so precious welfare? Considering that the reader elected this last one, if there is a correct understanding of it, then one should be absolutely familiar with commentaries like the one from “Sandra”, a former drug dependent, one among millions in drug rehabilitation centers throughout this world: “If it was not so troublesome for me being a drug dependent, I am sure that I would not have cured myself. If, everyday, when I’d wake up, I knew that it was easy for me to get my drug of choice without any worries, I am positively convinced that I would not be able to stop using it ever. The opposite should happen. Drugs are like that”.

People should understand that this statement is the real paradigm of the drug dependent thought – everything he/she needs, is definitively not more drugs, available or not, in the name of their “human rights”. What he/she wants, what he and she are begging for is help to escape that “life” the circumstances dropped them in. If anyone has any doubts about this, please make an enquiry and ask them what they’d prefer: a costless and painless drug free program versus more drugs, and listen to the answer!

So addressing the question: In a free society, shouldn’t everyone have the freedom to do what they want with their body since that does not harm any third party? Answer: no. First of all, although the individual could be free when he begins using drugs, once he gets dependent, he looses that freedom immediately. The consumption, becoming imperative, ends-up subverting the rules of any society, no matter how authoritarian that society may be.

Secondly, we all are gregarious by nature. In modern societies nobody can be an island, we all depend upon each other. To the alcoholic or to the drug dependent, the surrounding ambience – the husband/wife, the children, the neighbour, the friends, the co-workers, the society in general – shall always be affected by his/her deviant behavior. Not to mention the suffering of the families, often greater than the dependent’s own suffering, because adding to their own sorrows and suffering they are punished as well by their relative’s drug problems. That is why, regarding the collective, each and every individual ought to always subordinate to limitations, which mean that living in society implies to accept restrictions to individual liberty.

As it was said by the, so considered to be, father of the modern liberalism, the English philosopher John Stuart Mill (1806-1873) in his classic “On Liberty”, in 1859:
“Over himself, over his own mind and body, the individual is sovereign… …The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others…”

It is a fact that drugs destroy the brain structure that allows us to decide freely. And free decision making is the pillar of man’s dignity and man’s right to assume responsibilities. In being enslaved to drugs, man is discarding his most fundamental right: the right to control his own actions. Man has the right to his free decision making abilities. Furthermore – in being indebted to do it in a responsible way, he cannot escape that obligation. And drugs reduce or retire him from that right of free choice.

So, we can affirm that human rights are incompatible with drug abuse. Consequently, politic officials have the moral and civil obligation to protect them. Each and every policy that undermines human rights, each and every policy that supports, encourages and promotes the use of drugs, questions essential values like health and safety and violates established rights. Each and every policy that allows one significant part of the population to remain enslaved chemically and psychologically by drugs, is a cruel and inhumane one, and must not be accepted.
Let’s make it clear; sometimes people do not understand, or pretend not to, that drug abuse aggravates social and emotional misery and undermines human rights. By facilitating drug consumption, addicts such as all the “Sandras” in the world are being neglected and penalized.

If society as a whole, doesn’t emerge in refusal of the concept that it is a human right to take drugs, one of these days we could be waking up in a world where the common understanding is that… the marginal ones, are those who do not use them! As someone once said, the message should be explicit: “It is in our best interest to help find solutions for drug dependency, not to let the dependents destroy themselves and all those around them!”

One may ask people who use the human rights argument to reach the goal of legalization, if, to their understanding, legalization would make drugs become less available? Would then they be less attractive? Or be less addictive? Would they raise productivity? Or diminish road accidents? Diseases? Crimes? Can it ever be the solution the drug dependents and the world are expecting it to be? Can it solve these problems? There is no need for expertise in this subject to understand that legalization, sustained by the human right to use drugs, definitely is not the best way to protect and improve the wellbeing of the individual and society. It is definitely not the most intelligent way to protect public health and to offer security and a balanced approach to the drug problem. Very often when we think about the drugs market, we forget what is primary and secondary.

The fact that Mother Nature produces plants like poppy, or that international crime cartels took property of drug distribution, is not a primary factor. The primary factor is that millions of people are ready to break the norms and rules for the goal of using drugs, be them natural or synthetic – most of these people are children, they’re young people! We dont have to read the declaration of children’s rights to understand that, as a responsible society we have the obligation to protect them and to not allow those who carry drugs destroy them.

“Legalize drugs and send the dealer to unemployment” we very often hear. Concerning this, there is a lot of misconceptions about the drug seller role. Most people have the misconception that the classic “dealer” – that evil guy we see on movies usually in black clothes – is the entity responsible for a considerable amount of the miseries drugs carry to our youth. Eventually for them, were drugs to be legalized, the consequent free market of drugs
could definitely put them out of business and consequently children released from their influence could recover their normal lives and perspective a better future.
Unfortunately, anyone who studies the problem with any accuracy knows that the reality is very far from that. In real life what happens is that, the very first accountability for the very first contact with drugs is…mine, yours. It concerns most of our beloved ones, as well as our regular relatives and friends. They’re the ones who naively and without dimensioning properly or understanding what they are really doing, want to share – since they feel good using them – through friendly complicity with their beloved ones, the source of their ever ready easy way to “happiness” – in the beginning drugs feel good, if they didn’t, they wouldn’t be the problem they are and we would not be speaking about them now.

The classic “dealer” usually appears later on when the dependence is already well established and/or when they feel that someone wants to stay clean. Then, has it happens a lot of times, they come very nicely and give their product money free, as the “good friends” they are. With this bit of knowledge, the reader who has the responsibility to raise his children, can now easily understand why for us, the ED’s statement ”Above all we must move human rights into the mainstream of drug control”, is so, to say the least… hugely polemic!

Shall prevention strategies acting by dissuading the youth from drug use, be considered at any time obstructive or oppressive of human rights? No they can´ t. Not for the drug user, nor for all those around him or her. In the name of liberty, solidarity, equality, democracy, human dignity and…human rights, we all, be us children or adults, have the right to grow up in drug free places. To treat the drug dependent (inside or outside prison) is not a question of compassion. It is a question of love for his neighbor, a question of respect for human rights.

AWe are afraid that moving human rights into the mainstream of drug control, as the UNODC’s ED proposes, might be scarily similar to Goethe’s (1749-1832) pessimistic prescience anticipating the “humanist medicalization”.
He wrote: “I believe that in the end humanitarianism will triumph, but I fear that, at the same time, the world will become one big hospital, with each person acting as the other´s nurse”.
(J.W. von Goethe, “Letter to Charlotte von Stein” (June 8, 1787) in Gedenkausgabe, 11: 362. – Szasz, T. in Pharmacracy, Syracuse, 2003, pag 165.)

Manuel Pinto Coelho August 4, 2010

Filed under: Prevention (Papers) :

A report of a recent heroin prescription trial in Britain published in the Lancet (29th May 2010) was widely promoted as a success. The fact is that for a very costly intervention a surprisingly small minority got off street heroin.
Of the 43 clients that received a heroin dosage of 450mg twice a day plus a nightly oral methadone supplement over a 26 week period, just 5 of them managed to get off street heroin. Hardly a measure of success.
That means that the remaining 38 although they decreased their consumption of street heroin (hardly surprising) are still involved in the illegal heroin market, and still involved in the crime, harm and misery related to it.
Regardless of the at best mixed results, the authors make the following recommendation based on their study: “UK Government proposals should be rolled out to support the positive response that can be achieved with heroin maintenance treatment for previously unresponsive chronic heroin addicts.” This is not the way policy making should be informed.
It would be a surprise if a free handout of 900 mg a day of heroin would not decrease street heroin consumption to some extent. What is a significan and surprise finding is that even when offering free heroin, the program has such a limited impact on the use of street heroin.
The cost of heroin prescription per client is estimated to be about €18.000 a year, far more than for other treatment options. The UK government has spent about €700.000 on two heroin trials last year.

Misleading media reports

Reports in the press pretend that the project kept people “off street drugs”. That is stretching the truth quite a bit. This is how Reuters (Reuters Health) quote the researchers: “Prescribing heroin to addicts who can’t kick their habit helps them stay off street drugs, British researchers said Friday”, under the headline “Prescription heroin helps addicts off street drugs”. This is clearly misleading, and it reflects badly on the researchers that are clearly unable or unwilling to present a correct picture of their results.
The clients were measured on their reduction of street heroin, not other drugs. They were in fact not even tested for other drugs. For a specialist in drug treatment and for health politicians this is not very helpful. Drug addiction must be seen as a whole and not as unrelated consumption of various substances.
Associated Press reports that “Some heroin addicts who got the drug under medical supervision had a better chance of kicking the habit than those who got methadone, a new study says”, under the title “Study: heroin better than methadone to kick habit”.
First of all, to “kick the habit” means to get off the addiction. But the aim of the trial was not to get people off addiction. It did not even measure that. Second, the study does not say that treatment with heroin is better than methadone, it suggests that for some hard to treat/reach clients (5-10% of the heroin addicts) heroine may give better results. For the vast majority of problem heroin users methadone would be more suitable.
To see such inaccurate and misleading reporting by the world’s two most serious news agencies should worry everyone who is interested in how science is translated. Much of the responsibility should however lie on the researchers since they presumably were given the text for verification before release. In any case one would expect the researchers to immediately ensure that the grossly misleading reports were corrected.

“A ripple of excitement”?

The journalists’ reports lack precision and insight; the researchers however seem to have engaged in pure spin.
Professor Strang is quoted by The Independent in an article from September last year that the “the findings have sent a ripple of excitement through the addiction treatment community, which is unused to seeing progress with hard core addicts.” The researchers claim they have uncovered “”major benefits” in cutting crime and reducing street sales of drugs”.
See Kathy Gyngells blog at Centre for Policy Studies from September last year where she reports on some of the spin behind this affair while searching for the facts behind the “excitement”.
How is it possible to be positively surprised about these results, one may ask. Anyone would understand that if you give addicts heroin they will not have to buy it. The surprise is that so many of them continue to buy street heroin nevertheless.

Moralism, determinism and a bit of science

The biased approach of the researchers gets even more evident by reading the quote by Thomas Kerr, one of the researchers. He is director of the Urban Health Research Initiative at the University of British Columbia in Vancouver. He says to Reuters “I would argue it’s completely immoral and unethical to fail to treat those individuals and to allow them to suffer and allow the community around them to suffer”.
The first question to consider is if this is at all treatment. Treatment per definition should address the addiction and the health problems. This does not. If anything, it is primarily crime prevention. If treatment was paramount then why are treatment outcome indicators not measured? Their findings of psychosocial benefits are only anecdotal.
Second, the term, “allow them to suffer” assumes that their suffering is caused by “street” heroin and relieved by prescribed heroin. This represents a very narrow and simplistic understanding of the harm and problems related to addiction and drug use.
The researcher seems wedded to the myth of the demon drug. A basic social profile of the 43 clients would show that a host of social and psychosocial problems was well established before the drug problem and the addiction became the dominant issue.
Kerr question may therefore be turned around: Is it not equally “immoral and unethical” to fail to treat those individuals’ underlying problems and “allow them to suffer and allow the community around them to suffer”?
Why is it apparently more moral and ethical to substitute street heroin with prescription heroin and thereby reducing crime levels than actually treating their addiction and underlying social problems?
Do they know what addiction is?
The researchers seem to display a profound lack of understanding of what addiction is. Strang says the results shows they have “turned around” the users drug problem. “Turned around”? What happened with the few people that started to use less street heroin and more prescribed heroin cannot be called a turnaround. Some of them would commit somewhat less crime and spend a bit less time running for the next fix. Some contact is established. But where is exactly the “turnaround” in terms of the addiction and health problems? Their drug problem is not turned around and certainly not the addiction.
What this trial illustrates is the limitations of such harm reduction measures rather than its strengths. It also illustrates how scientific results may be distorted and misleading, possibly intentionally. Heroin prescription may have some benefits for some people, but they appear to be very limited, very costly and we know too little about it to make a judgement anywhere near what the researchers did in this case.
The simple question remains: what exactly is the treatment objective? What is the health related benefit? And where is the continuum of care and treatment? The programme has managed reach this very difficult group that is hard to reach and hard to treat. A politician would ask: OK, you’ve reached some of them, so what do you do?

Source: Report by Anders Ulstein, Updated 12.06.10 , published by Drug-Watch International
The study is called “Supervised injectable heroin or injectable methadone versus optimised oral methadone as treatment for chronic heroin addicts in England after persistent failure in orthodox treatment (RIOTT): a randomised trial”, written by John Strang and colleagues.

Filed under: Prevention (Papers) :

A rare finding of substantially reduced youth substance use following a media campaign demonstrates the value of well tailored content and an effective, manageable delivery mechanism.
The campaign included print materials such as posters and promotional items such as book covers, tray liners, T-shirts, water bottles, rulers and lanyards, intended to associate drug-free lives with early teen aspirations for autonomy (“Be Under Your Own Influence” was the campaign’s identifier). Over two years school staff distributed the materials to secondary school pupils while community leaders involved in drug prevention worked with project staff to devise broader campaigns intended to reinforce the school-based measures. 16 communities across the United States were randomly allocated to mount these campaigns or to act as controls. Parental permission was received for 4216 first year pupils (average age 12) to participate in the study. They were surveyed before the interventions and then three more times, the last time after they had ended.

The key question was whether growth in substance use was retarded in the media campaign communities. The answer was yes, most clearly for drinking and cannabis use and less clearly (but still substantially) for smoking.
In the two sets of communities, at the start roughly the same proportions of pupils had tried these substances. Over the next two years, half as many pupils in the campaign communities started to use each of the three.
An earlier analysis suggested that the school campaign had worked by fostering the perception that substance use was incompatible with the pupils’ aspirations.

In context

Its inexpensive strategy meant the project could afford repeated exposure in a way that would not have been possible with mass media ads. It also gave teachers and school counsellors (who often distributed the materials) a chance to amplify the effects through interaction with the pupils and for pupils to discuss the campaign among themselves. Possibly relevant too were the marketing and PR backgrounds of the leading researcher and campaign strategist, who co-opted strategies used by companies seeking to sell to young people. Effects were much larger than the norm, probably because the study incorporated principles of effective media campaigns including tailoring to the community, preparatory research with the intended audience, a theoretical foundation, targeting to relevant sub-groups (in this case, youngsters largely yet to try drugs), novel and appealing messages, and effective delivery channels.
However, a third of the pupils did not participate in the study (among whom are likely to have been those most prone to substance use) and larger conurbations were excluded. Nor we do not know whether frequent use was also retarded, though this seems likely.

Practice implications An expertly planned and adequately resourced media campaign systematically focused on preventing substance use in young people can make a difference. Localities which want to achieve this will need to maintain focus on this objective rather than the many others campaigns can explicitly or implicitly serve. Upbeat messages about the advantages of not using seem to have more effect and less potential to backfire than negative warnings. Despite the emergence of important principles ( Incontext), there is no formula which guarantees success. Especially since there are also no demonstrably successful UK examples, any campaign should be evaluated against its objectives or a close proxy. If they will cooperate, schools are an effective and inexpensive delivery mechanism, but such activities are not an alternative to drug education lessons or pastoral interventions for high-risk pupils.
Featured studies Slater M.D. et al. “Combining in-school and community-based media efforts: reducing marijuana and alcohol uptake among younger adolescents.”
Health Education Research: 2006, 21(1), p. 157–167 DS
Contacts Michael Slater, School of Communication, Ohio State University, 3022
Derby Hall, 154 North Oval Mall, Columbus, OH 43210, USA, slater.59@osu.edu.
Thanks to Neil McKeganey of the Centre for Drug Misuse Research at the University
of Glasgow for his comments.

Source: Findings.org.uk

Filed under: Prevention (Papers),Social Affairs (Papers) :

There has been a considerable scientific effort over the past three decades in to identifying and understanding the core features of alcohol and drug dependence. This work really began in 1976 when the British psychiatrist Griffith Edwards and his American colleague Milton M. Gross collaborated to produce a formulation of what had previously been understood as ‘alcoholism’ – the alcohol dependence syndrome.
The alcohol dependence syndrome was seen as a cluster of seven elements that concur. It was argued that not all elements may be present in every case, but the picture is sufficiently regular and coherent to permit clinical recognition. The syndrome was also considered to exist in degrees of severity rather than as a categorical absolute. Thus, the proper question is not ‘whether a person is dependent on alcohol’, but ‘how far along the path of dependence has a person progressed’. The following elements are the template for which the degree of dependence is judged:

Narrowing of the drinking repertoire

A normal drinker’s consumption and choice of drink varies from day to day and week to week, with the drinking being patterned by varying internal cues and external circumstances. The dependent person may drink to the same extent whether it is workday, weekend or holiday, irrespective of whether he is alone or in company, and whatever his mood. With advanced dependency, the drinking may become timetabled to maintain high alcohol levels.
Increased salience of the need for alcohol over competing needs and responsibilities
As dependence advances, the person gives priority to maintaining their intake. Their partner’s distressed complaints are ignored, income is used to support their drinking rather than provide for the family, and the need for drink may become more important for the person with liver damage than consideration of survival. A person who used to have moral standards now begs, borrows and steals to pay for drinking.

An acquired tolerance of alcohol

A given amount of alcohol will have a smaller effect on the dependent person than on a naïve drinker due to changes in brain function arising from repeated consumption of alcohol. Tolerance is also shown by the dependent person being able to sustain an alcohol intake and go about their business at blood alcohol levels that would incapacitate the non-tolerant individual. However, in later stages of dependence this tolerance declines and the drinker is incapacitated by quantities of alcohol that he would previously hold easily.

Withdrawal symptoms

These vary from a mild shaking of the hands in the morning through to convulsions and the life-threatening illness of delirium tremens (confusion, hallucinations, tremor). As dependence increases, so does the frequency and severity of the symptoms. Symptoms of withdrawal may occur during the day as blood alcohol levels drop. The four key symptoms are tremor, nausea, sweating and mood disturbance. A person may wake in the morning with soaking sweats, or they may vomit in the morning. In the early stages, a person may feel a ‘bit edgy’, but as dependence develops, they may experience terrible agitation and depression, or may show phobic reactions. Other symptoms include muscle cramps, sleep disturbance, hallucinations and grand mal seizures.

Relief or avoidance of withdrawal symptoms by further drinking

In the earlier stages of dependence, the person may feel at lunchtime that the first drink of the day ‘will help me straighten up a bit’. At the other extreme, a person may require a drink every morning before they can get out of bed. They may try to maintain steady alcohol levels which they may have learnt to recognise as being comfortable above the danger level for withdrawal.

Subjective awareness of compulsion to drink

The person may become aware of their ability to lose control: ‘If I have one or two, I won’t stop’. They may start to experience and express their craving for alcohol. Cues for craving include the feeling of intoxication, incipient withdrawal, mood or situational cues (e.g. seeing a drinking friend). They may constantly think about alcohol when experiencing withdrawal.

Reinstatement after abstinence

If a severely dependent drinker is abstinent for a year and then attempts to return to social drinking, it is likely that within a few days they will be back to an intensity of withdrawal experience which had previously taken many years of drinking to develop. Dependence has memory.
There is no signpost to a person becoming dependent. Whilst a severely dependent person is easy to recognise, it can be difficult to detect a problem in the early stages. Clearly, it is essential to be able to diagnose early problems, before drinking gets out of hand and there is a precipitous decline in the quality of life that accompanies increasing dependence.
In the latter stages of dependence, there may be rapidly mounting intensity of morning distress, appalling shakes and suicidal thoughts and delirium tremens. Gross and incapacitating intoxication becomes common.
The person is intoxicated after a couple of drinks, there is a gross and repeated amnesia (they may disappear for several days but not remember where), and there are desperate attempts to avoid withdrawal by topping up. Drinking makes the person very ill – this is partly due to mounting intensity of morning distress, but also due to various alcohol-induced physical problems (e.g. liver disease). Psychiatric disorders may become common at this stage

Source: www.wiredin.org.uk 2009

Filed under: Effects of Drugs (Papers),Prevention (Papers) :

Adaptation and Testing of the Strengthening Families Programme 10-14 (SFP10-14) for use in the United Kingdom

Summary
Introduction
Numerous studies in Europe report high rates of alcohol use among young people. A European School Project on Alcohol and Drugs (Hibbell 1999) reported that the UK had among the highest rates of drunkenness and binge drinking and alcohol consumption in Europe. Participants reported that 75% had had one episode of drunkenness, while nearly one third had 20 or more episodes in their lives or 10 or more episodes in the last year. Half had been intoxicated in the last month and a quarter intoxicated at least three times in the same period. The trends of the last decade are: more young people are drinking regularly (at least once a week); weekly drinkers are drinking more; regular young drinkers are drinking more alcohol per session; there are changes in the types of alcohol consumed (alcopops/designer drinks) (Alcohol Concern 2005).

The Strengthening Families Programme 10-14 (SFP10-14) is a seven session video based family skills training programme designed to increase resilience and reduce risk factors for alcohol and substance misuse, depression, violence and aggression, delinquency and school failure in The SFP10-14 has been evaluated for primary prevention effectiveness with young people and their parents living in mainly rural areas in Iowa, U.S.A. (Spoth et al 2001a; Spoth et al 2001b).

Whilst initial reports of implementation of the SFP10-14 in the UK are valuable it has been recognised that the US SFP10-14 programme materials and approach might need to be adapted to meet the needs of a UK audience and that a more systematic approach to evaluation of SFP10-14 in the UK was needed (Coombes et al 2006).
This report presents the results of the adaptation process and exploratory pilot study of the adapted SFP10-14 materials and approach in the UK.
Aims of the study
1. To adapt the US SFP10-14 materials and approach for the primary prevention of alcohol and drugs misuse in the U.K.
2. To model and explore the adapted SFP10-14 (UK) materials and approach with young people in the UK.
3. To develop a protocol for a large-scale evaluation study of the SFP10-14 (UK) including a cost-effectiveness assessment.

Method
Adaptation of US SFP10-14 materials
A small number of professionals and participants who had facilitated/attended SFP10–14 programmes in the United Kingdom using the United States programme materials was recruited and an advisory group formed. Four professionals, four mothers, two fathers and five young people agreed to join the advisory group. The advisory group was established with the remit to meet on one occasion only, with any further contact being by correspondence. The advisory group reviewed the original SFP10-14 materials and made recommendations about how the original programme should be adapted for a UK audience, using a nominal group technique to collect data. The advisory group was asked to review the US SFP10–14 materials and generate an individual list of positive features, and areas for improvement. A ‘round robin’ recording of individuals’ ideas into a single list was undertaken until all ideas were exhausted, and duplicates eliminated. The advisory group was then asked to discuss each item of the final list and to reach a consensus on the areas for improvement. The final list was the pooled results of individual opinions. The process of the nominal group’s work was recorded and the completed list of suggested improvements was then sent to all participants at a later date to check for accuracy
and agreement. The US SFP10–14 materials were then revised according to the agreed lists of improvements to produce the SFP10-14 (UK) materials.

Modelling of revised SFP10-14 materials
Focus group meetings involving parents/guardians and children were held in schools in four different geographical locations in the United Kingdom: Barnsley, Chester, Oxford and Peterborough (see Table 1). The sites and participants were selected purposively guided by time and resources. The focus groups critically reviewed the revised SFP10-14 (UK) materials, identifying what they felt were their strengths and weaknesses.
At the start of each focus group, short extracts from the original US SFP10–14 materials were shown. This was done to enable participants to provide a reference point for discussion of the adapted SFP10-14 (UK) materials. Participants were then asked for their opinions about the US SFP10–14 materials. This process was repeated for the SFP10-14 (UK) materials.

All focus group interviews were audiotape recorded and transcribed. The transcripts were coded and the codes were then aggregated to form larger conceptual categories. Conceptually meaningful themes were constructed from categories of the data. Validation of the thematic analysis was achieved through the use of independent individuals to check the analysis and interpretation of data; external checks on the inquiry process and debriefing with informants.

Exploratory pilot study of SFP10-14 (UK)
The SFP10-14 (UK) materials produced from the adaptation and modelling stages were field tested in three different geographical locations. In each of the three sites sufficient families were recruited to participate in the SFP10-14 (UK) delivery sessions. Subsequently, in each of the three sites a similar number of families were non-randomly selected into a comparison group. The comparison group children received the standard alcohol and drugs education delivered as part of the school curriculum. The SFP10-14 (UK) group received the standard alcohol and drugs education delivered as part of the school curriculum plus the SFP10-14 (UK) intervention.

Study self-report questionnaires were completed by youth and their parents/carers pre- and post- intervention, and at 3 months after completion of the programme. The study questionnaires were adapted from validated tools used in previous SFP10-14 evaluations in the US (Spoth et al 2001a; Spoth et al 2001b) and those used in ESPAD (European School Survey Project on Alcohol and Drugs) research studies. To supplement and enrich the quantitative data, focus groups were held to gain feedback from participating families. Two tape-recorded, focus group interviews lasting approximately 60 minutes were undertaken with the parents/caregivers and young people in Barnsley and Chester who had completed the SFP10-14 (UK) programme. Interviews focused on the parent’s/caregiver’s and young people’s experience of the SFP10-14 materials and approach. All interviews were tape recorded and transcribed and a content analysis of transcripts undertaken. The transcripts were coded and codes aggregated to form larger conceptual categories. Conceptually meaningful themes were constructed from categories of the data. Validation of the thematic analysis was achieved through the use of independent researchers to analyse and interpret single sets of data, external checks on the inquiry process and debriefing with informants.
Findings
Adaptation & Modelling of revised SFP10-14 materials
The results from the nominal group meeting and subsequent focus group meetings provided useful information on whether and how the original US SFP10–14 materials could be adapted for use in the United Kingdom, while at the same time retaining essential ingredients of the effective US programme. Twenty-one parents/caregivers and sixteen young people participated in the focus groups. The nominal and focus group study led to the development of newly revised programme materials, now referred to as SFP10–14 (UK), that were used in the subsequent exploratory pilot study.
Exploratory pilot study of SFP10-14 (UK)

There were 23 parent/caregivers and 24 young people from 3 sites in the SFP10-14 (UK) intervention group. There were 24 parent/caregivers and 22 young people from 3 sites in the non-random comparison group.
The study questionnaires were completed by all participants without difficulty, and analysis and interpretation was straightforward. Given the small sample size and short-term follow-up in this pilot study no statistically significant effects were predicted or found, though data are summarized here for completeness: overall, there were no clear or consistent outcomes associated with the SFP10-14 programme in terms of alcohol use, substance use, parenting behaviour, general child management, parent-child affective quality, or measures of supportive and controlling family environment.
16 adults and 14 young people participated in the focus groups. Feedback from parents, carers and young people was overwhelmingly positive. The following key themes have been selected for the summary:

Expectations and reasons for attending the SFP10-14: some participants commented that they did not have any idea what to expect before attending the programme, while others identified a particular aspect of the programme that they had come to find out about. What became clear during analysis of the focus group data was that the important aspect of the programme for many parents/guardians was not necessarily to do with drug and alcohol prevention, but more to do with strengthening family functioning.

Involving youth in the programme: participants acknowledged that in some cases it had not been easy to persuade their youth to attend the first group meeting. There were examples given that showed some youths were quite determined not to go with their parents at first. However, after participating in the first group, barriers and obstacles to attendance were overcome.

What worked well for participants: participants identified that the SFP10-14 (UK) had helped strengthen the family unit and had also helped them identify different strategies to manage situations. Their responses indicated that they felt that the SFP10-14 (UK) provided parents with a range of strategies (or ‘tools’) which they can draw on to help manage different situations. Some of these strategies involved a change in the adults’ behaviour and how they responded to challenging situations.
Some participants also observed that by working with a group that were all there to learn about parenting and improving their skills helped them to be open about their problems. The sessions that focused on peer pressure were identified as being particularly helpful by participants.
When speaking about the parent sessions of the programme, the group spoke positively about the support they felt they had from one another. They felt that everyone had participated and contributed to the sessions and therefore the group had gained from that.

Use of DVDs, actors and scenario: generally, participants found the DVDs useful to illustrate particular potentially problematic aspects of family life, and felt they could identify with the families (actors) homes and the locations that were used. Some participants felt the approach taken in the DVDs was patronising when they first saw it, but generally, they developed a more positive perception as they became more engaged with the programme. Participants felt that the actors and scenarios helped get discussion going in sessions by encouraging people to reflect on their own situations and how they dealt with these.

Exercises and activities in the programme: participants were very positive about the activities and family exercises to help families have fun and learn about each other, particularly enjoying activities such as creating the family tree and the family shield. However not all comments about this aspect of the course were entirely positive. Some participants found some of the exercises or games rather frivolous, although they did understand that there was a purpose behind the group activities.

What did not work so well for participants: participants were asked if they could identify aspects of the SFP10-14 (UK) that they felt did not work so well for them or for the group as a whole. One of the issues that was identified related to the tight control of time. The delivery of the SFP10-14 (UK) relies on strict time keeping within a two hour time frame: in the first hour parents and youth work separately, in the second hour they work together. It is critical that both sessions end together, on time, or the following family session will over-run and participants will be late leaving for home. Participants felt they were sometimes rushed with not enough time being available for discussion. However they also acknowledged that there is a need for some time limits.

Timing of the programme: the SFP10-14 (UK) is generally facilitated in the evening as this suits most families. The timing of the programme had been negotiated with parents and carers at the information evening held prior to the programme. Participants felt that this had worked well for most members of the group.
Crèche: the programme also offered a crèche for families who had younger siblings. This was viewed very positively by both the parents and the children who attended the crèche.

Positive outcomes:
throughout the focus group sessions parents and carers spoke of what they had learned and how their parenting had changed since attending the programme. The following are a selection of some of the comments made:

• “What I’ve learnt is to really, really listen to my kids feelings. Even if the answer is going to be no to whatever the request is, because some have to be no, but they need to air their feelings”
• “It changed my behaviour towards my children, I listen to what they say, I don’t lose my temper so much”
• “I used to confront him and the situation would get worse and worse and it could spoil a whole evening…but by walking away its much better, it’s a really calm approach”
• “We have definitely got closer since doing the course, I think what they (youth) have done in combination with what we have done – I think its made her think a bit more about her behaviour at home and I’m certainly thinking about my behaviour more”
• “I’m a single parent I’m on my own, it’s very hard to be a mum and a dad, but the tools gained from the course have been extremely beneficial”
• “I feel that you have never got enough skills as a parent, I’ve learned a lot from this course, my son’s learned a lot from this course and its brought us closer together and I think it would bring any family closer together”
• “I’ve got nothing but praise for what has happened, it’s a transformation. Getting called into school and they asked ‘what has changed in ****, what have you done that is different? There is a noticeable and marked difference in the way **** has adopted a more mature attitude’ and that, that’s the proof of the pudding isn’t it? As they say”
•
Youth Feedback: the young people who had participated in the programme were equally enthusiastic in their evaluation of their experience. They enjoyed the companionship, the role play, games and exercises. They also commented that some of the tools and strategies used in the programme had worked for them in their family setting. One example of comments from one young person is:

• “I was like a bit nervous when I first came – but then enjoyed it. I liked the first week, especially the treasure map, and the fifth week with the shield. The last week was good with the role models. I liked working with mum and dad. I enjoyed the DVDs and having the family meetings. The role play and acting was good especially ‘setting up situations’. The games were good I liked the three legged game”
• “I liked it all – no negatives”
• “I learned about drugs and keeping out of trouble. And about rules – in the driving game”
• “It has been better at home. We use the points and I earned 8 points and that meant a meal in the pizza hut. 10 points and we have an Indian meal. I get the points when I clean my room, putting my shoes away. For cleaning the car or cutting the grass”

Conclusions
Although there were no clear or consistent outcomes associated with the SFP10-14 programme on examination of the quantitative data, we need to be cautious about our interpretation of these data. The purpose of this pilot study was primarily to test the adapted materials and the evaluation tools in a “live” programme delivery setting in the UK. Further research based on a randomised controlled trial design, with adequate sample size, is required to fully evaluate the potential of the programme in the UK.
The qualitative data that were obtained allow us to draw some conclusions about the perceived benefits of the SFP10-14 (UK) from the participant’s perspective. These results suggest that parents, carers and young people enjoyed and felt that they benefited from the intervention. Parents/caregivers and young people reported that
the SFP10-14 (UK) had played a part in improving family functioning through: strengthening the family unit, improving parent/caregiver communication, using a more consistent approach, increasing the repertoire for dealing with situations, developing better positive and negative feedback, working more together as a team, identifying family strengths, strengthening family bonds, receiving group support, working more closely with mum and dad, learning to listen more, learning to get along with each other better, helping parents/caregivers more, better understanding of what parents/caregivers/young people are saying, changing the code of behaviour and developing more interaction among the family.
A protocol for a large-scale trial of the SFP10-14 in the UK has been developed and is being submitted to various funding agencies.

Source: Research Report No. 28 ISBN: 1-902606-25-6
www.brookes.ac.uk/schools/shsc/4

Filed under: Prevention (Papers) :

Editor’s Note: This article is the first in a two-part series on Neurofeedback in the Treatment of Substance Abuse. This article presents evidence of the neurological basis, specifically EEG dysfunction, underlying addiction that makes it such a complicated condition to treat, and explains how neurofeedback addresses cognitive, emotional and physical symptoms. The second part of this article will include a discussion of the efficacy models of neurofeedback and a review of the research applying neurofeedback to substance abuse treatment, as well as address the possible mechanisms of its effectiveness in addiction.
Over the last two decades a new research and clinical approach—neurofeedback—has shown promise in the treatment of substance abuse. This article addresses how it works, what makes it so effective, why it is a potentially important tool in addiction, the neurophysiological issues it might address, the existing promising research and, most importantly, that neurofeedback can be a significant adjunct to the therapeutic and counseling process with addicts.

The category of disorders associated with substance abuse is the most common psychiatric set of conditions affecting an estimated 22 million people in this country (SAMHSA, 2004). Furthermore, the disorder is accompanied by serious impairments of cognitive, emotional and behavioral functioning. These conditions and symptoms so significantly alter a person’s brain and its functioning, that we often refer to the drug as hijacking the brain, making it very difficult to think logically and appropriately weigh the consequences of the drug related behavior.

Detoxified addicts have been shown to have significant alterations in brain electroencephalographic (EEG) patterns and children of addicts also exhibit EEG patterns that are significantly different than normal (Sokhadze et al., 2008, for review). This indicates that, not only are we dealing with the neurological consequences of drug-related behavior, but there appears to be a genetic pattern as well, that places certain people at greater risk for addictive behaviors. The complexity of these factors makes the treatment of addiction one of the most difficult areas of mental, emotional and physical rehabilitation.

Multiple factors in addiction
Treating addiction is compounded by the many factors contributing to its onset and maintenance. Furthermore, the addiction itself masks many other clinical conditions that become more evident once the drug user becomes abstinent. In fact, it is frequently other psychiatric problems that lead to drug abuse as the addict attempts self-medication. It has also been shown that people with cognitive disabilities are more vulnerable, and more likely to have a substance abuse disorder (Moore, 1998). These impairments appear to include attentional issues as well as the hypo-functioning of the frontal cortex, sometimes referred to as the executive brain, where decision making takes place (Fowler, et al., 2007).
As a result, we are learning that no one approach has all the answers. Multiple mechanisms require multiple considerations and approaches. In addition, addicts are a diverse group, resulting in the need for many tools and approaches. It appears that programs offering the most diversified array of treatment modalities are the most effective (Vaccaro & Sideroff, 2008). That is also why, for example, most programs urge the inclusion of a 12-step program for ongoing support.

But how do you address the biological and genetic aspects while also addressing the traumatic and emotional factors, the social cognitive and attentional factors? How do you deal with the apparent “procedural memory” and conditioned factors that cause an abstinent addict, on his or her way home from work, to all of a sudden take an inappropriate turn and end up at the drug dealer? Neurofeedback appears to be a tool, a training that has the facility to address many of these factors associated with addiction.

History of promising treatmentsOver the years, there have been a number of developments that have been promising in the treatment of addiction. Each time a new approach is identified, it is immediately seen as being the long sought after “silver bullet” that will solve the addiction problem. This occurred with the development of methadone, and later Levo-Alpha Acetyl Methadol (LAAM). When I entered the field in 1976, as a post-doctoral fellow of the National Institute of Drug Abuse, Naltrexone was gaining popularity. Naltrexone is a long-acting opiate antagonist that blocks the effects of opiates, such as morphine, heroin and codeine.

It was around this time that the importance of addiction-related stimuli was becoming widely recognized (Wikler, 1984). In research examining the conditioned aspects of addiction, it was found that stimuli associated with the drug using behavior could serve as conditioned stimuli that would trigger an unconditioned psychophysiological response that had similarities to withdrawal and included anxiety, fear and physiological arousal (e.g. Sideroff & Jarvik, 1980). This conditioned patterning of response lead to the proposal that relapse liability might be determined by exposing addicts to these conditioned stimuli and monitoring their responses (Sideroff, 1980).

Following this conditioning model, one potential mechanism of Naltrexone treatment would be the behavioral extinction of some of the conditioned associations of addiction. In other words, if the addict attempted to get high while on Naltrexone, the lack of reinforcing effect might lessen the conditioned effects of drug related stimuli. This, in turn, might reduce readdiction liability. All that needed to happen was for the addict to use, without experiencing any effect; a perfectly reasonable theoretical assumption. So, not only was Naltrexone expected to be successful in keeping addicts from using, but it also could address conditioned aspects of addiction.

When I arrived at UCLA and the Veterans Administration at Brentwood in 1976, I was surprised to discover that the treatment program to which I had been awarded a fellowship, was already eliminated—almost before it began. With the help of the director of the methadone clinic, I started a new experimental Naltrexone treatment program, drawing recruits from the VA’s metha¬done maintenance population.

Unfortunately, Naltrexone did not meet its high expectations. While many methadone patients expressed interest in using Naltrexone, the long process of withdrawing from methadone—necessary in order to begin taking the opiate antagonist—eliminated more than 80 percent of volunteers. Also, as we enrolled volunteers, we found that 90 percent of the addicts who began using Naltrexone never used opiates while on the antagonist; and the 10 percent who did use, only used once. It was as if the addict immediately experienced this “no reward” condition and thus didn’t bother to waste his money. This, in itself, was an interesting finding, as it showed this population to be able to demonstrate impulse control under certain circumstances (Sideroff et al., 1978). As a result, we never had the opportunity to test our theory of extinction.
The use of Naltrexone for opiate addiction has subsequently been viewed as an unworkable model. Yet, for the small fraction of individuals who were able to detox and begin taking Naltrexone, it did change their lives.

Typically, the “Silver Bullet” has been thought of in terms of a drug; something that could either eliminate craving or eliminate the high of the drug of abuse. What have become most useful, have been drugs of substitution, such as buprenorphine, (Johnson, et al., 2000), as we continue to search for an effective treatment combination that includes psychotherapy.

EEG and addiction
The EEG is one objective representation of how the brain is functioning. The EEG is recorded from scalp electrodes, and is a representation of electrical activity produced by the collective firing of populations of neurons in the brain, in the vicinity of the electrode. Figure 1 presents a chart of brain wave frequencies and the primary functions associated with their production. It should be pointed out that this is a gross representation and that more precise differences—beyong the scope of this article – can be found when you look at specific single frequencies within each range. While all frequencies and frequency ranges are important and necessary, problems arise when there is too much or too little of a particular type of brain wave; there is difficulty shifting in response to changing needs; or the EEG is to reactive.

For example, in a healthy functioning brain, if we look at the amount of theta being produced and we compared it (using 4-8 Hz) with beta frequencies between 13 and 21 Hz (cycles per second), there is approximately a 2 to 1 ratio. When we assess the EEGs of people with Attention Deficit Disorder (ADD), we see ratios that are 3 to 1 and much higher (Lubar, 2003).

These higher ratios indicate that the brain is producing too much of the slow waves relative to the beta waves, where the beta waves represent a more focused and engaged brain. In other words, these brains are under-activated. On the other hand, if we look at the EEG patterns of people with anxiety, worry and tension, there is typically too much activity occurring in the higher frequencies, usually between 24 and 35 Hz. The EEGs of people with substance abuse problems can show both of these patterns.

It has been demonstrated that the EEGs of addicts show specific abnormalities when compared to normative data. Studies of detoxified alcoholics indicate an increase in absolute and relative power in the higher beta range, along with a decrease in alpha and delta/theta power (Saletu, et al., 2002). Low voltage fast desynchronized patterns (high beta) may be interpreted as demonstrating a hyper arousal of the central nervous system (Saletu-Z et al., 2004); and Bauer, showed a worse prognosis for the patient group with a more pronounced frontal hyper-arousal (Bauer, 2001).
The fact that these EEG patterns as well as alcohol dependence itself are highly inheritable further supports the biological nature of this disease (Gabrielli et al., 1982; Schuckit & Smith, 1996; Van Beijsterveldt & Van Baal, 2002).

These specific abnormalities show both a worse prognosis and a predisposition to development of alcoholism. Indivi¬duals with a family history of alcoholism were found to have reduced relative and absolute alpha power in occipital and frontal regions and increased relative beta in both regions compared with those with a negative family history of alcoholism. In another study, these abnormalities also were associated with risk for alcoholism (Finn & Justus, 1999).

It is a common belief that at least part of the cause of addiction is an attempt at feeling better—self-medicating. When someone with reduced or an absence of synchronous alpha rhythm takes a drink of alcohol, it results in the generation of an alpha rhythm or what is referred to as alpha synchrony, which a normal functioning brain has much greater capacity to produce (Pollock et al., 1983). Thus, it appears that the alcohol is helping the addicted person compensate for their brain’s inability to produce an alpha rhythm which is associated with a state of calmness. This mechanism helps to explain the use of alcohol by this group of addicts.

In related research on abstinent heroin-dependent subjects, it is interesting to note similar abnormalities of deficits in alpha frequencies, along with excessive high beta EEG activity (Franken et al. 2004; Polunina & Davydov, 2004). Although it appears that in some studies, these changes found in early abstinence normalize after several months of abstinence (Shufman et al., 1966; Polunina & Davydov, 2004). Cocaine-dependent subjects may show similar increases in beta activity, but in addition show increases in frontal alpha (Herning, et al., 1994). These changes, specifically the elevation of fast beta activity, appear to be correlated with relapse in cocaine abuse (Bauer, 2001). In contrast, meth¬amphetamine abusers have been shown to have significant increases in delta and theta frequency bands (Newton et al, 2003).

There are many questions that this research does not answer with regard to the relationship between abnormal EEG patterns and addiction. For example, it is not known if these dysfunctional elements are coincidental or causal. In addition, these EEG patterns are found in many mental disorders, some that are typically coincident with substance abuse. These questions do not minimize the probable conclusions that the EEG dysfunction creates specific vulnerabilities of these subjects. For example, frontal alpha, which is also found with some types of ADD, results in impairment of executive functions, such as decision making; and excessive fast beta activity can result in excess emotional and physical tension as well, as obsessive qualities.

Other substances of abuse have also been shown to correlate with abnormal EEG patterns. For example, studies have demonstrated that subjects with a chronic history of marijuana use demonstrate EEG patterns of frontal elevations of alpha frequencies. (Struve, Manno, Kemp, Patrick, & Manno 2003). This is referred to as “alpha hyper-frontality.” Another common feature of the EEG of chronic users is a reduction of alpha mean frequency, which may indicate some deficits in intellectual functioning.

Neurofeedback
Neurofeedback, as a subset of biofeedback, monitors a subject’s brain waves and feeds back selective information about these brain waves, in order to gain control over these patterns. Neurofeedback programs typically allow for the setting of thresholds within specific frequency bands or ranges so that when the EEG either rises above the threshold or drops below the threshold, some form of signal or reinforcement is presented to the subject. This feedback lets the brain know when it has been successful, thus, in an operant conditioning model, encourages this rewarded brain wave response. When the goal is to have the signal go above a threshold, we refer to this as “up training” or rewarding. When the goal is to reinforce signals that drop below a threshold, we refer to this as “down training,” or inhibiting this component of the EEG.

Joe Kamiya, a researcher at the University of Chicago, was the first researcher to discover that when a subject was informed that he was producing alpha brain wave frequencies, he would then be able to learn to detect, on his own, when he was in alpha (Kamiya, 1968). As a result of this finding, he designed a study in which he similarly gave feedback to the subjects as to their production of alpha, with the instruction to produce alpha. He found that when given this feedback, subjects were able to increase their production of synchronous alpha waves (Nowlis & Kamiya, 1970). Interestingly, his success led to the popularity of alpha training in mass culture, which coincided with its loss of credibility in the academic ¬community.

Neurofeedback research and its acceptance took on a new impetus when Sterman, working with cats, was able to train these animals using a similar operant conditioning model, to increase the amount of synchronous spindle activity in the 14 Hz frequency range (Sterman, 2000). Since these spindles occurred over the sensorimotor cortex, he labeled them sensorimotor rhythm (SMR). These studies confirmed that the production of these brain waves—associated with motoric stillness—resulted in animals that were more resistant to the triggering of seizures. Sterman, then adapted this EEG biofeedback procedure with epileptic patients and demonstrated its effectiveness in reducing the frequency and intensity of seizures.

When a subject produces SMR activity, he is mentally alert with relaxed muscles (lower muscle tone). Lubar, working in Sterman’s laboratory, recognized the potential of this discovery, and in a series of research studies, he and his colleagues were able to train children with hyperactive disorder to increase their production of SMR activity with feedback, resulting in reduced hyperactivity (Lubar, 1985).

The training procedures have evolved so that in addition to reinforcing SMR frequencies, the training of ADD also typically reinforces slightly higher frequencies of either 15 to 18, or 15 to 20 Hz activity, and at the same time, down trains the slower (theta) frequencies. The protocols address the ratio be¬tween the slower (theta) brain waves, with the faster brain waves, with a goal of training greater activation of the brain, which translates into improved attention. In one follow up study, Lubar and associates were able to demonstrate that gains made in variables of attention were maintained in subjects 10 years following training (Lubar, 1995; 2003).

At the same time that neurofeedback was being used to address attentional and cognitive deficits, primarily by training the activation of the brain, it also was being used to help people relax and establish autonomic and neuromuscular balance. With populations demonstrating aspects of anxiety, obsessive compulsive disorder and tension, the procedure has been to train increases in alpha frequencies (8-12 Hz) or a combination of alpha and theta (Moore, 2000). In these cases, the process is one of training a lowering of activation of the brain. A wide range of neurofeedback protocols have now been applied to cognitive, emotional and physical symptoms and conditions with a growing range of positive results. A bibliography covering these studies is available (Hammond 2008).

Acknowledgement: The author wishes to express his appreciation to Eleanor Criswell, Jay Gunkelman, David Kaiser and Hugh Baras for their helpful comments.

Dr. Stephen Sideroff, PhD, is a licensed clinical psychologist, consultant and Assistant Professor in the Psychiatry Department at UCLA and one of the Clinical Directors at Moonview Sanctuary. Dr. Sideroff is an internationally recognized expert in behavioral medicine, biofeedback and peak performance, and wa the founder and former clinical director of Santa Monica Hospital’s Stress Strategies, which presented programsfor individuals and corporations to better cope with stress.

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Source:www.counselormagazine.com Nov 2009

Filed under: Prevention (Papers) :

11/17/2004

News Feature
By Erika Miles Edwards

South Boston is a close-knit community of 3 square miles and 30,000 people. It’s the kind of place where everyone knows everyone else, and gossip, good or bad, spreads like wildfire.

South Boston also is a community with a significant heroin problem. In the past three years alone, 125 young people from South Boston aged 17-24 have died from using heroin. An estimated five to ten times as many have overdosed — some several times — but lived. The community is on the front lines of an epidemic of heroin use among young adults in the greater Boston area, where the drug is $4 a bag and so potent that it can be snorted instead of injected. Heroin overdoses are one of the leading causes of death among young adults in the region.

People in communities that lose children to tragic circumstances tend to bond together, and South Boston is no exception. In response to the crisis, a group of 10 mothers with children addicted to heroin formed the South Boston Family Resource Center and started a 24-hour hotline for families who need help. The group finds treatment for those who want it, even driving people to their first appointment. For many young adults, they are a lifeline.

Strange Remedy

Sometimes crises bear solutions that, under any other circumstance, would seem strange. In the case of the mothers of the South Boston Family Resource Center, that solution came in the form of the Dorchester Drug Court, founded by Judge Robert Ziemian, presiding justice of the South Boston District Court, with help from the Robert Wood Johnson Foundation.

The drug court is a collaborative process designed to help addicted individuals facing criminal charges get through treatment, a process that can take 15 months or more. Participants start out in detox, and then go to residential treatment for a minimum of six months. When they’re ready, they move to outpatient treatment, then relapse prevention, before being left unsupervised. Then, they are on their own, their criminal charges erased.

Drug-court participants are motivated through the system with sanctions, drug testing, encouragement, and support. Most adult drug-court clients are severely addicted, with long histories in the criminal-justice and social-service systems.

“If you think someone should be in jail, that’s who we want in drug court, because we know drug court keeps people in treatment,” said Ziemian. “Most people have setbacks, but from our experience, we know when those are going to occur. We’re watching them, and we’re encouraging them to succeed.”

After Ziemian started his drug court in 1995, word spread quickly of this place where people with criminal records were getting treatment and leaving clean and sober. He soon was approached by a mother in South Boston, asking him what he could do to help stem the tide of heroin overdoses.

“We normally work with hardened addicts,” said Ziemian. “They’re older, and have had a longer history with substance abuse. It’s easier to convince them that they need treatment. But we had to do something to help these kids. We needed to stop the overdosing before another death occurred.”

Mothers of children at risk of overdoses received letters from the probation office, inviting them to discuss solutions. The result: The women decided to apply for restraining orders against their heroin-addicted kids. Since a child breaking a restraining order is subject to criminal charges, the parents reasoned, these young adults would get connected to the criminal-justice system and be supervised in the South Boston Drug Court, receiving life-saving treatment in the process.

Not surprisingly, word of the solution spread like wildfire throughout South Boston. Even with a shortage of resources, the court has produced dramatic results. “One of the things we’ve learned about drug court is that you can usually coerce someone into treatment with the threat of jail or brief incarceration,” Ziemian said. “We and the parents have a chance to get through to them.” Notably, not a single person under active supervision of the drug court has died of a drug overdose.

Building on History

For years, America has fought an expensive war against drugs, using tactics ranging from extensive eradication efforts to lengthy periods of incarceration. In 1989, a judge in Miami dared to try something different, offering people with criminal cases treatment instead of incarceration and, in doing so, created the nation’s first drug court.

Around the same time, Ziemian returned to Massachusetts from Operation Desert Storm. Assigned to the Dorchester District Court in South Boston, he processed cases involving guns and drugs, and gained a reputation for sentencing criminal defendants to lengthy periods of incarceration.

Ziemian’s first impressions of drug courts were less than positive. “I went to a workshop about it at a bar association meeting, and I thought the guy was out of his mind,” he recalled. But Ziemian was urged by the Boston Coalition Against Drugs and Violence and by Join Together to look into the concept. A turning point was when Ziemian went to Miami to see the first drug court in action.

“For those familiar with court proceedings, drug courts are very different,” said Ziemian. “You really have to go, watch what happens, talk about it afterwards. But once you’ve seen it in action, it all makes sense.”

Today, Ziemian is the driving force behind the development of more than 30 drug courts in Massachusetts, Connecticut, Maine, New Hampshire, and Rhode Island. His Dorchester drug court is a model recognized by the National Association of Drug Court Professionals.

Each drug court develops differently, but in Massachusetts and throughout New England, many follow Ziemian’s model — with his assistance. The process starts with the support of a district’s presiding judge, who brings the other justices on board. Ziemian then meets with the justices and the clerks, probation officers, lawyers, treatment providers, and public-health officials who need to work together to make the drug court succeed.

Over objections heard from every drug court he has ever established, Ziemian sets the first drug-court date for as soon after the initial meeting as possible; the only way to learn is to do, he believes. Cases stay in their courts of origin, which forces teams in those regions to work together to come up with solutions. Every probation officer, for example, has to learn how to work with serious drug offenders and treat substance use disorders holistically, coach people through treatment, even find them treatment slots.

Strong Results, But a Struggle for Funding

But do drug courts work? Research shows that addiction treatment significantly reduces drug use, crime, and additional medical problems. Drug courts specifically reduce recidivism, or re-entry into the criminal-justice system, which saves states significant amounts of money. Nationally, incarceration costs at least $20,000 annually per person, whereas drug court costs about $4,000. Additionally, one study found that the Lackawanna Drug Court in upstate New York State saved over $2.1 million annually in public assistance, foster care, substance-free births, and child support.

Despite widespread support within the criminal-justice system, however, Ziemian and his drug-court colleagues struggle for financial stability. The Massachusetts state legislature has never provided line-item funding for drug courts, so the state’s drug courts run on skeleton crews of committed lawyers, justices, and probation officers. Ziemian has received federal grant funding to hire a coordinator that he shares with other regional courts, but worries about what he will do when that support runs out.

“Drug courts have a lot of moving pieces — many more than regular courts,” said Ziemian. “People are with us for much longer than people with other types of sentences. We build relationships with them. They count on us. We don’t want to give up on it because of lack of resources.”

“We want to do everything we can to help these kids,” added Ziemian. “We need to institutionalize this system. We need data to show that it works. We need an alumni network that could mentor the kids in the system. We can’t do that without help.”

Despite such funding worries, Judge Ziemian hopes that all judicial districts in New England will soon have drug courts. “The only thing I don’t have to do is convince people that their communities have problems with drugs. Drugs are everywhere,” he says. “With drug courts, we can do something about it.”

Filed under: Prevention (Papers),USA :

Though unable to securely document outcomes, three projects have shown that British communities can generate the kind of coordinated action which new reports from the USA and Sweden have shown curtail alcohol-related violence and injury, creating substantial cost-savings for society.
FINDINGS Rather than targeting risky drinkers, all the projects targeted high-risk neighbourhoods, aiming to modify features of the social and physical environment which generate alcohol-related violence and disorder.
UK From 2004, parallel projects Jointly known as the UK Community Alcohol Prevention Programme. in Glasgow, Cardiff and Birmingham sought to generate action locally to promote responsible service of alcohol in bars and shops, enforce licensing and allied laws, limit alcohol outlets, and to modify the environment and transport services to improve safety. Awareness-raising initiatives aimed to stimulate support from residents, politicians, licensees and local services. The projects were among only five in the UK found to meet international criteria1 for ‘multi-component’ programmes which simultaneously bring a range of influences to bear on alcohol problems.
The featured report2 documented how all three were able to generate activity of the kind they sought. In the absence of a systematic evaluation, official statistics and data gathered by the projects themselves was used to assess whether this activity had reduced alcohol-related problems – problematic, because the projects’ effects could not easily be isolated and the figures fluctuated due to factors other than the real levels of crime or injury.
Perhaps clearest was the impact in Birmingham, where in the targeted area (a transport corridor crossing three suburbs) the project started with a clean slate in terms of existing community organisation. Birmingham too seems to have had the strongest enforcement component, shown by research ( In context) to be the greatest single influence. Trading standards staff visited all the area’s alcohol outlets, alerting staff to their responsibilities and warning of future ‘sting’ operations to test whether outlets would sell to underage youngsters. Police recorded reports of licensing infringements, followed up with an advice visit, and mounted highly visible operations similar to those used in relation to illicit drugs.
Possibly as a result, offences such as vehicle crime, domestic burglary and robbery in the area fell by over a third compared to just 9% in a neighbouring area, and public place wounding fell by 30% compared to 17%, though the numbers involved were small. Unlike elsewhere, after the project was established few premises sold to underage test purchasers and most asked for proof of age.
USA The US project targeted two poor neighbourhoods relatively crowded with alcohol outlets and blighted by crime and alcohol-related problems. A robust Staggered implementation at the two sites and before and after measures benchmarked against the rest of the city offered multiple checks on whether the interventions were responsible for any improvements.evaluation3 documented reductions in violent crime and injuries, among the priorities for UK projects.
Local community organisations prioritised control of alcohol outlets to tackle underage drinking and alcohol-related violence. Training in responsible beverage service was taken up by 40–70% of outlets after personal and persistent approaches by project staff and police. Shop managers were warned that police would mount test purchases by underage youngsters. An accompanying officer immediately initiated proceedings against offending outlets. Given this backing, there was a clear reduction in sales, prompting replication city-wide. Similar operations were not undertaken in bars where, without enforcement backing, staff training on its own did not lead more premises to refuse service to drunk patrons. The bottom-line finding was that across both sites, the interventions were followed by significantly greater falls than in the rest of the city in assaults According to both police and medical records. and injuries Before the waters were muddied by city-wide implementation, there was also a greater reduction in injuries specifically related to drinking or drug use. due to traffic accidents. Some of the relative reductions were substantial – over a third for assaults and traffic accidents. Given the social costs imposed by such incidents, the project was likely to have been cost-beneficial.
SWEDEN The Swedish report4 showed that such programmes can indeed save society money. It attached monetary values to an earlier finding5 that a city-centre programme targeting licensed premises reduced violence Represented by reports to the police. by 29%. The resulting estimate was that it saved society 39 times more than it cost, primarily due to reduced criminal justice expenditures. The calculations were subject to potential error but even when savings were limited to police work, the most securely estimated element, they were seven times greater than costs. A dip in quality of life after being the victim of a crime meant that the interventions also gained one quality adjusted life year (QALY) for each 3000 Euros spent, well within the Swedish yardstick of 54,000 Euros.
After an upsurge in violence when on-licence outlets expanded, Stockholm County Council initiated the programme to curb serving of drunk patrons in the central district. Test purchases by apparently drunk actors generated support for responsible beverage service training, later made a condition of licence renewal for late-night venues. Liquor law enforcement (especially the ban on serving drunk patrons) was stepped up by police and the licensing board, largely in the form of warning letters rather than formal proceedings. Resulting reductions Inevitably the calculations incorporated arguable assumptions, but the magnitude of the gains were such that substantial benefits seem certain. in violence were estimated on the basis of before and after trends in the intervention district compared to the next most similar area. Benefits grew in line with the unfolding of the programme, reinforcing the case that this was an active ingredient. Once again, enforcement was thought to have been the main influence. Even in the comparison area, underage sales fell after activists organised test purchases and notified offenders to the police, who banned some from selling alcohol.
IN CONTEXT Reviewers6 have concluded that the ‘environmental’ approach7 (controlling the geographic, retailing and social environments in which alcohol is distributed, sold or consumed, and stepping up enforcement) tested in these studies can be more effective than trying to affect individuals through education or persuasion. However, impacts sometimes remain modest, partly because the scope for local action is limited by national or regional laws.
Police or licensing authority action backed by ultimate legal sanctions can on its own have a major impact, but requires other components to amplify and sustain its effects. Publicity makes authorities aware of the need for action and licensees aware of the potential consequences of failing to comply, while local lobbying helps gain support for the required intensity and persistence of effort.8 9 Possibly enforcement works because it stimulates defensive management actions10 such as firm and clear policies on adhering to regulations and a system for monitoring staff compliance. Commercial considerations often mitigate against such policies, but can also generate them if otherwise the business faces closure or costly restrictions.
British research includes a landmark study11 based on test purchases by underage youngsters which suggested that many vendors’ primary concern was not to avoid underage selling as such, but to avoid successful prosecution for selling to children who were clearly underage. In Cardiff,12 the main lessons of a programme to curb alcohol-related city-centre violence and disorder seemed to be that intensive implementation is needed to have a major impact. Planning and licensing decisions which increase the density of drinking outlets, and competitive and financial pressures driving the policies of large club or pub chains, can counter the benefits. However, benefits remained and were probably enough to create substantial cost-savings for society. Though not formally evaluated, similar enforcement-led programmes13 stimulated by the 2004 English national alcohol strategy have encouraged licensee compliance and appear to have reduced alcohol-related crime and disorder. Sales to underage youngsters have also been curbed by recent test purchase14 operations15 allied with trading standards and/or police follow-up.
PRACTICE IMPLICATIONS The UK report argued for environmentally-based community projects on the grounds that these probably represent the best chance for minimising harm in the face of national deregulation and promotion of alcohol consumption. Yet the leverage local projects can exert depends partly on the tools made available by national laws and policies to the projects and to the authorities they seek to influence, tools abolished or weakened or by deregulation. Given adequate powers, local lobbying and coordination can maximise their potential and tackle factors beyond the reach of the law.
So a crucial issue is how far national UK frameworks provide the required support and legislative tools. New British alcohol strategies and laws and attendant funding do provide a basis for projects similar to those featured, particularly the powerful tool of test purchases to expose underage service. But at the same time (less so in Scotland) they limit the scope for licensing authorities to respond to community concerns. Click here for summaries of the situations in England, Wales and Scotland.
Flexibility is essential because the impacts of commonly used tactics depend on the environment with which they interact; a different mix works best in different situations.1 10 The ideal16 is when national support and regulations afford localities the required tools within an accountability framework which motivates effective action, but which also gives localities discretion on what to target and how.
There are however some general principles. Regardless of the interventions built upon them, test purchasing and the construction of a database linking untoward incidents to particular premises are important in motivating and targeting action and assessing its impact. The visible and credible possibility of enforcement action against alcohol outlets must be persistently maintained if it is to have anything but a fleeting impact. Attention should be paid both to alcohol consumption and the factors17 (such as crowding, transport problems, divorcing alcohol from food, poorly kept or managed premises, glasses easily transformed in to weapons, inadequate training and monitoring of staff) which potentiate violence and disorder.
In the UK guidance on local strategies18 is available and a new database19 features examples. International lessons on community alcohol interventions have also been usefully encapsulated.20 These include: devolve decision-making to the community while supplying research-based knowledge; rapid feedback of results motivates participants and keeps projects on track; recruit influential and respected local leaders; considerable lead-in time is needed to build the social and organisational infrastructure for community action, and projects need a few years to fully deliver; project staff must expect and permit adaptation not just of methods but also aims in response to the community’s strengths and self-perceived needs; success comes easier in communities where the project’s aims are already high on the agenda; community norms and alcohol availability restrictions have their greatest impacts in self-contained, stable communities whose residents and businesses cannot easily escape their impact; a key element is the surer detection and sanctioning of transgressors brought about by the more intensive use of existing legal powers; however, these legal powers must in the first place have the potential to be effective.
Source: address http://findings.org.uk Feb.2009

Filed under: Prevention (Papers) :

The following paper consists of detailed extracts from a paper which analyses carefully the costs and benefits of effective drug prevention initiatives. I makes sobering reading when the costs to society of substance abuse are revealed. Good drug prevention clearly benefits the whole of society – and especially tax-payers – not just the individual.
Whilst this document relates to the United States there is no doubt that similar results would be attainable in the United Kingdom.

1. Executive Summary
Policymakers and other stakeholders can use cost-benefit analysis as an informative tool for decision making for substance abuse prevention. This report reveals the importance of supporting effective prevention programs as part of a comprehensive substance abuse prevention strategy. The following patterns of use, their attendant costs, and the potential cost savings are analyzed:
Extent of substance abuse among youth
• Costs of substance abuse to the Nation and to States
• Cost savings that could be gained if effective prevention policies, programs, and services were implemented nationwide
• Programs and policies that are most cost beneficial

1.1. Costs of Substance Abuse
Studies have shown the annual cost of substance abuse to the Nation to be $510.8 billion in 1999 (Harwood, 2000). More specifically,

• Alcohol abuse cost the Nation $191.6 billion.

• Tobacco use cost the Nation $167.8 billion.

• Drug abuse cost the Nation $151.4 billion.

Substance abuse clearly is among the most costly health problems in the United States. Among national estimates of the costs of illness for 33 diseases and conditions, alcohol ranked second, tobacco ranked sixth, and drug disorders ranked seventh (National Institutes of Health [NIH], 2000). This report shows that programs designed to prevent substance abuse can reduce these costs.

1.2. Savings From Effective School-Based Substance Abuse Prevention
If effective prevention programs were implemented nationwide, substance abuse initiation would decline for 1.5 million youth and be delayed for 2 years on average. It has been well established that a delay in onset reduces subsequent problems later in life (Grant & Dawson, 1997; Lynskey et al., 2003). In 2003, an estimated:
• 8 percent fewer youth ages 13 to 15 would not have engaged in binge drinking
• 11.5 percent fewer youth would not have used marijuana
• 45.8 percent fewer youth would not have used cocaine
• 10.7 percent fewer youth would not have smoked regularly

The average effective school-based program in 2002 costs $220 per pupil including materials and teacher training, and these programs could save an estimated $18 per $1 invested if implemented nationwide. Nationwide, full implementation of school-based effective programming in 2002 would have had the following fiscal impact:
• Saved State and local governments $1.3 billion, including $1.05 billion in educational costs within 2 years
• Reduced social costs of substance-abuse–related medical care, other resources, and lost productivity over a lifetime by an estimated $33.5 billion
• Preserved the quality of life over a lifetime valued at $65 billion

Although 80 percent of American youth reported participation in school-based prevention in 2005 (SAMHSA, 2004), only 20 percent were exposed to effective prevention programs (Flewelling et al., 2005). Given this level of participation, it is possible that some expected benefits already exist for these students, and the estimates in this paper are adjusted for these probable benefits. These cost-benefit estimates show that effective school-based programs could save $18 for every $1 spent on these programs.

Table A1 in the appendix lists 35 effective prevention programs and strategies and the estimated cost-benefit ratios for each program. The array of demonstrated effectiveness among prevention programs and strategies is impressive. Of the 35 substance abuse prevention programs, practices, or related interventions, 15 reduced medical, criminal justice, and other spending by more than the cost to implement the program.

1.3. Conclusion
The cost of substance abuse could be offset by a nationwide implementation of effective prevention policies and programs. SAMHSA’s Strategic Prevention Framework should include a planning step that considers cost-benefit ratios. Communities should consider a comprehensive prevention strategy based on their unique needs and characteristics and use cost-benefit ratios to help guide their decisions. Model programs should include data on costs and estimated cost-benefit ratios to help guide prevention planning.

Increasingly, the American public supports investment in prevention programs as a strategy for dealing with America’s substance abuse problems (Blendon & Young, 1998; Maguire & Pastore, 1996). Research demonstrates that substance abuse prevention programs work: they can reduce rates of substance use and can delay the age of first use. Studies also have shown that prevention programs not only prevent substance abuse; they can contribute to cost savings (Aos et al., 2004; Caulkins et al., 2002; Miller & Hendrie, 2005; Swisher et al., 2003).

As well as reporting the ratio of benefits to costs, a cost-benefit analysis typically provides a net benefits estimate, which is computed by subtracting the cost of intervention from the benefits of the intervention (Mishan, 1988). For example, the All Stars program has a cost-benefit ratio of 34:1 which means it returns $34 dollars in savings for every dollar invested, yielding net benefits of $4,670 per pupil ($4,810 in social cost savings minus $140 in program costs). By comparison, the Life Skills Training program has a cost-benefit ratio of 21:1 and yields net benefits of $4,380 per pupil.

Although the All Stars and Project Northland programs save more than it costs to develop and deliver them, the return on investment in All Stars is 34:1, and the return on Project Northland is just 17:1. However, other factors should be considered, e.g., the level of outcome and long-term effects. For example, Project Northland also involves developing a community coalition that remains after the program and can address related issues without additional costs. In allocating resources, analysts often trade off the most efficient investments—those with the highest cost-benefit ratios against those with a broader reach that can produce a larger total benefit.

Direct Economic Impact of Substance Abuse
NIH ranks alcohol second, tobacco sixth, and drug disorders seventh among estimated costs of illness for 33 diseases and conditions (NIH, 2000). The year 1999 is the most recent year, with estimates available for all three categories of substance abuse. Despite a smaller number of deaths from alcohol use, alcohol-related costs are greater than tobacco costs because alcohol-related mortality tends to occur at younger ages than smoking-related mortality.
The categories used to develop the alcohol and drug abuse estimates include specialty alcohol and drug services; medical consequences; lost earnings due to premature death; lost earnings due to substance-abuse–related illness; goods or services related to crashes, fires, criminal justice, other; and lost earnings resulting from crime. The categories used to develop the smoking estimates were medical consequences and lost earnings due to morbidity and premature death. Tobacco prevention costs are excluded; the largest share of these prevention costs, State spending, averages $600 million annually (Campaign for Tobacco-Free Kids, 2004).

The social cost of alcohol, tobacco, and drug abuse in the United States by substance are as follows:. Alcohol abuse was responsible for $191.6 billion (37.5 percent) of the $510.8 billion, tobacco use was responsible for $167.8 billion (32.9 percent), and drug abuse was responsible for $151.4 billion (29.6 percent).

Loss of potential productivity and earnings: Smoking accounted for almost 440,000 deaths in 1999 (Fellows et al., 2002), alcohol abuse accounted for 42,000 (Harwood, 2000) to 76,000 deaths (Midanik et al., 2004), and drug abuse accounted for an additional 23,000 deaths (Harwood & Bouchery, 2001). Additional productivity losses occurred when individuals who abused substance

Lost productivity makes up two-thirds of the costs of substance abuse. Lifetime wage and household work lost to premature death is the largest component of these costs, followed closely by work lost to acute and chronic illness and injury. Incarceration results in $32 billion in earnings losses. Almost $25 billion more is lost when people who abuse substances pursue criminal careers rather than enter the labor force.

These estimates are conservative; they omit some costs that result from substance abuse. Specifically, they exclude (1) the impact on the quality of life of those who abuse substances and the people they harm and (2) the health care costs and work losses of victims who were involved in alcohol-attributable crashes even though they had not been drinking. These estimates also exclude the impact on the quality of life.

Costs and Benefits of Preventing Substance Abuse
This section uses the percentage of youth who might have started using substances in the United States and published estimates of prevention effectiveness to analyze the probable impact of a nationwide implementation of effective school-based substance abuse prevention programming. The following were estimated:
• Potential reduction in substance use and abuse as a result of providing effective school-based prevention interventions to all U.S. youth ages 12–14 in middle school
• Potential social cost savings as a result of providing effective school-based prevention interventions to all U.S. youth ages 12–14
• Social return on investment in preventive intervention measured in terms of costs and benefits
• Potential State government savings in juvenile justice and education costs as a result of providing effective school-based prevention interventions to all U.S. youth ages 12–14

The analyses primarily draw on data from the following sources:
• A report by Caulkins and colleagues (1999) for RAND titled An Ounce of Prevention, a Pound of Uncertainty: The Cost-Effectiveness of School-Based Drug Prevention Programs
• The NCASA report titled Shoveling Up: The Impact of Substance Abuse on State Budgets (NCASA, 2001)
• National Survey on Drug Use and Health (NSDUH) (SAMHSA, 2004))
• Youth Risk Behavior Survey (YRBS) (Centers for Disease Control and Prevention, 2003)
Two meta-analyses on the effectiveness of school-based youth substance abuse prevention programs (Aos et al., 2004; Hansen et al., 2004)

4.1. Youth Delaying or Never Using Substances
Nearly every youth ages 12–14 is at risk for trying alcohol, tobacco, and drugs and may be aware of social norms and feel peer pressure to start using these substances. The initial analysis involved estimating the number of youth who would not have tried or would not regularly use these substances if effective school-based prevention programs were in place nationwide. To determine these estimates, the number of youth ages 12–14 was multiplied by three factors: the low, medium, and high estimates of the percentage of youth who would delay initiating use of each substance if they received effective school-based prevention programming. The effectiveness estimates were drawn from two meta-analyses on the effectiveness of school-based youth substance abuse prevention programs (Aos et al., 2004; Hansen et al., 2004

The midrange estimates of youth receiving effective school-based prevention services across intervention programs are as follows:
• 4.7 percent will delay using alcohol
• 4.1 percent will delay using marijuana
• 2.7 percent will delay using cocaine
• 4.7 percent will delay smoking

These estimates represent the mean values from an array of school-based prevention programs that evaluations found significantly (>.05) delayed or prevented initiation of youth substance use. The individual estimates of effectiveness were derived from meta-analyses that generally excluded evaluations that did not use some sort of comparison or control group. Prevention programs for cocaine use had the smallest range of effectiveness from 2.3 percent to 5.3 percent of youth delaying or never initiating use. Prevention programs that delayed or prevented initiation of alcohol use had the greatest range of 1 percent to 10.3 percent.

Table 4 shows a range of estimates of the number of youth who would delay substance use if they received effective school-based prevention programming. For all youth ages 12–14, universal prevention programming in 2002 would have delayed 1.5 million initiations of substance use, with a range from 0.7 to 3 million. The largest absolute impact would be on drinking, with 446,000 youth delaying their first drink, followed closely by smoking with 436,000 youth delaying their first smoke. (A youth who delays both smoking and drinking is counted in both categories.
For drug abuse, the corresponding estimates are 247,000 youth delaying their first cocaine use and 389,000 delaying their first use of marijuana.

The rationale for this analysis is that when youth delay onset of substance use, on average, two years less of lifetime use occurs. When prevention programs delay the onset of substance use, the number of future dependent users also decreases (Grant & Dawson, 1997), but the analysis does not estimate that further saving.

Effective nationwide school-based prevention programming for youth ages 12–14 in 2002 would have prevented 267,000 youth from drinking during 2003, 183,000 from using marijuana, 138,000 from using cocaine, and 205,000 from using tobacco . Prevention programming also would have prevented 169,000 youth from binge drinking in 2003, and 72,000 youth from smoking regularly.

Effective prevention programs would reduce binge drinking by 8 percent, marijuana use by 11.5 percent, cocaine use by 45.8 percent, and regular smoking by 10.7 percent

The impact of substance abuse prevention may extend over a lifetime and is most obvious when prevention fails to deter an individual from substance abuse, and the abuse results in premature death. Substance abuse may last many years and often entails periods of recovery and relapse. Furthermore, the effects of substance abuse may continue well beyond the period of time when an individual is actively abusing substances.

The following cost factors were considered:
• Medical costs
• Other resource costs, ranging from property damage to police, criminal justice, litigation, and insurance administration expenses
• Lost wage and household work
• Value of pain, suffering, and loss in quality of life

Cost-Benefit Ratios
To achieve these savings school-based prevention programming would cost an estimated $220 per pupil nationwide. This cost represents the average across the 11 school-based prevention programs analyzed in this section. Knowledge of program costs makes it possible to estimate the cost-benefit measures defined in Section 2. The return on investment in school-based prevention services would range between $7.40 and $36 per dollar invested, with a medium estimate of $18 The best estimate equates to a net saving of $3,740 per youth served, including a $74 net savings in medical and other resource costs ($294–$220). Since expected medical and other resource cost savings exceed program costs, the program would yield net cost savings to society. School-based substance abuse prevention programming that effectively addresses substance abuse appears to be an excellent investment and is likely to pay for itself in resource cost savings alone.

For every dollar spent per pupil, society would save $18.

SAMHSA’s continuum of care suggests some overlap in prevention programs (i.e., universal, selected, and indicated). For example, when the Strengthening Families Program prevents a youth from adopting multi-risk behavior, it clearly is prevention. Similarly, when Project Northland prevents a youth from ever trying cocaine or delays initiation of cocaine use, it unambiguously prevents illicit substance use. Indicated prevention programs can also work to prevent an increase or expansion of early experimental substance use behaviors. When the topic is preventing the costs of substance abuse, the distinction blurs between programs that prevent binge drinking per se and those that prevent costly adverse consequences attributable to substance abuse (e.g., programs to prevent drinking and driving).

Universal preventive interventions are targeted to the general public or a segment of the entire population with an average probability of developing a disorder, risk, or condition. Selected preventive interventions are targeted to specific populations whose risk of a disorder is significantly higher than average, either imminently or over a lifetime. Indicated preventive interventions are targeted to designated individuals who have minimal but detectable signs or symptoms suggesting a disorder or who carry biological markers for a disorder often referred to as high risk. Youth ages 12–17 who abuse substances constitute approximately 11 percent of people who engage in binge drinking and 15 percent of people involved in illicit drug use in the United States

Family-centered interventions with a school component generally are more costly than school-based life skills training, but they offer larger benefits per youth assisted. The most effective programs strengthen youth bonds to family, school, and community, increasing protective factors while reducing risk factors. These include Adolescent Transitions, Strengthening Families, Guiding Good Choices, Project Northland, and SOAR. Although family-centered programs achieve more in terms of bonding and protective factors, some narrower life skills programs offer larger returns per dollar invested. With a limited budget, life skills programs allow a school system to reach the most children. However, the same money probably would yield greater benefits per youth assisted if spent targeting the broader family-centered programs and related mentoring to the schools at highest risk.

As these findings indicate, the costs of substance abuse to society are significant, and cost savings may offset the cost of providing effective prevention

Substance abuse has a wide range of adverse consequences. In order to optimally reduce consumption and its adverse consequences, a comprehensive package of prevention programs and strategies is required. No single intervention will reduce the problem so dramatically that no further public action is desirable. Given the number and diversity of proven interventions, optimal resource allocation requires selecting the most complementary, politically feasible, and culturally and demographically appropriate set to maximize a return on investment within the available funding. Of critical concern is to identify a sensible package of interventions that complements existing interventions. Policymakers selecting substance abuse interventions can apply a series of filters. The estimates in this report provide the first filter: eliminating interventions that offer a questionable return on investment.

However, new and improved versions of the original DARE program, Here’s Looking At You (Farley & Associates 2002) and the Adolescent Substance Abuse Prevention Study (Sloboda & Hawthorne, 2003) have produced better results and consequently better cost-benefit ratios and should not be dismissed arbitrarily. This financial information should be used as only one of an array of measures in selecting effective programs. Additional filters that policymakers can use in selecting interventions are political feasibility, local priorities, appropriateness for the target population, cultural sensitivity, affordability, and the immediacy of the impact (weeks versus years). Political feasibility is especially important. A slightly less cost-beneficial program can be superior if the alternative with the higher return has a lower chance of widespread implementation or involves a long delay in implementation. As the subsections that follow describe, all things are not equal when selecting a package that yields the maximum gains at the lowest possible price. Other factors, such as aggregate benefits obtained, overlapping effects, spillover costs and benefits, and government cost can and should weigh into the decision process.

Conclusion
If effective prevention programs were implemented nationwide, substance abuse initiation would decline for 1.5 million youth and be delayed for 2 years on average. In 2003, an estimated:
• 8 percent fewer youth ages 13–15 would not have engaged in binge drinking
• 11.5 percent fewer youth would not have used marijuana
• 45.8 percent fewer youth would not have used cocaine
• 10.7 percent fewer youth would not have smoked regularly

The average effective school-based program costs $220 per pupil. It would save an estimated $18 per $1 invested if implemented nationwide. Nationwide school-based effective programming in 2002 would have had the following fiscal impact:
• Saved State and local governments $1.3 billion, including $1.05 billion in educational costs during 2003 and 2004
• Reduced social costs of substance-abuse–related medical care, other resources, and lost productivity over a lifetime by an estimated $33.5 billion
• Preserved the quality of life over a lifetime valued at $65 billion

These cost-benefit estimates show that effective school-based programs pay for themselves and more. For every dollar spent on these programs, an average of $18 dollars per student would be saved over their lifetime. Among 10 effective school-based life skills programs, the average return on investment exceeded $15 to 1. That is, every dollar spent on these programs returned an average of $15 dollars per student. The probable costs and cost savings involved in implementing a composite of these programs for middle school youth ages 12–14 nationwide were estimated. The average program would delay more than a million initiations of alcohol, cocaine, marijuana, or tobacco use by youth for an average of 2 years. Its cost would be $220 per pupil.29
The out-of-pocket expenses would be repaid by savings to the education system alone in less than 2 years. The program would offer additional savings to State and local governments by reducing spending on Medicaid, police, and other criminal justice services. School-based programs that offer a particularly large return on investment include All Stars, Family Matters, Keepin’ It Real, Life Skills Training, and Project Northland. Although Project TND and STARS for Families yielded lesser returns than competing NREPP programs, they still yielded $4 in savings per $1 invested. Programs designed to strengthen families generally cost more than the school-based life skills programs. Several of them also were highly cost-beneficial and offered much larger returns in the aggregate per youth served than the school-based life skills programs.
In a program targeting families with low income, intensive home visitation, coupled with preschool enrichment, reduced infant/toddler abuse (Aos et al., 1999; Karoly et al., 1998). As these toddlers reach adolescence and adulthood, visitation programs also can reduce a range of problems including substance abuse and violence. However, the net returns are often realized in the long term (for actual longitudinal cost-benefit results see Karoly, et al., 1998; Schweinhart, et al., 1993). The proven interventions often cover different aspects of the problem (such as youth drug use initiation, impaired driving, and violence), which make a complementary set of interventions more beneficial. Several interventions are best directed toward different aspects of the problem. If they are massed against the same aspect, the size of that aspect will shrink, and the return on added interventions will decline below the levels shown in this study. Taken as a whole, the benefits of substance abuse prevention well outweigh the costs of providing that service. Cost-benefit ratios can guide the selection of an optimal intervention package within the available resources. Political feasibility, cultural and demographic differences, and local priorities also must be considered.

Source: Miller, T. and Hendrie, D. Substance Abuse Prevention Dollars and Cents: A Cost-Benefit Analysis, DHHS Pub. No. (SMA) 07-4298. 2008

Filed under: Prevention (Papers) :

By Lauren G. Block, Vicki G. Morwitz, William P. Putsis, Jr, and Subrata K. Sen
Adults may think teenagers don’t pay attention to media messages urging them to avoid destructive behavior. But a study of a well-known anti-drug advertising campaign from the late 1980s reveals that they were.

Over the years, advertisements run by the Partnership for a Drug-Free America (PDFA) have turned into popular culture icons. Spots like “This is your brain . . . this is your brain on drugs” have become part of the lingua franca. Over the years, PDFA, a non-profit started in 1986 and backed by the American Association of Advertising Agencies, has received more than $3 billion in donated media from the broadcast, cable, and radio networks, more than 1000 newspapers, and more than 100 magazines and medical journals. The massive amount of donated media PDFA receives annually makes it the largest advertiser of a “single product” in the United States – after McDonald’s.

But does all that spending work? After all, as any parent will testify, it can be difficult getting through to teenagers. So we decided to investigate whether the target audience of the advertising – adolescents – was listening.

Fortunately, there were good data available. Before it aired the ads, the PDFA began conducting annual surveys to independently test whether the advertising campaign was associated with a change in adolescents’ drug use. These were known as the Partnership Attitude Tracking Surveys (PATS) and were obtained by getting teenagers to fill out anonymous questionnaires at central locations like malls. The first “wave” of PATS was initiated during February and March, 1987, three months before the first anti-drug messages were aired. Additional waves, which took place in 1988, 1989, and 1990, measured respondents’ recall of PDFA advertisements. (The sample sizes of adolescents aged 13–17 years were 797, 1031, 870, and 1497, respectively.) These four waves formed a “natural experiment.” Respondents during the first wave were not exposed to PDFA advertising, whereas respondents in subsequent waves were.

A preliminary examination of the PATS data reveals that the percentages of respondents who reported marijuana or cocaine/crack use in the previous 12 months did, in fact, decrease significantly between 1987 and 1990. Survey data from the University of Michigan’s Institute of Social Research and National Household Survey on Drug Abuse corroborate this trend. But while this pattern is consistent with the hypothesis that anti-drug advertising reduces drug consumption, this analysis does not accommodate other potential explanations for changes in drug consumption over time, such as exposure to school-based anti-drug campaigns. To adjust for such other factors, we developed a detailed behavioral economic model that investigated the relationship between adolescents’ recall of anti-drug advertising and their probability of using marijuana, cocaine, or crack – as well as the volume of use for those already using these drugs.

Model Behavioral

We began with an individual-level behavioral economic model of drug use, focusing on the impact of advertising. This well-established economic framework provided the rigorous link between the underlying theory and the statistical model needed to estimate individual behaviors. We then relied on health behavior theory to select the specific variables used within this empirical specification. The measures used in the analysis represented the predominant benefits and costs of drug use identified in major health behavior theories. We analyzed marijuana use separately from cocaine/crack use because reasons for use differ for specific drugs. And we combined cocaine and crack into a single category because 92% of respondents reported using both with equal frequency.

Respondents indicated how often in the past 12 months they had used each drug by selecting a number on a scale running from 1 – meaning no use – to 7 – meaning 40 or more times. These responses allowed us to determine both the percentages of respondents who reported using each drug in the previous 12 months and the volumes of use. In the case of users of both drugs, we divided their volume of use at the median and considered those below the median to be light users and those above the median to be heavy users.

The PATS surveys also included questions related to a variety of factors associated with drug usage. We used responses to these questions as input to our model. Perceived susceptibility was measured by asking respondents to rate three items (on 4-point scales) indicating the degree to which people risk harming themselves by using drugs. Perceived severity was measured by having respondents rate four items (on 4-point scales) indicating the degree to which they would fear the consequences of being caught with drugs. Attitudes toward drugs were measured by having respondents indicate their level of agreement with 14 items (on 5-point scales) describing benefits of drug use. Attitudes toward drug users were measured by having respondents indicate whether each of 27 personality characteristics would describe a marijuana, cocaine, or crack user. Other factors measured included peer pressure, and how difficult it was to obtain drugs. Finally, respondents were asked to read a short description of six advertisements that were aired nationally, and to indicate how often they had seen each advertisement.

The probabilities of a respondent’s reporting use of marijuana and cocaine/crack over the previous 12 months were expressed in a standard “probit” formulation as a function of both the attributes of the individual (e.g., demographic characteristics) and his or her attitudes towards drugs and drug users, and perceptions of drug use itself (e.g., perceived severity). We considered three versions of this formulation, each of which involved a slightly different assumption about the relationship between the cocaine/crack and marijuana use decisions.

An Independent Choice?
First, we estimated the marijuana and cocaine/crack equations independently, assuming that the decision to try the two drugs is independent. (Empirical research suggests that the process may be sequential; that is, one first tries marijuana and then cocaine/crack.) Second, the common syndrome theory suggests that individuals have a “predisposition” to use drugs that manifests itself first in marijuana use. Third, certain factors associated with the experience of using marijuana could lead people to use harder drugs, such as cocaine/crack. This has been referred to as a “gateway” or “stepping stone” theory. These three alternatives resulted in different statistical specifications, which allowed us to test the hypotheses with the available data. In addition to the “use” choice, we investigated the decision regarding how much to use (the “volume” decision), given that an individual has reported using marijuana or cocaine/crack. For this analysis, individuals were categorized as “light” or “heavy” users.
The result is a classic sequential-choice decision: an individual uses the drug and then, on the basis of his or her experience and additional information (e.g., anti-drug advertising), decides whether or not to use the drug again. Accordingly, for each drug, we initially estimated stage one probability equations and then estimated the probability of a given individual’s being a light or heavy user conditional on previous use. Thus, including only those who had previously used drugs, we estimated each second-stage equation using a dichotomous dependent variable indicating heavy or light usage.
The first “wave” of PATS (conducted before the initiation of anti-drug advertising) provided us with the data necessary to assess the determinants of drug use in the absence of PDFA advertising. This was the “control” in our natural experiment. We were then able to assess the significance of recall of PDFA advertising in terms of use and volume decisions via a series of “treatment” groups consisting of each of the subsequent waves exposed to advertising.
We began by estimating the three sets of probability-of-use equations (“independent,” “gateway,” and “predisposition”) using the wave one data for marijuana and cocaine/crack. Then, on the basis of the best fitting of these equations, we estimated the second stage regressions for the probability of being a light vs. heavy user, also using the wave one data. This provided us with a detailed analysis of the factors influencing the decision to use and the volume of use for each drug before the commencement of PDFA advertising.
So what did we find? Using nested tests, we concluded that the “predisposition” formulation – i.e. that individuals have a “predisposition to use drugs” that manifests itself first in marijuana use – fit significantly better than the notion that the decision to try the two drugs is independent. Consequently, we used this formulation throughout. In addition, the data led us to reject the hypothesis that marijuana use increases the probability of cocaine/crack use. To be sure, individuals who have used marijuana in the past are indeed more likely to use cocaine/crack. But the reason is that – statistically speaking – individuals who are predisposed to try marijuana are also predisposed to try cocaine/crack.

Does Anti-Drug Advertising Work?
This analysis, conducted with the wave one “control” group, provided the basis for analyzing the significance of recall of PDFA advertising in waves two, three, and four. The findings demonstrate that recall of anti-drug advertising was associated with a decreased probability of marijuana use. The advertising coefficients in the marijuana use equation were all statistically significant and of the “correct” sign. In the case of cocaine/crack use, the advertising variables were also significant in waves two through four. The estimated advertising coefficients in the volume portion of our results were all statistically nonsignificant with the exception of the wave four marijuana volume-of-use equation. This suggests that recall of PDFA’s anti-drug advertising had little or no impact on the volume of use among existing users.

To ensure that the negative advertising coefficients imply that recall of advertising leads to lower marijuana and cocaine/crack use and are not due to the omission of variables like exposure to other anti-drug programs, we examined the correlation between the advertising-recall variable and the estimated equation error. This correlation was found to be statistically nonsignificant for each equation, suggesting that omitted-ariable bias was not a significant problem.

Finally, we estimated the marginal impact of the advertising-recall variable to determine the change in the probability of use associated with a 1-point change in advertising recall, with recall being rated on a three-point scale. We estimated the cumulative impact on use probability given a particular wave’s level of advertising awareness by subtracting the average predicted probability of use in the absence of PDFA advertising from the average predicted probability given the level of recall generated by PDFA advertising in that wave. The marginal effects of PDFA advertising on the probability of drug use were significantly greater for marijuana than for cocaine/crack across each wave. The cumulative effects suggest that, after three years of PDFA advertising, approximately 9.25 percent fewer adolescents were using marijuana and 3.6 percent were using crack/cocaine.

Our results are consistent with the hypothesis that anti-drug advertising reduces the probability of marijuana and cocaine/crack use among adolescents. However, our results also suggest that recall of anti-drug advertising is not associated with adolescents’ decisions regarding how much marijuana or cocaine/crack to use among those already using each drug.

This study was not without limitations. Although the sample was constructed to be representative of American adolescents, central-location sampling was used. It is also possible that respondents were exposed to other anti-drug intervention programs in addition to their exposure to anti-drug advertising. However, past research has demonstrated that these alternative programs have been largely ineffective.

Despite these potential limitations, our findings have important public policy implications. Our model, based on survey data from 1987 to 1990, indicates that increases in amounts of anti-drug advertising are associated with decreases in teenage drug use. During this time period, media financial support for anti-drug advertising increased, from a low of $115 million in 1987 to a high of $365 million in 1991. Given the results, this increase appears to have been a worthwhile investment.

A longer version of this research appeared in the American Journal of Public Health, August 2002, Vol 92, No. 8.
Source http://w4.stern.nyu.edu/sternbusiness/fall_winter_2003/justsayingno.html

Filed under: Prevention (Papers) :

Just as in the 1970s, the drug legalization movement has received a great deal of media attention. Also just as in the 1970s, this movement, unfortunately, has contributed to the rise in drug use by painting the picture that drug laws – not drugs – are the villains. Legalization advocates attempt to support their position with faulty analogies, misrepresentations, and unsupported theories. This fact sheet will address the myths propagated by the pro-drug movement.

MYTH: Drug laws infringe on individual freedom and privacy as well as make criminals out of otherwise law-abiding citizens.

FACT: All laws, by their nature, restrict a certain degree of freedom – the freedom to do as one pleases, whenever one pleases, regardless of the harm or potential harm to oneself or others. Civilized society has the right and the responsibility to regulate behavior in order to protect individuals from their own poor decisions as well as others from the risks of certain behavior. Drunk driving, traffic regulations, possession of explosives and weapons, incest, and child labor are but a few examples.

Those who want to legalize drugs would have you believe that individuals who choose to engage in illegal behavior bear no responsibility; but, instead, the law is to blame, even though most of our citizens elect not to violate the law. The legalization advocates focus on the rights of drug users while ignoring the rights of the public. Based on their philosophy, it is acceptable to allow a very small segment of our society to get high with impunity while placing the majority in great jeopardy from their intoxicated state. Based on their theory, drunk driving should not be against the law. A drunk should only be punished after he or she has a traffic accident and kills or maims someone.

Additionally, the majority of our citizens do not fear law enforcement. It is those few who choose to violate the law who feel threatened by the police. They seek protection of their own freedom while they choose to violate the freedom of others.

MYTH: Drug use is a victimless crime.

FACT: There are actually four classes of drug use victims: the users themselves, the family and friends of users, the individuals who are victimized by the acts of those under the influence, and the taxpayers/consumers who are paying the price. Tell these people, who have had firsthand experience with drug abusers, that they are not victims. Tell the mother and father whose child was killed by a drugged driver, or the husband whose wife was raped by somebody loaded on cocaine, or the sister whose brother was brutally beaten by a “speed freak” that they are not victims of drug use. The nexus between violence and being under the influence is indisputable. Tragic stories of promising young adults dropping out or children beaten by their drug-using parents are all too common. How anyone, assuming that they truly understand the drug culture, can suggest a policy that would facilitate drug use is beyond comprehension.

MYTH: Alcohol and illicit drugs are no different; thus, it is hypocritical for society to allow alcohol use while outlawing other drugs.

FACT: Alcohol and illicit drugs have a major difference. Most people use alcohol as a beverage and don’t drink to become intoxicated; whereas, with drugs, intoxication is the sole purpose. That is why marijuana smokers seek the higher THC content in marijuana and why crack is so popular among cocaine users. A more factual analogy would be to compare drug use with drunkenness. In addition, illicit drugs are far more addicting than alcohol. Also, approximately one-half of our citizens use alcohol, whereas only approximately 6 percent use all of the illicit drugs combined – the simple reason being that alcohol is legal, relatively inexpensive, readily available, and socially acceptable, whereas illicit drugs are not.

MYTH: The legalization of illicit drugs should be based on the alcohol model.

FACT: Alcohol is hardly the model to use to justify legalizing illicit drugs. Legal alcohol has been consumed by a majority of our young people, whereas only a small percentage use illegal drugs. There are more people addicted to alcohol than use all the illicit drugs combined. Alcohol kills five times more people, the medical costs are triple, and economic costs are double those of all illicit drugs combined. There are also three times as many arrests for alcohol offenses as there are for drug offenses. The paradox is, while society is strengthening and demanding stricter enforcement of alcohol laws, there are those who want to decriminalize and even abolish drug laws.

MYTH: We tried alcohol prohibition, which was a failure, proving that prohibition against drugs does not work.

FACT: Alcohol prohibition, under quite different circumstances in the 1920s, was an attempt to pass laws that the majority of the people did not support. Even with that, there was an approximate 50 percent reduction in alcohol consumption, deaths from alcohol-related diseases, admissions to mental institutions, and alcohol-related psychosis. Unlike the legalizers would lead you to believe, crime did not skyrocket. Prior to enforcing drug laws and alcohol prohibition, from 1900 to 1920, the murder rate jumped 300% (1.5 to 8 per 100,000) from 1905 to 1919. During prohibition, the rate climbed only 30% (8 to 9.5 per 100,000). Rescinding prohibition after only 13 years was insufficient time to change society’s attitude following 2,000 years of acceptance. Regardless of whether you drink alcohol or not, you would probably agree that our society would be much better off if we didn’t have alcoholic beverages.

MYTH Elimination of drugs would reduce crime and free prison space for the more serious violent offenders.

FACT: Removal of laws would reduce incidents for those specific violations, but the behavior would not change. Lowering the age consent to 12 would reduce the number of child molestation crimes, but it would not change the fact that predators were molesting young children ages 12 to 18. The advocates fail to recognize what drug experts are well aware of: that a high percentage of drug dealers and addicts were criminals first and foremost. They would continue their criminal behavior in order to acquire sources of income. The Mafia did not disband after Prohibition nor would the Crips and Bloods become choirboys if drugs were legalized. The drug black market would continue unless all drugs for all ages were legalized, a proposal few support.

The nexus between being under the influence of alcohol and/or drugs and violence is well documented. Because drugs alter the mental state, drug users commit a disproportionate number of violent crimes. These acts of violence are often against family members and friends. Fifty percent of all child abuse cases are attributed to drug-using parents. Drug users are five to ten times more likely to be involved in fatal traffic accidents than drunk drivers. The perpetrator was under the influence in well over half of the violent crimes such as murder, rape, and serious assault. Only 5 percent of all murders are committed because of drug laws, whereas approximately 25 percent are committed because the murderer was under the influence of drugs.

There are three times as many arrests for alcohol violations as there are for drug violations. Legalizing substances such as alcohol was supposed to reduce crime, or is it that intoxication leads to more crime?

Ninety-three percent of all state prison inmates are violent and/or serious repeat offenders. Only 1.4 percent are first time, “non-violent” drug offenders. Keep in mind that “non-violent” only describes the act for which individuals are incarcerated and not their past history or previous behavior. If an organized crime “hit man” were convicted for income tax evasion, then he would be considered a non-violent inmate. In addition, only approximately 10 percent of those arrested for drug offenses actually end up in prison. The simple truth is that if we legalize or decriminalize drugs, the acts of violence against our citizens would skyrocket.

MYTH: Other countries have had successful experience with a more lenient and/or pseudo-legalized drug policy.

FACT: In the 1970s legalization advocates cited Great Britain’s decriminalization of heroin as a model drug policy. When Britain’s failed policy resulted in increased addiction, while the addict population remained stable in the United States, the advocates discontinued citing Britain. They then pointed to Platzspitz Park in Zurich, Switzerland, which essentially offered free drugs. This program was to prove all the so-called positive benefits of legalized drugs. The advocates expected less crime, more addicts accepting treatment, decreased AIDS, and the isolation of addicts. After five years, this experiment was abandoned because crime increased, drug-related deaths doubled, AIDS rose, and the health care system was overwhelmed. The very persistent advocates then began focusing on the Netherlands and its “enlightened” drug policy of not enforcing laws against selling and using marijuana in certain areas. After a number of years, the Netherlands began experiencing the consequences of lenient drug laws with increased drug use, unemployment, and crime. From 1984 to 1992, teenage drug use in the Netherlands increased 250 percent, while in the United States, at the same time, teenage drug use was reduced by 50 percent. Crimes of violence in the Netherlands – for instance, serious assault – increased 65 percent.

The advocates actually don’t have to look beyond this country to examine the results of legalization. The experience in Alaska with decriminalized marijuana resulted in twice as many Alaskan teenagers using the drug as those in the rest of the nation. Also, in the early 1900s, prior to legal sanctions, when drugs were inexpensive, available, and legal, the drug crisis per capita was triple today’s drug problem.

The advocates failed to examine the assertive drug policies of Japan and Singapore that resulted in the virtual elimination of the drug problem. Along with some Muslim countries, Japan and Singapore have proven that tough drug laws, coupled with aggressive enforcement, work.

MYTH: The cost of enforcing drug laws is too expensive, and the money could better be spent on social programs dealing with the root causes of drug abuse.

FACT: What the legalization advocates fail to address is the cost to this country if drug laws were not enforced. Making illicit drugs legal, inexpensive, and readily available would lead to a significant increase in the number of users and increased consumption among current users. Increased use and consumption would result in corresponding greater costs for homelessness, unemployment, welfare, lost productivity, disability payments, school dropouts, lawsuits, medical care, chronic mental illness, accidents, crime, and child neglect, to name a few.

Fifty to sixty percent of mental health care patients are substance abusers. Drug-using teens are three times more likely to commit suicide than their non-using peers. Seventy-five percent of teenage runaways are substance abusers. Hundreds of thousands of newborns are drug-exposed and impaired, costing taxpayers over $100,000 per child.

The current economic cost of illicit drug abuse is still half that of one legal drug – alcohol. The money raised in taxing alcohol covers less than 10 percent of all social and health expenditures due to that drug. Federal, state, and local government expenditures for drug law enforcement, which includes police, prosecutors, public defenders, courts, and prisons, is approximately $10 billion, which is less than 1 percent of total government expenditures. Relatively speaking, this is not a significant investment considering drug law enforcement, when compared to alcohol, helps save hundreds of thousands of lives and hundreds of billions of dollars.

Putting drug law enforcement expenditures into perspective, our federal government spent ten times that amount paying the interest on the public debt, ten times that amount on the war on poverty, and more money on the Food Stamp Program alone than all federal, state, and local expenditures for drug law enforcement.

There is also an assumption that with legalization there would be no governmental costs to regulate and control the distribution, sale, and use of drugs similar to those we currently have with alcohol. In addition, drug law enforcement would still be required for those drugs that remain illegal or to police the sale to and use by those under age.

Most importantly, the cost-saving argument, referred to as “blind-side economics,” only addresses economic issues and not the more tragic costs in terms of loss of life, pain and suffering, broken families, child neglect, and the general poisoning of Americans.

MYTH: The answer to the drug problem is increased drug prevention and treatment and not law enforcement.

FACT: It is interesting to note that most drug treatment and prevention professionals are against legalizing drugs. They consider law enforcement an essential precursor to both successful prevention and treatment. Good drug policy requires all three disciplines. Drug treatment experts agree that law enforcement offers strong incentives not only to receive treatment, but once treatment has been completed, to stay off of drugs. Making drugs legal, inexpensive, and readily available would eliminate that important incentive. Drug prevention experts agree that legal sanctions and public attitude against drug use are essential for successful education and prevention programs.

MYTH: This country’s 80-year war on drugs has been a failure, proving that strict laws and enforcement do not work.

FACT: It should be noted that there is not actually a “war” on drugs, but a limited engagement. Even with that, drug sanctions and enforcement have been successful during this 80-year period. Experts estimate that in the early 1900s, prior to drug laws or enforcement, there were as many addicts in this country as there are today, even though the population was one-third smaller. Recognizing the tremendous costs and problems associated with drug use, citizens, through their government, elected to pass and strictly enforce drug laws. The drug problem was significantly reduced so that by the 1940s and ‘50s, it was relatively minor. Anyone attending high school during that period could testify that drugs were virtually non-existent for most people.

In the 1960s and 1970s, there was a major shift in attitude regarding drug use. Terms such as “recreational drug use” were coined; the legalization movement gained momentum; drug use was glorified; and drug law enforcement was de-emphasized. This resulted in a tremendous increase in drug use and related problems in America. In the 1980s, through a combination of increased law enforcement, highly publicized prevention messages, and more effective treatment, drug use was reduced by 50 percent in just twelve years. In 1979 there were 24 million drug users and by 1992 there were only 11.4 million. It was during that period that drug arrests and incarcerations doubled. High school seniors graduating in the class of 1992 were 50 percent less likely to use drugs than their counterparts in the class of 1979.

Studies and surveys show that while 70 percent of eighth graders had used alcohol, only 10 percent had tried marijuana, and only 2 percent cocaine. Additional studies demonstrate that a majority of students cite the fear of getting into trouble with the law as a major deterrent to drug use. Yet another study shows that 79 percent of those responding stated they had no chance to use cocaine. Of the 21 percent who did have a chance to use cocaine, over half did. The U.S. military’s tough drug policy dropped drug use from 28 percent in 1980 to 3 percent in 1992. Private industry has repeatedly proven that tough anti-drug sanctions are successful.

There have been few modern social problems in this country, such as welfare, teenage pregnancy, homelessness, high school dropouts, and test scores for American students that have shown the same degree of success as our country’s drug policy. If, for instance, teen pregnancies were reduced by 50 percent, homelessness reduced by 50 percent, or SAT scores raised by 50 percent, the successes would be applauded. Instead, a 50 percent reduction in the number of drug users is considered a failure.

Conclusion

You don’t have to be a drug-abuse expert, an intellectual, or hold a variety of degrees to understand that to make illicit drugs legal, readily available, relatively inexpensive, and reduce the risk would lead to increased numbers of drug users as well as increased consumption among current users. Likewise, common sense would dictate that with increased drug use and consumption, the problems affecting this country would be overwhelming. Drug abuse exacerbates most social problems facing this country and touches all segments of our population. There would be no greater threat to destroy our country from within than making drugs inexpensive, available, and legal. I don’t think this is a legacy that we want to leave our children or our grandchildren. Instead of repeating the mistake of the 1970s, we should build on the successes of the 1980s. It is a mystery as to what drug culture the legalization advocates are referencing. Drug abuse experts are positive it isn’t the one they deal with on a daily basis. Intellectual theory, although interesting, often has no basis in reality

Source: Executive Director Thomas J. Gorman The Rocky Mountain HIDTA (CO)

Filed under: Prevention (Papers) :

This paper was developed as part of a wider training programme in drug prevention for St. John Ambulance. Although it was published in 1999 the points made are still very relevant today.

By Peter Stoker, Director, National Drug Prevention Alliance

‘All that is necessary for the triumph of evil is that good men do nothing’.
Edmund Burke 1729-97

‘We have seen
Good men made evil, struggling with evil
Straight minds grow crooked, fighting crooked minds
Our peacefulness betrayed us; We betrayed our peace
Look at it well.
This was the good town once’.
From The Good Town by Edwin Muir 1887-1959

Historical background

Although the primary purpose of prevention programmes is to address avoid contact with drugs, it is necessary that we also look at attempts to relax the laws that relate to drugs. Why essential? Because the status of the law is fundamental to the structure of prevention. There is no point on concentrating on building a “a beautiful tower of prevention” whilst ignoring somebody else undercutting the foundations. We often don’t give as much time as we should to considering fundamental questions, but they can teach us a lot, and two current questions we should perhaps ask ourselves are:

What is so good about prevention?
What is so bad about legalisation?

I’ll offer you my answer. Prevention delivers on the promise of enriched lives in wholly healthy people positively inter linked with one another across whole communities and society as a whole. Legalisation gives encouragement to negative, self-centred and health compromising behaviours in the individual and across society. The law defines how we feel about behaviour in general and as such the law is one corner stone of prevention; remove it and you risk total collapse of your prevention structure.

Whilst the drug culture covers many countries of the world it can usefully be studied by paying particular attention to our own country and to America. These two countries have been said to have long had a “Special Relationship”, but in these days of a drug promoting culture this phrase has taken on a more sinister meaning.

Britain and America have long been associated on the drug scene. You could say an early ‘War on Drugs’ came when the Americans threw all our tea into Boston Harbour! But more serious developments started in the 1960’s and 70’s as marijuana in the USA merged with hippie culture, anti-Vietnam protests, and big-time rock/pop music. In Britain we had our anti-nuclear protest groups, we had (they tell me) the Swinging Sixties, and we had the Beatles. Legend has it that it was Bob Dylan who turned the Beatles on to dope, thence to travel through the gateway into Strawberry Fields watched over by Lucy in the Sky with Diamonds (or LSD for short).

By the late 60’s an ambitious young American lawyer, Keith Stroup had conceived the idea of NORML, the National Organisation for the Reform of Marijuana Laws, ‘Playboy’ Hugh Hefner bankrolled it for 10 years, and the battle for legal pot was under way. Britain wasn’t really turning on yet; pot use was viewed stereotypically as the preserve of musicians (see Harry Shapiro’s book ‘Waiting for the man’ pub. Mandarin 1990), immigrant West Indians, and degenerate intellectuals. But we would catch up fast.

NORML and its bizarre fellow travellers like the Yippies (a bizarre group of loony activists) tended to go up to the front door and flamboyantly say what they wanted out loud. This had the effect of generating lots of opposition which usually beat them. The lesson they learnt was twofold: (a) if you’re going to the front door wear suits and don’t shout and (b) better still, go round the back, sneak in and take what you want. The Drug Policy Foundation was the eventual manifestation of the first lesson, together with the unrestrained manufacture of ‘reasons’ why the general public should feel good about pot. Use the hemp (it is the same plant) to make clothes; plant the bushes to “save” the atmosphere, and – above all – use it as a “medicine”; all these and more devices have been deployed. The ‘medical use’ gambit came in while Stroup was still building NORML; in the 70s NORML are on public record as bragging ‘We will use the medical marijuana argument as a red herring to give pot a good name’. And still it goes on. Meanwhile, under item (b) a steady infiltration of key offices was sustained, and is still very much a factor today.

As we worked our way through the 80’s there was still no sign of America buckling under drug culture pressure. Levels of use had peaked and were in decline as PRIDE and other parent-youth prevention groups got into their stride.

Britain was by now moving too. In 1981 the government-funded Standing Conference on Drug Abuse (SCODA) passed a resolution understood to be still in force today calling for decriminalisation of cannabis. One member of SCODA around that time was LCC, the Legalise Cannabis Campaign, thus demonstrating another lesson legalisers learnt i.e. if you can’t beat ’em, join ’em, then persuade ’em from within.

Thus far the link between legalisers across the Atlantic divide were tenuous and occasional. One reason for this might well have been a xenophobia amongst British workers in the field; a distaste for foreigners which was out of all proportion to the rest of Britain’s population (who these days seem to be in love with things American). Whatever the reason, not much happened for some time but then in the mid 80’s changes started. A bridge was constructed with one end in Washington DC and the other end in Liverpool, England. Why Liverpool? Because it was a fountainhead of British drugfolk wisdom, and was saying things the American legalisers wanted to hear. Liverpool has long had a severe drug problem. It has also had a vigorous dislike of London and its lawmakers, dislike based in the class struggle and regional inequalities in funding. Drug workers nation-wide tended to affinity with Liverpool and the views expressed in its magazine, the Mersey Drugs Journal; it seemed to talk more like the clients they dealt with, they identified with and (in my opinion) too often over-identified with. Their near-neighbour Manchester formed an enthusiastic axis with them which to this day constitutes a powerful influence on UK drug wisdom.

Sometime around 1986 British drug workers from Liverpool-Manchester axis were invited to speak at a NORML conference in Maryland. They were feted and hosted by pro-drug, academic, ‘celebrities’ such as Norman Zinberg. They visited NIDA and other agencies, meeting officials who (allegedly) “confessed privately” that the War on Drugs was failing. The Brits returned to report that (a) they had nothing to learn from the Americans and (b) the 12-step method – the basis of the worldwide AA movement – was (quote) “cr*p”. (When asked what the 12 steps were, they said they didn’t know (but they did know they were “cr*p”). The Mersey Drug Journal’s front page at the time summed up their view: ‘Drug War – The Americans Go Over the Top’. This dismissal of the American Official Approach (including, of course, prevention) was manna from heaven to the xenophobic Brits who disproportionately populate the Health Professional Scene and paved the way for recommending the Unofficial Approach i.e. legalise the stuff.

One important aspect, however, distinguished the British legalisation strategy, and was given a fortuitous boost by a tragic new development in the health scene. AIDS was now a reality in Britain as well as America, and amongst many in Britain the view expressed was that AIDS represented “a greater risk to society than drugs”. The incidence of AIDS gave the British Harm Reduction movement a great shove forward, and coincided with the emergence of America’s Drug Policy Foundation as a major player in drug legalisation.

Current Situation

The main section of this paper will now address the following headings:

(a) What does ‘the professional subculture’ mean?

(b) What drives this sub culture?

(c) Who is involved?

(d) How do groups like this obtain and retain power?

(e) What are some of the typical tactics?

(f) What are we on the prevention side doing wrong and what might we do better?

What does professional subculture mean?

This title refers to people who work in various professional settings but who have, for a variety of reasons, elected to act in ‘subcultural’ ways; they will seek to disrupt the status quo and replace it with something which they find more amenable. In the case of drugs this is generally turned out to be a more libertarian or acquiescent approach to the use of drugs and to the legislation around them. Some , but not all of the groups which these professionals belong to include Politicians, Judges, Policemen, Educators, Health workers, Social workers, Probation officers, Prison workers, Economists and of course, never to be over looked, the Media. These activists are always a minority of each of these professional groups, but they do make a lot of noise, and there is a lot of truth in the proverb that ‘the squeaky wheel gets the most grease’; certainly the dissident or activist professional get the most coverage in the media. This is only partly due to the fact that the media themselves are part of the problem, in that a number of them are – more or less – of a libertarian inclination; the rest of the explanation can be attributed to the fact that dissent and activism sells more copy than does the actions of those who seek to preserve the status quo, or even to enhance it- such as we prevention workers.

What drives such people, or groups?

It is a fundamental mistake to imagine that everybody on the pro-drugs side of the fence is there for the same reason. The reasons are many and very varied. Perhaps four main categories can be defined as Power, Money, Attraction and Ideology. Fringe activities like pushing for legalisation or decriminalisation of drugs most often comes from the people who are on the fringe of power but would like to be in the centre. This quest for power can sometimes produce strange alliances, for example in Norway the pro drug alliance combines the right wing Fascist group with the extreme left wing Anarchist group. Some see the use of drugs as a way to create revolution. Stalin was one of these, and a quote from his writings is:

‘By making readily available drugs of various kinds; by giving a teenageralcohol; by praising his wildness; by strangling him with sex literature and advertising to him or her . . . the psycho-political/preparation can create the necessary attitude of chaos, idleness and worthlessness into which can then be cast a solution that will give the teenager complete freedom every where. If we can effectively kill the national pride and patriotism of just one generation ,we will have won that country. Therefore there must be continued propaganda to undermine the loyalties of citizens in general and teenagers in particular.’

At the other end of the spectrum of activism, but still on the pro drugs side of the fence, are the fatalists and the compromisers. These are people who would rather that drugs weren’t used but who believe that it is inevitable that they will be used by the majority, that drug use will be the norm, and that the best one can do is to sue for a peaceful surrender with the drugs trade. The problem with climbing over to that side of the fence is that you are likely to be warmly embraced and dragged off to more extreme positions; this can be seen to have happened recently with Bolton MP Brian Iddon, in whose consistency five year old Dillan Hull was shot in what is reliably perceived as a drug-related incident. Iddon was elected in May 1997 and started off with fairly moderate statements about wanting to review drug laws; on BBC’s ‘You Decide’ programme he was heard at the end of the debate to say that he was now “confused”. His confusion has scarcely been lessened by some of the people with whom he has associated, and in November 97 he shared a bizarre press conference at the House of Commons seated along side Irvine Welsh, the author of ‘Trainspotting’ and Howard Marks, the former major smuggler of cannabis who served 7 years in an American prison, and who is now attempting to get into politics somewhere (he has tried Lincoln, where he lost his deposit, and is currently trying to become the mayor of his town of residence in Malta). Marks claims he is pursuing this political work to ‘give back something to all those pot users who have given him lots of money in the past’ (this is a paraphrase but is close to what Marks said). In truth, this ‘selfless’ campaign has already netted Marks large sums of money – he has sold around a quarter million copies of his autobiography ‘Mr Nice’ and he appeared to capacity houses in a various theatres, reading from this book and musing on his life. In reality Marks is still working the punters; the only difference now is that instead of selling them a poisonous substance he is selling them a poisonous philosophy. And with no danger of arrest.

The above has given at least some examples of what is meant by the quest for power and the quest for money. Another example of the quest for money concerns organised crime. Some people theorise that organised crime would be against law relaxation, because this would take the business out of their hands and put it into the hands of responsible people (like tobacco companies!). The evidence suggests otherwise. It is acknowledged, even by pro-drug campaigners like ex-Scotland Yard Drugs Squad supremo Eddie Ellison that nowadays the coffee shops in Amsterdam, which were to have grown their own in a ‘nice cottage industry’ approach, are actually receiving their supplies from the Mafia. The Dutch Minister of Justice has described Amsterdam reluctantly as ‘the crime capital of Europe’ and there are reports that the Mafia is considering moving its centre of operations from Italy to Holland because of the more conducive atmosphere there. It is also worth noting that the lawyers (and almost all of them were lawyers) who founded the Drug Policy Foundation – the most powerful pro-drug lobby in the world – can be found on public record as having often appeared as defence attorneys for the Drug Cartels . . . far from being automatically against law relaxation, organised crime has for years been moving its operations into legitimate businesses (to save costs of money-laundering, and to avoid the inconvenience of criminal prosecution). Were drugs to be legitimised then this revised legal status would scarcely represent an obstacle for them. Moreover, most of the proponents of law relaxation, quell public disquiet, suggest they would still expect to keep the laws in place for under 18 year-olds. In this hypothetical situation there would still be an enormous black market for organised crime to tap into, and if anything the pressure on the under 18’s would tend to increase, since supplies to over 18 year olds would be – presumably – coming from other sources other than organised crime.

As to the third main incentive i.e. the intellectual Attraction of being involved, this can be seen as one driving force amongst some of those arguing for law relaxation. It is not always easy to quit the centre stage and be put out to grass; some people like to leave their long-term employment by making one last mark. Policemen who have done this include the afore mentioned Eddie Ellison from Scotland Yard and Ron Clarke from Greater Manchester police. Those formerly on the bench, including Judge Pickles seem to find the attraction of radical statements sometimes to hard to resist. This should not be confused with the quotes made in 1997 by the Master of the Rolls who was misrepresented in the Sunday Independent as ‘calling for a review of the laws’. From a person who was present at the press conference that the Master of the Rolls was giving the subject was not even on his agenda. It came up towards the end of the conference, in the form of a question from the floor along the lines of ‘do you think the legalisation should be debated?’ The Master of the Rolls shifted in his seat uncomfortably and said something along the lines of ‘I am not minded to support such legalisation but I am minded to support the due exploration of the proposition’.

Ideology, the fourth reason, is a potent force – and in contrast to the other three reasons is less capable of change, in that you buy into it more emotionally than you would with power, money, or intellectual attraction. The Education profession is, by its very nature, more prone to this tendency, (see pages 7, 8 for more). The manifesto entitled ‘Down with prevention, up with free choice and harm reduction’ has spanned more than 15 years now (during which time use has soared), and despite the National Strategy espousing prevention there is so far little sign of change in organisations like SCODA, ISDD, and the like. The word ‘prevention’ may appear now in documents or utterances, but this is the perfunctory genuflection of the non-believer. Until we get this one right we are always going to collect a bloody nose in the educational arena.

Who is involved?

The line up of professions in an earlier section (What does ‘the professional subculture’ mean?) gives some indication. Politicians may follow this course perhaps because they genuinely (and we would say mistakenly) believe law relaxation will improve the situation. Some educators and, within that profession some youth workers, would support the ‘choice’ for young people to use drugs as part of what they would see as a ‘freedom of expression’. Health workers tend to be ‘Sickness Workers’ in that they are almost interminably involved with the demands of treating people who have been in some way become unhealthy; it is therefore an inclination on their part to support expedients that reduce harm, and some of them would extend this non-logic to the relaxation of laws. They have been suckered by the proposition that it is ‘the laws which are turning otherwise law abiding people into criminals’. The truth is that it is the users who are turning themselves in to criminals and doing so knowingly – no one can claim to be unaware of the illegality which surrounds illegal drugs. This tendency to go along with the needs of the perpetrator and do little or nothing for the needs of the victims of the perpetrator (i.e. people around the user and – ultimately – the whole of society) is not only typical of the health service; it can also be seen reflected in social services, probation service, prison service, youth services, and others of the so called ‘caring professions’. Somewhere along the way they have lost the track and they are now seeking to relax the constraints on such drug users, in the mistaken belief that this will facilitate the workers having a greater sense of identity, a better relationship with their youthful charges. A form of selling-out which deserves no respect – and gets none from the users themselves.

Another group with a minority supporting legalisation are Economists. A commentator once said that ‘if you want to know the answer to 2 + 2, a mathematician will tell you 4, a politician will say “somewhere between 3 and 5”, but an economist will ask “what would you like it to be?”. The partial and simplistic models which some economists use to support legalisation arguments are very questionable, and do nothing to enhance the reputation of their profession. Last, but certainly not least, we have the media. There are some media commentators who are now starting to speak out against a pro drug stance; people like Melanie Philips of the Observer, Peter Hitchens on the Express, Mary Kenny on the Sunday Express and Lucy Johnson, formally with the Big Issue, now with the Observer. But the pieces that they get published are small in terms of ‘column inches’ compared to those that their more libertarian colleagues manage to get into their pages. In America where there is such a thing as a Freedom of Information Act a large sample of newspaper proprietors found a majority of them were paid up members of the ACLU; American Civil Liberties Union, or other similar libertarian groups. It would be interesting to see a similar survey conducted here in Britain! The Sunday Independent push for decriminalisation of cannabis (covered at the end of this paper) was an example of just how far this libertarian juggernaut can be trundled if you have enough resources at the back of it. Mention of resources brings to mind another vital libertarian resource and that is people in Finance. The most notable of these is George Soros; he is the man who made hundreds of millions in the infamous Black Wednesday crash of the British stock market a few years ago. He is also the top man in a trust which has assets in excess of seven billion dollars. Soros has expressed an interest in stirring up a whole variety of different causes but one of them most noted is his funding of the pro-drug effort. He has given, it is estimated, (and there may be much more that is not known) in excess of 90 million dollars to pro-drug campaigners such as the Drug Policy Foundation in Washington DC. He has also funded the Lindesmith Institute and he was also the major funder in a successful push to get cannabis ‘legalised’ for medical purposes in the States of Arizona and California in 1996. But he had a predecessor in funding the Drugs Policy Foundation and other similar groups and that is a man called Richard F. Dennis. Dennis and Soros have something else in common besides their penchant for funding pro-drug groups, and that is that both of them are Futures Speculators. What this means is that if a particular commodity which they have bought into suddenly becomes more attractive on the market place they stand to make vast amounts of money. This may or may not be what is driving Messrs Dennis and Soros, but it should not be overlooked in any analysis of these gentlemen. It is also worth noting that Soros has bought into two banks, one in Columbia and one in the Netherlands, and he has also large tracts of cultivatable land in Colombia and Venezuela, purpose unknown . . .

How do these individuals and groups obtain and retain power?

The short answer is ‘gradually’. (Look back at descriptions of how NORML and the YIPPIES use to behave and now how they do behave – quoted in the introduction to this paper.) It was the Fabian Society, a think tank started many years ago for socialist intellectuals, which came up with the phrase ‘the inevitability of gradualness’. By this they meant that any movement whose approach is gradual but sustained has a much greater chance of success than any ‘crash, bang, wallop’ approach. One also needs to tap into any other movements that are happening in your arena and, as it were, swim or row along with them. One classic piece of research in this context comes from a noted sociologist called Kelly; he produced something called Kelly’s Repertory Grid. What the Grid does is to demonstrate that if a person buys into i.e. swallows a particular idea then they are also much more likely to also buy into ideas which seem to be in the same philosophical family. Therefore, for example, if I am helping young people to turn their lives around, I maybe against punitive justice sentences, I may also be against racism, bullying, violence and other things that get in the way of advancement of these young people, I will probably have some clients where AIDS and HIV has become issue and therefore I will be for the AIDS resources movement and out of all these factors I will probably be for the relaxation of drug laws. (It could be quite a useful SJA study group subject to try and write down other similar groupings that satisfy Kelly’s Repertory Grid criteria and perhaps one way forward in that would actually be to get the relevant research paper by Kelly out of your local library).

What the pro drug movement will do and indeed have been doing very successfully for certainly fifteen years (to this writer’s knowledge) and perhaps longer, is to infiltrate and penetrate the relevant organisations in the drug arena. These include central government, both at representative and civil servant level; local government both elected and appointed officers; and also other professions and voluntary sector workers in Education, Health, Social, Justice, Police, Youth Service, and other related fields. Most importantly, it will also get close to the media: National, regional, local of all forms TV and radio, printed page, magazines, are important targets. Information is power . . .

Whilst this infiltration maybe subject to setback when elections happen, generally it is the case that only the elected representatives disappear. Thus points of view, attitudes and philosophy can be perpetuated in Whitehall despite changes in Westminster. Leading journalist Melanie Philips has referred to this in her landmark book ‘All must have prizes’. Although this book focuses in particular on the struggles around basic education (reading & writing) it is uncannily close to the struggles around drug education/policy. Quoting from Melanie’s book:

One of the puzzles about education in Britain is that the seductive ideologies that so tenaciously grip it reached their high point during the eighties. Yet that was the very decade when Britain was governed by Mrs. Thatcher, as she then was, the most ideological Prime Minister in modern memory, and a leader, who was ostentatiously committed to root out precisely such attitudes, in education and elsewhere . . . It didn’t happen like that. The education establishment fought back with every weapon at its command. The Thatcher government found itself embroiled in a tenaciously sustained and debilitating guerrilla war in which it was outgunned and out-manoeuvered at every turn. Civil servants elsewhere may have been cowed or convinced by the Thatcherite ethos, but the Education Department was a ministry apart. Whitehall civil servants forged an astonishing alliance with educationalists to frustrate or dilute ministers aims and to substitute their own agenda wherever possible. Political will squared up to an entrenched culture and lost. The result was that, despite bringing about some improvements, the national curriculum actually made matters worse in some important ways, by institutionalising some of the worst attitudes, then giving them the force of law.

And later, when she talks about tackling academia in the context of English teaching;

But opposition to the English proposal was not confined to the formulation of Dons safely coralled within their ivory towers. It constituted instead a well developed network which had become so well integrated with the political institutions that reform had become impossible. The English teachers boasted they would subvert the reform from within, and they were correct.

In her column in the Observer on 21st September 1997 the title of the piece was ‘The Tories education policies were savaged by civil servants and academics. The same people can now scupper Blunkett’.

This article describes how the forces at play that Melanie had noticed in the Thatcher government are still in play and quite often seen to be involving the same civil servants and supporters. She says;

‘What price now David Blunkett’s determination to root out rotten practice in the class room? That central control will be used to mask the fact that there is no control. There won’t be, unless Tony Blair realises that many of the people upon whom he relies to produce education reform are the problem, not the solution, and replaces them, quickly’.

This all has a strong resonance for professionals working to counter the drug problem, and the main lever in the drugs context is so-called Harm Reduction. The practice of engaging with known users to reduce the harm they do to themselves, pending their cessation of use, is as old as drug services themselves. What is new is the extension of harm reduction ‘advice’ to all and sundry whether they are users or not, under the limp assertion that they might all need it in due course. Coupling this with a perfunctory prevention agenda – or in most cases no prevention at all – has the not-unexpected result of increasing use. This is then advanced as proof of the failure of ‘prevention’ and the need for even more ‘harm reduction’. A more honest description for this process would be ‘A Trojan Horse with legalisers hidden inside it’.

What tactics are employed by the pro drug lobby?

From Sumo to Judo – a good metaphor for what has happened to the tactics of the pro drugs lobbies. In the past they tried to make themselves big and push their opponents out of the ring, as a Sumo wrestler might. What they have now learnt is there is more to be gained by less effort if one works to use the energy of the opponent to trip them or otherwise flip them out of your path, as a judo fighter might. Thus, in Britain we currently have many people who are known to be sympathisers of pro-drug attitude insisting vociferously that ‘what we need is lots more drug education’. What they actually mean is ‘we need lots more of our kind of education about drugs and we are the people to deliver it’. Because the appropriate government and voluntary sector departments have been infiltrated there is an in-built system of control; this is of course supplemented by the degree of infiltration that is in the media. Taken together this is a potent combination of position and influence. If such sectional interests are allowed to advise and thus influence who will get money in the future then this also means that money, which is the ‘third leg’ to power, is in the hands of the same people. In December 1997 some of our European colleagues put together a bid for funding to do valuable prevention work across Europe; some of this work is proposed for Britain and for the Republic of Ireland. When the list of people reviewing the bid on behalf of European community (the funders) came to our notice it was immediately apparent that the names on it could have not been worse. People unsympathetic to prevention were in command of the key positions, able to decide who would be allowed to pass and who would be turned back.

When the National Children’s Bureau launched a new Drugs Education Forum the launch in 1996, which lasted two days, was opened by Lord Henley, one of the Education Ministers of that time. Lord Henley opened the conference by saying that he was delighted to see so many people committed to the government’s aims of discouraging drug use and of returning current users to a drug free status as soon as possible. After a few other supportive remarks he left, to return to the House. Scarcely had the doors finished swinging behind him than the next speaker stood up and said ‘Well, what ever you may think about the government strategy . . .’ a snigger rippled its way around the room and off we went on a dissection of the government’s approach and how it should be replaced with a harm reduction based approach. It was evident at this conference that all of the ‘old crowd’ who are known to be supporters of a harm reductionist approach were present, and it was also – sadly – noticeable that some of the more recent people entering the scene were being absorbed into this jolly little coterie. Department for Education health education coordinator John Ford startled some, including this writer, at the conference by delivering an apology for the Leah Betts video ‘Sorted’. He ‘explained’ that it had been put together in a hurry and that the Education Department hadn’t really had much input to it etc. etc. the broad impression was gained that it was not something with which they wished to be associated. (The video has been reviewed by this writer and is found to be generally not sensationalised; it certainly is emotional and emotive but then it is a true reflection of the feelings of the Betts family at that time). The Drug Education Forum has gone on to collect other supporters of the Harm Reduction orthodoxy; a token presence of Prevention workers is heavily outnumbered. In autumn of this year DEF’s steering Committee introduced a small but very significant change to the Mission Statement. Formerly it has expressed the aim of skilling young people “to make informed choices to resist drug misuse”. After the change the aim now is only “to make informed choices”. Resisting drug misuse is apparently not what is wanted!

The effect of all this intellectual conflict can be seen in the local government scene, not just the ‘Three W’s’ (Westminster, Whitehall and Wapping). Drug Advisory Teams (DATs) each control a number of Drug Reference Groups (DRGs) in areas roughly corresponding to Health Authority areas. There are variations in attitude about and commitment to the national strategy at all levels; the range of variance could be said to span from strong support to lip service, with outright antagonism to some aspects of the strategy. Another generalisation with some credence is that the further you get from central government the less the support for the government strategy.

Senior government officials and MPs seem strangely reluctant to contemplate that this may be happening – the word ‘conspiracy’ is an anathema (and probably pays the opposition too much credit anyway), but there has been some acceptance of the idea that a ‘confluence of thinking on several matters by otherwise disparate entities’ is having an effect. This is Kelly’s Repertory Grid in action. (See above ‘How do these individuals and group obtain and retain power?’).

What are we doing wrong?

A short answer is difficult, but will be attempted; shortcomings exist in the following areas: – not looking at the overall picture. Inadequate awareness of what is going on elsewhere in UK, in Europe, and across the world.

– dismissing the opposition as insignificant.

– inadequate evaluation of prevention (though the funders must take blame here).

– inadequate co-operation; needless competition.

– sanguine outlook; what someone once described as another AIDS – the Apathy, Ignorance and Denial Syndrome.

– the assumption that ‘someone else’ will deal with this distasteful matter.

The emergence of the NDPA some five years ago was a breakthrough in addressing these shortcomings, but its tiny funding base (until October 1996, when National Lotteries awarded NDPA its first substantial funding) severely limited its effectiveness.

None of the above shortcomings is beyond correction; that they still exist suggest that Britain’s famed ‘Dunkirk Spirit’ may yet be required, to pull us through. Unfortunately Dunkirk (in the drug scene) may have to happen before people wake up!

The particular case of the Sunday Independent

In the Autumn of 97 the Sunday Independent launched a campaign for the decriminalisation of cannabis. It did this in response to a flat rejection of this proposition both by the government in the person of Jack Straw and by the new Anti-Drugs Co-ordinator (Drugs Tsar) Keith Hellawell. It is also known that Jack Straw’s junior minister with the drugs portfolio, George Howarth has repeatedly rejected this proposition under an unequivocal three-part statement:

(a) No legalisation of cannabis

(b) No decriminalisation of cannabis, and

The last statement i.e. ‘no debate’ does not mean people’s democratic rights should be denied; in fact there has been a very voluminous exploration of law relaxation over the past 10-15 years world wide, and in Britain there has been a very heavy focus on the proposition especially over the past 5 and more years. George Howarth’s statement of ‘No debate’ simply means ‘No more government debate; we’ve heard it all before and we have reached a rational conclusion, and we don’t propose to waste any more Government time and money on a dead duck’. To say this is anything other than eminently sensible is a travesty, but then nobody could ever accuse the Sunday Independent or other pot campaigners of being sensible. Editor (at that time) Rosie Boycott announced in her opening feature on this subject that she was ‘a recovered alcoholic’ and a lapsed user of cannabis; in the normal parlance of the field Ms. Boycott would never be described as a recovered but only ‘recovering’ and her claim of ‘recovery’ would be viewed sceptically since she is still using another psychoactive drug. Whether Ms. Boycott’s drive in producing this campaign is altruistically based in her own drug experiences and her wishes for others to share them, or whether it has to do with producing a sensational initiative which may boost the flagging sales figures of the Sunday Independent must be left for the reader to judge. Currently the Sunday Independent is at the bottom of the circulation league for Sunday newspapers, and its circulation dropped some 20% between the most recent yearbook figure and the previous year. It sells around three hundred thousand copies.

On the 11th December (‘97) Sunday Independent held a one-day event in Westminster-‘a stoned throw from Parliament’. Originally put forward (to this writer and others) as a ‘balanced debate, with an equal number of speakers on both sides’ it ended up with 6 for decriminalisation, 3 against, and one who presented a commercial for more science in reviews (he was a scientist).

In the ‘pro’ side were Gianfranco dell Alba from Lista Panella, an Italian Radical Party. To roars from the crowd he described how in Italy they had pressed for a referendum on drugs, got one, lost it, and so resorted to planned civil disobedience. From Lindesmith Institute (which George Soros funds) Ms Lynn Zimmer was presented as an ‘impartial’ speaker – incredible, in that she has been recently listed as a Board Member of NORML (the National Organisation for Reform of Marijuana Laws) and more incredible in that Lindesmith’s literary output is consistently and heavily biased towards decriminalisation and legalisation of cannabis. When Zimmer took the stand all pretence of impartiality fell away.

Despite heavy promotion the hall was around one-fifth empty. Few anti-decriminalisation people bothered to attend, and no papers other than the Sunday Independent and Independent covered this sham affair. Years ago there might have been an argument for refusing to debate with legalisers, but that bridge has long since been crossed. The best than can be done is to debate factually and with dignity, and also make sure that the decision makers are aware of what is really going on.

Epilogue

Recommended reading on this subject of ‘professional sub culture’ is a paper by Professor Norman Dennis (1997) entitled Social Irresponsibility: How the Social Affairs Intelligentsia have Undermined Morality. Available from Christian Insitute, Eslington House, Eslington Terrace, Newcastle upon Tyne, NE2 4RF (Tel: 0191 281 5664). Professor Dennis is not himself a practising Christian; he was invited to present this paper at a CI conference.

With so much of the information/communication system influenced by or in the hands of libertarians and their fellow travellers, all this might seem a hopeless cause. Far from it. This path has been trodden before, and success for a prevention approach has been achieved (see this writer’s comparison paper for The Royal Holloway training, on the subject of ‘Prevention”). The opposing forces may seem awesome, like Goliath – with you as David. But remember, Goliath lost, and the reason he lost is very simple.

He got stoned.

Filed under: Prevention (Papers) :

By Jill Schlabig Williams, NIDA NOTES Contributing Writer
A multicultural version of a substance use prevention program tested in middle schools in Phoenix, Arizona, proved at least as effective as culturally targeted versions, according to recent research by Drs. Michael L. Hecht, Michelle Miller-Day, and Flavio Marsiglia and colleagues at Pennsylvania State University and Arizona State University. The NIDA-funded researchers compared a multicultural version of a drug prevention program–which included cultural values from all of the groups participating in the program–to two culture-specific programs. The latter programs are based on the hypothesis that messages matched to the student’s culture are more effective than messages that are not culture-specific.

“This is good news for the future of drug prevention in schools serving culturally diverse students,” says Dr. Hecht. “It is very difficult logistically to deliver culture-specific programs in culturally diverse schools. Multicultural programs are much easier to deliver, and now we find that they’re also as effective as culture-specific programs.”

Research has shown that students respond better to drug prevention programs when they see their culture and images of themselves represented in the prevention message. Moreover, minority youth respond favorably to programs that feature a teacher or characters from their own ethnic group.

“We know that kids need to see something of their own lives and cultures reflected in the programs,” Dr. Hecht explains. “But we wanted to test the effectiveness of multicultural prevention programs and compare their effectiveness to selectively targeted or matched interventions.

The prevention program, dubbed “keepin’ it R.E.A.L.“, is a school-based intervention targeting substance use among urban middle schoolers. Its goals are to reduce use of alcohol, cigarettes, and marijuana; promote antidrug norms and attitudes; and develop effective drug resistance decisionmaking and communication skills. Through NIDA funding, “keepin’ it R.E.A.L.” was developed, tested, and evaluated in 35 middle schools in Phoenix. Designed to reflect aspects of the adolescents’ cultures and learning styles in content and format, it includes 10 classroom lessons that promote antidrug norms and teach substance use resistance skills, life skills, risk assessment, and decisionmaking skills. The intervention was reinforced by a public service announcement radio and billboard campaign and by booster activities.

Three versions of the curriculum were created and delivered: one based on Mexican-American culture, one based on African-American and European-American culture, and a multicultural version using five lessons from each of the other two versions. The large proportion of Mexican or Mexican-American students (approximately 74 percent) in the study population contributed to the choice of Mexican-American culture for one curriculum version.

“In developing this program, we studied the process by which kids resisted drugs and used a narrative approach to teach these skills to other kids. The whole program is from youth through youth for youth,” observes Dr. Hecht. Stories of drug resistance were collected from adolescents in each ethnic group and used to write scripts for videos that were then performed and videotaped by local high school students. These 10 videotapes (5 for the Mexican-American version, 5 for the African-American/European-American version) form the core of the program. They teach resistance skills through enactments of successful drug resistance in recognizable locales, by youths similar to the students in age and ethnicity.

The lessons’ content is built on previous research on what is effective in drug prevention. In addition, researchers infused the curriculum with cultural norms and values that are predominant within certain groups–for example, the value of family to Mexican Americans, respect to African Americans, and individualism to European Americans. Affirming these values can help students use familiar behaviors and attitudes to resist drugs. The curriculum emphasizes family and cultural norms that discourage behaviors like drug use, equipping students with the skills to tap their social support systems to effectively resist drug offers.

“We don’t generalize about the cultures. We give them stories. We show them scenarios that come from their mouths. It’s always a specific situation, with no moralizing,” says Dr. Hecht.

In the fall of 1998, 25 Phoenix middle schools were randomly assigned to one of the three versions of the curriculum, and 10 schools were assigned to the control condition. Schools in the control condition received other drug prevention programs already planned for those schools, including a statewide antitobacco campaign. The research team administered a preintervention survey to all participants and then implemented the curriculum in 7th-grade classes in the 25 treatment schools. Followup surveys were conducted 2 months, 8 months, and 14 months after curriculum implementation. Surveys included questions on demographics; recent alcohol, cigarette, and marijuana use; use of resistance strategies learned in the program; antidrug norms; and intentions to accept substances. The final sample included 6,035 students, of whom 55 percent were Mexican American, 17 percent were non-Hispanic white, 9 percent were African American, and 19 percent were of other Latino or multiethnic Latino origin.

The results showed that the interventions were significantly more effective than the control condition, with statistically significant effects on the use of gateway drugs (alcohol, tobacco, and marijuana) and on norms, attitudes, and use of resistance strategies. Students participating in any of the three test versions reported better behavioral and psychosocial outcomes related to substance use than did the control students. Although use of alcohol, cigarettes, and marijuana increased over time for both sets of students, the rate of increase was significantly less for students who participated in the intervention. Those students also reported adopting more resistance strategies.

When researchers compared the three versions of the curriculum against the control group, they found that the Mexican-American and multicultural versions of the curriculum had far more significant effects over the course of the study. Students who participated in the multicultural curriculum had, on average, the smallest increases in use of alcohol and marijuana from pretest to final posttest, and the second-smallest increase in use of cigarettes. The Mexican-American and multicultural versions of the program had positive effects on several of the psychosocial outcomes studied, including intent to refuse substance offers and antidrug attitudes for themselves and their friends.

To determine if matching program content to a student’s ethnicity enhanced program outcomes, the researchers used the students’ ethnic self-labeling to categorize them as matched to the curriculum they received, mismatched, or mixed (i.e., various ethnicities receiving the multicultural program). Very few significant differences in program effectiveness emerged; therefore, the researchers found little support for the cultural matching hypothesis.

“We created an intervention that worked, and we found that the multicultural version worked as well as–or better than–the culture-specific versions,” says Dr. Hecht. “We found that it is not necessary to ethnically segregate students into narrowly tailored programs to achieve effectiveness. Rather, it is critical to incorporate a representative level of relevant cultural elements.”

The Center for Substance Abuse Prevention has recently added the “keepin’ it R.E.A.L.” curriculum to its National Registry for Effective Prevention Programs, recognizing it as an effective program and making it available to middle schools across the country for implementation. In the future, Dr. Hecht and his colleagues plan to study the effectiveness of offering intervention programs to students as early as 5th grade. They also plan to look at the process of acculturation, examining how Mexican-American youth make the transition to a new culture and language, how that process puts them at risk for increased drug use, and how to combat those risks.

“This is one of the first studies to compare multicultural and culturally specific substance abuse prevention approaches,” says Dr. Aria Davis Crump of NIDA’s Division of Epidemiology, Services and Prevention Research. “This research highlights the importance of continuing efforts to better understand how to effectively provide prevention services in a culturally diverse society.”

Source

Hecht, M.L., et al. Cultural grounding in substance use prevention: An evaluation of the Drug Resistance Strategies intervention. Prevention Science, in press

Filed under: Prevention (Papers) :

By NIDA Director
Nora D. Volkow, M.D.
Each year, substance abuse and addiction contribute to the death of more than 120,000 Americans and cost taxpayers nearly $300 billion in preventable health care, law enforcement, crime, and other costs, according to the U.S. Department of Health and Human Services. For NIDA, the key word in this assessment is ‘preventable.’ The best approach to reducing the tremendous toll substance abuse exacts from individuals, families, and communities is to prevent the damage before it occurs.

The science of drug abuse prevention is still in its early stages. Yet it has already made great strides. Twenty-five years ago, drug abuse prevention programs. where they existed, were based primarily on ideology and good intentions, Today, we have effective prevention programs anchored solidly in a base of empirical knowledge about fundamental factors that can promote or reduce substance abuse. These research-based programs have demonstrated that we can modify individual family, peer, and community factors that we know to be risk factors for drug abuse and, in this way, steer many young people away from abusing drugs. Two NIDA-sponsored National Prevention Conferences and a research-based guide on preventing drug abuse by children and adolescents synthesize key findings, detail fundamental prevention principles, and describe programs that have successfully applied these principles.

While recognizing these accomplishments. we are also compelled to do better to protect our children and adolescents. Buoyed by our successes and encouraged by our ongoing research, we know that science can do more to make drug abuse prevention more effective. The most urgent need is to make better use of what we already know. Recent research indicates that only one in seven of the Nation’s public and private schools offers prevention programs that incorporate proven elements and deliver them in the most effective way (see “Few Middle Schools Use Proven Prevention Programs’ NIDA NOTES, Vol. 17, No. 6). These findings underscore the need for additional research focused on accelerating the faithful adoption and application of research-based prevention approaches in communities across the Nation.

The difficulties inherent in translating precisely structured research- based programs into the culture and operations of diverse communities require that the scientists who develop programs and the practitioners who deliver them, work together effectively to improve drug abuse prevention. Toward this end. NIDA has been promoting a working alliance between research and practice to identify programmatic, organizational, and local circumstances that foster or forestall the adoption and effective implementation of research-based programs by communities, schools, and service delivery organizations. A primary goal of this partnership is improved delivery of currently available interventions.

Our recently launched National Prevention Research Initiative (NPRI) has fast-forwarded this research practice partnership with four large-scale community trials of programs that have been shown to prevent drug abuse on a smaller scale, In these trials, scientists and practitioners are delivering a research-tested intervention to populations in urban, suburban and rural sites. Each trial examines specific implementation factors, such as how different training methods affect a program’s delivery or how accurately the staff of a community service program delivers an intervention to different groups in various settings. Results of these studies should reveal systemic. structural and other barriers to implementation and strategies to overcome these barriers. Ultimately, this information will enable many more communities to adopt research-based programs and use them effectively to prevent drug use. for more information on NPRI. see NIDA National Prevention Research Initiative Begins Broad Range of Studies,” p. 5.)

Blending the knowledge gained from research with the realities of the community practitioner should do more than accelerate the adoption of current prevention programs. It also should foster the development and testing of the next generation of prevention programs. Data from our field studies will inform the new prevention approaches that flow from NPRI’s expanded basic and transdisciplinary prevention research and make them more feasible Thus, tomorrow’s prevention programs will more closely reflect the practical circumstances of the practitioners, the community settings in which programs are delivered, and the children, youths, and families who will take part in them.

Because our schools play such a central role in preventing drug abuse. NIDA is particularly interested in bridging gaps between the researchers and practitioners who develop and deliver drug abuse prevention program in our Nation’s public and private schools. In April, NIDA took an important step toward this goal by bringing together educators, researchers, and representatives of Federal and State funding agencies to discuss school-based prevention at a 2-day meeting in Bethesda, Maryland. More than 100 meeting participants explored the many challenges to and opportunities for conducting prevention research in schools and in integrating research-based programs into the school curricula and operating environment. Meeting these challenges and seizing these opportunities will be key to improving the feasibility and effectiveness of school prevention programs and increasing their impact on young peoples’ drug abuse.

The final step in getting effective approaches working in the community is communicating the latest scientific findings on preventing drug abuse to those who are in a position to apply them. To accomplish this, we are building on the success of our first research-based guide to preventing drug abuse among children and adolescents. An updated version of the guide synthesizes the significant advances in prevention science during the last 5 years and makes them accessible to parents, teachers, and community leaders.

Our National Prevention Research Initiative, our conferences and meetings. and our dissemination of the latest prevention information demonstrate NIDA’s strong commitment to closing the gaps between prevention research and practice This blending of science-based knowledge with community realities will result in wider adoption of more effective programs and major progress toward the ultimate goal: that far fewer of our Nation’s children and adolescents become snared in the destructive web of drug addiction.

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Filed under: Prevention (Papers) :

By Peter Stoker, Director, National Drug Prevention Alliance
to the ECAD 10th Anniversary Mayors’ Conference Stockholm
May 15, 2003

‘Creating the Alternatives – Policy and Prevention’

My links with ECAD have been partly with Tomas, but also in my own country with Peter Rigby – so sadly lost to us all last year. In giving this paper I would like to record my personal gratitude to Peter, and all that he did through ECAD in the struggle for sanity, in this sometimes crazy world in which we find ourselves
I have worked in this field for over 15 years; in Counselling, Treatment, Justice, Education and – not least – in Prevention. I have visited or dialogued with drug programmes and agencies in more than 20 countries and NDPA continues to exchange information and good practice with many more, through our membership of organisations like Drug Watch International, the Drug Prevention Network of the Americas, and the Institute for Global Drug Policy. All this has woken me up to the ‘World of Alternatives’, and this morning I hope to bring you some insight into practical, workable Alternatives you could apply in your own city.
Alternatives. Creating the Alternatives. It is said that we live in a sometimes crazy world, and one sign of this occasional craziness is when we give unjustified hearing to people who offer ‘alternatives’ to our present social and legal policies which may suit them very well, but which would be deeply dangerous to our children and to our society. Maybe we should blame ourselves for this; perhaps the Crazy Alternative might not sound so attractive if we became more effective in making people hear the Sane Alternative.
As we are in Scandinavia, let’s consider Hans-Christian Andersen’s story of the Emperor’s New Clothes – in which it took the innocence of a child to open the eyes of adults, an internationally-known metaphor describing blindness to the truth. An affliction taken to new heights when it comes to drug abuse.
Society obviously differs between different countries, but in western society we can see some broadly similar patterns. Let me describe what we see in the UK. Our society is one in which behaviour is conditioned by the conspicuous pursuit of consumption, by the demand for rapid gratification (‘Give me pleasure NOW); by an environment in which people march for of their rights but never for their responsibilities, by the idea that we have ‘ a right to be happy’, by the elevation of the Self above the Society (Me first) – and certainly by the elevation of youth, above all. [Ref 1] When you take all this into account, it is easy to see how drugs can have assumed a new prominence.
We also live in a society where ‘Political Correctness’ shackles our thinking, so that, for example, I can no longer call myself ‘able-bodied’ but must instead call myself ‘a person who is non-disabled’. This is just one more example of how clever use of words can confuse the mind, in the same way that the Tailor confused the Emperor – and the way in which the Emperor’s subjects went along with the deception.
This is the fertile ground in which drug-abuse grows, and one of the cleverest tactics of the pro-drug lobby is to convince you that there is no alternative – we must surrender to the inevitable; accept drug use, legalise it, and keep the harm to a minimum – for the users, that is!
We have allowed ourselves to be seduced by clever words and convoluted arguments – and a major part of this process is that the sane counter-argument to this insane dialogue gets only a tiny proportion of the media’s attention. If we were to apply the ‘Emperor’s Clothes’ logic that is advanced for drug abuse to other social behaviours there would be a national, if not international outcry.
Let’s take a fictitious example. Suppose you were designing a new social policy concerning rape. Would you think it enough to just provide services for the victim after the attack? Surely not. How about some Harm Reduction advice for the rapist? They have rights too, you know. After all, maybe it was just ‘recreational rape’ – and the rapist’s lawyer says he is ‘an otherwise law-abiding person’. Maybe if we relaxed the law this would improve things – and look at all the police time we would save! ……It is at times like this that I envy that child who showed us that the Emperor had no clothes. I envy him because his story ended with the community recognising the truth and common sense of what he said.
I have enough faith in human behaviour to believe that we will achieve this condition of sanity with drugs policy in the end – but I am also sure that it will not be achieved through apathy. Ultimately, we get the society we deserve. That is why the commitment all of you are showing through your support of ECAD – and through your actions which flow from that – is so very important. The question then is, how can we create saner alternatives?
My eminent fellow-speakers this morning will be telling you about their successes in treatment and rehabilitation. I have visited several of them in my travels, including Delancy Street – whose speaking slot I have filled today – and I can testify to what marvellous projects they are. They do an enormously valuable job, and deserve more support. But we don’t beat problems only by treating the casualties – and the sheer numbers of those with problems mean we have to do something else as well. Just consider the numbers. If we take the four major projects presenting here, and add in other large projects such as Betel in Spain, Delancy street in America, and Synanon in Germany, their combined throughput is probably something under 10,000 people a year, and yet it is said that in Britain alone we have more than 250,000 addicts. One thing is sure; treatment centres are unlikely to become redundant in our lifetime or our children’s lifetime.
Another concern is that whilst the projects presenting here today are models of good practice, not everybody matches these standards. A survey of British treatment projects on behalf of the Big Issue magazine found that most drugs other than heroin were rarely addressed by treatment centres, and that for heroin there was often only the ‘new solution’ of prescribing methadone. Big Issue found that far from weaning people off drugs, methadone prescriptions were supporting 33% of addicts for 5 years or more and 16% for 10 years or more, with both percentages rising. Moreover, 80% of methadone ‘clients’ were also using street drugs, with 44% of those on prescribed methadone using heroin on a daily basis. – and up to 50% of them still commit crimes.
If treatment and rehabilitation alone cannot turn the tide, what else is there? Let’s go back for a minute to that imaginary social policy we were looking at; the policy for rape. If we agree that rape is a bad thing; bad not just for the victim, but bad for the rapist and bad for society as a whole, our policy would not confine itself to just reacting to it, and treating the casualties. Our core policy would be to prevent it.
Rapes still happen, but we do not take this as evidence that the prevention of rape should be abandoned, anymore than we seek to dissolve driving schools because we still suffer car crashes. We take a rational view that if we were to be fatalistic about rape, there would be a lot more of it around. So, instead of surrendering, we work harder at improving our rape prevention technology.
I want however to qualify one point in my remarks: there is actually a limited scope for Harm Reduction – provided you deliver it to the right people in the right setting. It was properly defined and limited as to its scope in Britain’s first National Drug Strategy in 1995 [Ref2], a definition also enshrined in the 1998 strategy [Ref 3] which Keith Hellawell – whom you heard speaking so eloquently yesterday – designed and introduced. The ‘limit of scope’ is to use it only with people you know are users, on a one-to-one basis, as part of the treatment process; that is, whilst the user is moving towards cessation. Drug workers like myself have always practised this limited scope – indeed one could argue that there is a moral obligation to do so. But this practice only relates to a fraction of our population – it has nothing to do with the hijacked version of Harm Reduction [Ref 4] which is applied to the whole population, and which asserts that:
• You cannot prevent drug use
• You are inhibiting personal rights if you try
• Everyone may use at some time, so
• Guidance for everyone on how to use is the key, and
• Policy should be confined to reducing harm
This is a very cunning alternative – for if you introduce it, and then find that use increases, its proposers will say this proves that Prevention is useless and therefore Harm Reduction is clearly the right path to follow. A self-fulfilling prophecy. (The story of how this came about is too long to repeat here).
The truth is that in the past we have rarely tried to prevent, in the true sense of the word, that is, working ‘pre the event’. This is the Alternative on which I want to focus for the remainder of this paper, and in the process to give you some useful Alternatives to consider, from the examples I’ve seen around the world.
Let’s start with a piece of Prevention history. A common claim by the pro drug lobby is that “the Just Say No approach doesn’t work”. This has been repeated so many times that it has become a mantra – a classic example of the Orwellian principle; that if you repeat a lie often enough it becomes perceived as the truth. Saying that Just Say No “doesn’t work” is simply another way for the pro-drug lobby to claim that “the War on Drugs is failing”. Another cliche. Another lie.
Very few members of the general public know that in the so-called ‘War on Drugs’ a victory was recorded every year for 12 years, and that over those 12 years drug abuse was reduced by over 60 per cent – an astonishing public health success by any standards. [Ref 5] Even if they do know that, they are unlikely to know that one particular prevention programme was pre-eminent throughout the period. The name of the country? America. And the name of the programme? Just say No.
The Just Say No programme was much more than the chanting of slogans. It was a comprehensive personal, social and health education programme, backed up by trained volunteers and professionals. I have copies of their manuals and I can assure you of that. [Ref 6] But we can now see that a major factor in its success at that time – between 1980 and 1992 – indeed perhaps the main factor, was the culture of the society in which it was operating.
Culture is vital as the deciding factor in behaviour. And the key cultural force that swung into action to generate those successful years was not the Ministry of Education, or the Ministry of Health, or the Police and Courts – it was the community. Ordinary communities like yours, in cities across America. Parents were the main activists, acting just as that little boy did when he saw the Emperor – they exposed the truth, which the professionals had been too blinded by dogma to see. The parents shamed the professionals into producing truly preventive programmes – with the splendid results I have just stated. And those proven techniques are still available to you today – if your city only has the political will to use them.
America may have been one of the first to properly tackle prevention, but it was by no means the only one. Let’s take a quick trip around the world and see some of the other things that have happened in this context: Most countries have good and bad aspects, so in the time available this will have to be a simplified review.
Poland: The Warsaw Institute has seeded many good prevention programmes.
Germany: More than 30 of our Teenex camps, plus parent skills trainings.
Portugal: Projecto Vida and others have executed many good projects, including over 35 Teenex camps..
Belarus: Is keen to co-operate with UK on prevention.
Kazan: Has sent young people to UK Teenex prevention camps. Keen to do more.
Bulgaria: Excellent community structures are now addressing drug prevention and other services. Burgas, on the Black Sea coast, is an ECAD member and is one of the cities in which we have just started work.
Italy: Has changed to more preventive policies. Hosts the World Prevention conference 2003 – in Rome.
Belgium: Exemplary work has been initiated in the Eastern cantons, over many years.
Sweden: Has drug use levels far below the rest of Europe, largely from inducing a culture which discourages drug abuse.
Latin America: Countries like Brazil and Peru have vigorous prevention programmes. The next world conference of the International Task Force on Strategic Drug Policy will be in Argentina, next month.
Spain: Have just invited UK to co-operate on a primary school prevention programme.
Australia: Birthplace of two wonderful prevention programmes – Life Education Centres (now operating in several countries) and the Kangaroo Creek Gang.
New Zealand: an oasis of prevention – make sure you get a copy of ‘The Great Brain Robbery’ – one of the best advisory books for non-expert parents and community officials I have ever seen.
America: so much has been and is being done to prevent drug abuse. Check out the websites at NIDA and CSAP, which you can reach via the links on our site. I would also like to say a word at this point about a great programme, which has so many daggers sticking out of its back it looks like a porcupine. That programme is DARE. It is precisely because it has been so successful, so widely adopted, that it has become a constant target for the pro-drug lobby and the professionally jealous. Like everything else, it has had its faults in the past, but it has addressed many of these and is now launching a strengthened curriculum. Its unique involvement of police officers in a sustained relationship with schools – not just a quick visit – has many benefits in and beyond prevention. Already seven police forces in UK are using it, with more coming.
United Nations: Despite all our worries about the money and heavy pressure applied to it, the UN came up with the right result in its recent 46th meeting of its Commission on Narcotic Drugs – ruling out any weakening of drug laws. I am sure that the 1.3 million signatures collected by many groups – including ourselves – under the leadership of Hassela Nordic Network had a big influence, and I would like to add my congratulations to HNN for this tactical masterpiece.
Plenty of good news, then. But before you assume everything’s solved, I must emphasise that the well-financed and highly-resourced machinery of the pro drug lobby is having a significant and growing effect…

Holland: Their story is well documented, liberalization continues, despite polls showing that 70% of Dutch citizens want the lax drug laws rescinded.
Switzerland: We hear glowing reports of their heroin experiments, but this is hardly surprising when we learn that the head of the experiments is also the head of the Swiss branch of the International Anti-prohibition League, a major player in legalisation.
United Kingdom: We have been subjected to enormous pressure, with international backing for the pro-drug lobby, and we are almost certainly about to have cannabis re-classified to a lower class of legal penalty – ridiculously demoted to rank alongside steroids instead of alongside amphetamines. This is despite a wide range of new research against cannabis – and no new science in favour of it. But the good news is that both the Select Committee [Ref 7] and the Advisory Council to the Government have turned their back on all the dishonest argument, and have said they will not recommend legalisation or decriminalization – (and, for good measure, they have said the same thing about ecstasy). They have also exposed the ‘medical cannabis’ argument by inviting scientific trials, but ruling out any use of ‘cannabis as grown’ (because if its extreme variability and pharmacological unreliability as well as undesireable side-effects) and they also rule out any use of smoking as a delivery method. Their stated intention is to test extracts of cannabis, not smoked but ingested by normal medical means, and not to be of psychoactive effect. So, you don’t smoke it and you don’t get high – not at all what the pot lobby had in mind!
East Europe: As I have said already, there are good outcrops of prevention, but this region is held to ransom by pro-drug influences, most notably George Soros, who has put tens of millions of dollars worldwide into weakening drug laws.
Australia: When South Australia first decriminalized cannabis possession there was a significant increase in use by young people, compared to neighbouring states. Sadly, this experience has not deterred the liberalisers, and worse is to come. Western Australia is now considering following suit.
Canada: Policy is deteriorating in the same way as Australia.
From time to time I encounter drug liberals who assert that there is no proof of prevention. I usually refer them to the research work of Nancy Tobler; [Ref 8] she analysed no less than 240 successful prevention programmes. 240. And still they come, with their cries that there is no evidence. And yet if you press them on the subject, the more honest of them will admit that there is little or no evidence of effectiveness of Harm Reduction. Such evidence as there is can often be damning, as is the case with Baltimore in the USA; this city has one of the biggest needle exchange and condom issue schemes in the USA and yet it has ended up with the highest levels of drug abuse, the highest level of HIV infection and is amongst the highest levels of addiction. Harm Reduction may be having an effect in Baltimore, but it is not the effect that the public were promised. Coming back to Nancy Tobler; she looked at the 240 programmes and found 140 that had enough common factors to allow her to conduct what is called a meta-analysis. From this she was able to indicate the components of the more successful programmes. Another advanced researcher, Bonnie Benard, who is now with NIDA – the National Institute on Drug Abuse – has repeated the same kind of comparative exercise over many years, and from this has produced a set of “Criteria for Effective Prevention” which are a classic, timeless in their value. [Ref 9] A summary of Bonnie’s criteria is included in the written paper supporting this talk.
If I had to choose just one key criterion from what I have seen in all these countries, it would be Culture. Localised programmes will be effective locally, and programmes concentrating on one topic – such as self-esteem or drug awareness – may be effective in those areas, but not much elsewhere. If you are intent on generating a healthier environment in your city then you need to look to generating a health-oriented, prevention-oriented culture right across your community – in the home, in the school, in the workplace, in the youth organization, in the leisure areas, in the shops, in the churches and temples – and certainly in the media.
Culture can be artificially distorted, at least in the short term – which is where the media can be particularly effective, or particularly damaging. But cultural changes generally are slower to happen, and require steady application of energy. If that effort is sustained then change will occur, like the dripping of water that wears away the stone. The drug liberals have learnt this truth – we must learn it too, along with another truth.- that we sometimes forget that today has not always been . We did not always have the drug culture and the society culture we have now. It was changed before, by others. It follows that we can change it again.
What can an ordinary city do to produce a more healthy culture? One of the most comprehensive examples I have seen of this is “Project Revitalisation” in Vallejo, California. [Ref 10] The project is designed to tackle drugs, alcohol and crime in the city’s worst areas. The heart of the project is a strong community partnership: – the Vallejo Fighting Back partnership, Vallejo Code Enforcement, Vallejo Chamber of Commerce, Vallejo Police Department, Vallejo Neighbourhood Housing, California Employment Department, the Private Industry Council, and many neighbourhood associations. It works to integrate neighbourhood revitalisation, alcohol and other drug policy, neighbourhood safety, job-training, and co-ordination of human services into a comprehensive effort. The project’s goals are to sort out and regularize the jumble of disorganized buildings and facilities, regenerating the neighbourhood; to reduce crime, and foster safety and quality of life for the residents of these deteriorating, crime-ridden neighbourhoods.
Project Revitalisation is based on four principles:
• The physical make-up of a community has an important influence on its vulnerability to crime. This is equivalent to the very successful “Broken Windows” project run in New York [Ref 11]
• Neighbourhoods where residents have commitment and interest in improving their area can influence the level of crime
• Everybody, individuals and families, must personally gain from the project. You cannot expect people drowning in problems such as unemployment, addiction, lack of child care and other human service shortages to be interested in improving their neighbourhoods
• problems with alcohol and other drugs contribute to neighbourhood deterioration and must be specifically addressed.
In a five phase process, Project Revitalisation moves from initial assessment to detailed assessment, then to initial ‘pilot’ interventions before full implementation. The final phase is to reinforce the new stability of the neighbourhood by establishing permanent neighbourhood groups.
First reports of results from the project show encouraging improvements; there has been a reduction in police call-outs and an improvement in the perception of safety by residents – this is a very important feature in my own country, where fear of crime is often as crippling as crime itself.
The efforts to reduce illegal drugs are probably well understood already; particular alcohol policies that Vallejo introduced included:
• ‘Conditional use’ (trial) permits for regulation of new alcohol outlets.
• Improved ordinances to regulate existing outlets.
• An ordinance for youth parties, to reduce non-commercial access of alcohol by young people
• A social nuisance ordinance to hold property owners accountable for standards of building maintenance and for the conduct of their residents
• A rental property inspection ordinance
Vallejo is a very comprehensive scheme but I’m sure you will agree that there is no ‘rocket science’ in what they are doing. Their deliberately steady progress, involving all the elements of the community at each stage, is reminiscent of the excellent work done by Dr Ernst Servais [Ref 12] in the Eastern cantons of Belgium. Both projects recognised that unless you carry the community with you at each stage, the effect of your labours is likely to be short-lived.
In summary, then, what Alternative do we have? What tools do we have in our toolbox? We could list these under three simple headings;
• Before drug use
• Early stages of drug use, and
• Problematic stages of drug use
Before:
Culture. Prevention. Education. Parenting. Big Brothers and Sisters. Peer-group prevention. Policing for prevention. Media. Spiritual aspects. Workplaces. Sports (including FIT technology). Arts. Music.
Early stages:
Intervention. Counselling. Befriending. Harm reduction. Policing. Diversion (Alternatives). Containment.
Problematic stages:
Primary care. Treatment. Harm reduction. Justice. Drug courts. Restorative justice. Probation. Prison-based rehab treatment. Halfway houses. After-care. Relapse prevention.
Encompassing many of these initiatives, one brand new and usefully comprehensive addition to NDPA’s library has been the publication ‘Blueprint for a Drug-Free Future’ [Ref 13] by the Hudson Institute, USA.
Money – as always – comes into it. And because treatment is easier for accountants to count, it has traditionally tended to get much more of the available funding than other services. In economic terms, however, prevention gives a better return; even using conservative figures, prevention can be seen to give a payback of $6 for every dollar spent, [Ref 14] compared to only $3 for every dollar spent on treatment.
How might we inter-relate these services? Here is my model for doing that:
With the overall aim of a healthy society, the strategy relevant to the majority of the population has to be prevention. This does not mean that you have to accept anything in the name of prevention, or preventive education. You have every right to ask questions as to what a project is specifically aiming to achieve – and demand evaluations to make sure you get what you were promised.
For those who start to get involved – and they are still a minority – it is probably enough to expose them to prevention processes which they may well not have experienced before. Those who continue to stay involved will need more intervention effort, maybe even some form of treatment, but the outcome should still be that when they cease using this is affirmed by prevention processes. The problematic users are the ones we hear about most, but they are almost certainly only a few percent of your population. This whole structure needs to be buttressed by firm but fair legal and justice systems which firstly deter, then intervene, and – above all – correct aberrant behaviour. A justice system does not have to be confined to punishment, indeed I would argue that such a system is likely to be counter-productive; it should be a sensitive mix of punishment, retribution, restoration and rehabilitation.
CONCLUSIONS:
• There is no one programme around that does it all.
• What works for one person very well will not work at all for another .
• We need to see all of our services – prevention, education, intervention, treatment and so on as part of a continuous whole – and apply them holistically.
• We should not be afraid of having a variety of initiatives, but we should make sure that they are all inter-related.
• Don’t rush it, and don’t tamper with bits of the problem. This is like playing with the ecology – and will probably be equally disastrous.
• Always monitor and evaluate for process and outcome.
• Don’t be afraid to trust your gut feeling. If you have clear goals, then something which feels bad probably is bad.
• Don’t try to be an expert, but know where the ‘experts’ live – and in choosing them, be careful to check their background and agenda .
There is a great deal that you can do in managing a team of experts by asking some simple questions, such as: What are we trying to achieve? How are we trying to achieve it? What is it for? Is everything we are doing pointing in the same direction – if not, why not?
And remember – if one of these ‘experts’ offers you a wonderful new set of clothes, fit for an Emperor – get rid of him!
REFERENCES:
[up] 1. Stoker, P: Moralising, demoralizing .. the fight for Personal and Social Education. 2000. NDPA.
[up] 2. UK Government: Tackling Drugs Together. UK Drug Strategy 1995. HMSO.
[up] 3. UK Government: Tackling Drugs to Build a Better Britain. 1998. HMSO.
[up] 4. Stoker, P: The History of Harm Reduction. 2001 NDPA.
[up] 5. US Biennial National Household Surveys, correlated with Michigan Schools System. (Ongoing).
[up] 6. Just Say No International. Just Say No Club Book/Teen Leader Guide.1989. Walnut Creek, CA USA.
[up] 7. UK Home Affairs Select Committee. The Government’s Drug Policy – Is it working?. 2002. HMSO.
[up] 8. Tobler, N. Meta-analysis of 143 adolescent drug prevention programs. 1986. Journal of Drug Issues.
[up] 9. Benard, B. Characteristics of Effective Prevention Programs. 1987 acquisition. (Contact NIDA, USA).
[up] 10. Sparks, M. Project Revitalisation – Vallejo, California. 1998. Prevention Pipeline (NIDA).
[up] 11. Kelling, G. L., Coles C. M. Fixing Broken Windows. 1997. pub Touchstone, NY USA.
[up] 12. Servais, E. Before it’s too late. 1991. SPZ-ASL, Schnellewindgasse 2, B-4700, Eupen, Belgium.
[up] 13. McGarrell, E. F., Hutchens, J.D. Blueprint for a Drug-Free Future. 2003. Hudson Institute, Indianna.
[up] 14. Masi, D. A. Designing Employee Assistance Programs. 1984. Published by Amacom.
NDPA, P O Box 594, Slough, SL1 1AA, UK. Tel/Fax: +44 (1753) 677917.
Email: ndpa@drugprevent.org.uk
website: www.drugprevent.org.uk
Attachment to Peter Stoker paper to ECAD Conference, May 03,Stockholm
CHARACTERISTICS OF EFFECTIVE PREVENTION
By Bonnie Benard (With annotations by Peter Stoker to relate to the UK scene)
PROGRAMME COMPREHENSIVENESS/INTENSITY
A. Multiplicity: the causes of drug/alcohol abuse are multiple: personality, environmental, behavioural (Kandel, Logan, 1984; Hawkins et al, 1951). Programmes tackling only one area usually fail. You should target multiple systems (youth, families, schools, community, workplace, media, etc). Also use multiple strategies (information, lifestyles, positive alternatives, community policies) (Botvin, 1982).
B. Target whole community. School based programmes benefit less than community based approaches.
C. Target all youth. not just “high rise for prevention. Adolescence is seen to be a high risk time (for all youth in terms of health compromising behaviour. Labelling ‘high risk’ youth can provoke stigmatisation and lead to self fulfilling prophecies. There is however an argument for defining ‘high risk’ communities where an additional resource over and above the general prevention effort could be justified.
D. Build drug prevention into general health promotion. Drug abuse has been found by several (Lofquist, 1993) to be part of a complex pattern of interrelated factors e.g. delinquency, truancy, school failure, precocious sexuality, which share common antecedents.
E. Start early and keep going! Even in infancy there are influences in later behaviour. Developmental difficulties by age 3 are difficult to overcome (Burton White). Here it is of course relevant to mention Trevor Williams, Noreen Wetton and Alysoun Moon of the Southampton University team who have demonstrated so graphically in their “Jugs and Herrings” research paper that primary age children are not blissfully ignorant of drugs and alcohol. Prevention programmes starting from what children actually know are essential. Many secondary schools still seem to regard Years 11 and 12 as the age at which discussion of drugs or indeed sexuality) should be facilitated. Stable doors and horses come to mind!
F. Adequate quantity. ‘One shot prevention efforts do not work (Kumpfer, 1988) There must be a substantial number of interventions, each of a substantial duration Project DARE (Drug Abuse Resistance Education) initiated by Los Angeles Police and now in several other states delivers no less than seventeen onehour lessons to any given year and this is only part of the school programme.
G. Integrate family/classroom/school/community life. This is easier to say than do, but where it has happened results have been enhanced.
H Supportive environment, empowerment. Where young people are encouraged to participate and take responsibility their behavioural outcomes are improved. In Britain now peer education methods proven elsewhere are being piloted.
PROGRAMME STRATEGIES
J. Knowledge/Attitudes/Behaviour. Address these as a set, i.e. each must be directly tackled rather than assuming one will flow from another. The behavioural component is in part addressed by social skills development, but also supported by positive reinforcement activities drug free social/sporting events, commendations (preferably with something for everyone), media coverage, etc. Research suggests that Social Learning Theory (Bandura, 1977) produces some of the most profound improvements.
K. Drug specific curriculum. Affective education programmes that had not specifically covered drugs (including alcohol) were found unsuccessful, even though they addressed knowledge, attitudes and lifeskills.
L. Gateway drugs. So called because people now using heavy end drugs almost always started on these. Gateway drugs can be tobacco, alcohol and cannabis or, these days in Britain, even heroin! Concentration on prevention of these is therefore likely to prevent use of all substances. British research by MORI (Parents against Tobacco, 1990), showed that of youth who smoked tobacco 50% had also tried an illegal drug compared with only 2% of those who did not smoke tobacco. It should be particularly noted that cannabis is far from harmless: physical, mental and social damage is now being increasingly accepted as a reality.
M. Salient material. Whatever is used needs to identify with the audience, including:
• Ethnic/cultural sensitivity
• Appeal to youth interests
• Short term outcomes to be emphasised as important to youth as well as long term
• Appealing graphics and appropriate language, readability
• Appropriate to real age/reading age a key factor:
In a survey of 3,700,000 young American children, 25% of 9 year olds felt ‘some’ to ‘a lot’ of peer pressure to try drugs or alcohol (Weekly Reader, 1987).
N. Alternatives. Activities have to be plausible, be more highly valued than the health-compromising behaviour. Too often these alternatives are poorly thought through.
P. Lifeskills. Development of these will be of wider benefit than drug prevention. Included will be:- Communication, Problem Solving, Decision Making, Critical Thinking, Assertiveness, Peer Pressure Reversal, Peer Selection, Low Risk Choice Making, Self Improvement, Stress Reduction and Consumer Awareness (Botvin, 1985).
Choosing your friends has been found in some research to be more effective than resisting the peer pressure of said friends. Consumer awareness is a ‘companion’ to resisting peer structure, i.e. resisting media pressure.
Q. Training prevention workers. For the school setting the greater emphasis on experiential and interactive work requires teacher training to extend into youth work skills. Community development skills are valuable in taking school initiatives into the community. Imported ‘prestige’ role models are all very well, but good results have been achieved with parents, peers, teachers, or outside agency workers.
R. Community norms. Consistency of policies throughout schools, families and communities can greatly enhance impact.
S. Alcohol norms. Because of its dual status as a beverage and as an culturally accepted drug, alcohol is problematic for prevention. However, heart disease and tobacco prevention programmes have shown that societal norms can be changed.
T. Improve schooling! Listed here as a target because of its important correlation with healthy lifestyle. Within the current British economic and academic climate the most realistic hope may lie with co operative learning, see the TRIBES program for example.
U. Change Society. Don’t just stop with improving schools: add your voices to pressure for improvement in employment. housing, recreation and self development. (See ‘Project Revitalisation’ in Vallejo, California, for example). It is naive to suppose that prevention can take place in a political vacuum. Jessop recognises that failing to acknowledge the need for macro environmental improvement while at the same time placing the responsibility for health solely with the individual is tantamount to ‘blaming the victim’.
THE PLANNING PROCESS
V. Design, implementation, evaluation. Evaluations have generally concentrated on outcomes rather than the quality of design. However, implementation is as much dependent on engaging all sectors of the community (be it a school. a workplace, or a town) as it is on quality of design. Evaluation should therefore measure process as well as outcome.
W. Goal setting. Unrealistic or immeasurable goals help no one. It is important to set not only long4erm outcome goals (for prevention is long term) but also “process goals” such as increased involvement of parents and community, academic success, increased student teacher interaction. and so on.
X. Evaluation and amendment. Prevention workers have been criticized for giving too little attention to this area., the crushing shortage of funds has much to do with it (in America the ratio of funding between interdiction policy and prevention is about 200: 1). This lack of emphasis on evaluation has been the Achilles heel which pro drug campaigners have gleefully attacked. Effective evaluations have been those including longitudinal design, multiple measures of process as well as outcome (Tobler, 1986), and cost benefit analysis (CBA). CBA is perhaps the greatest marketing tool prevention has; where CBA has been applied substantial cost effectiveness has been demonstrated.

Bonnie Benard can be contacted at NIDA, the National Institute on Drug Abuse, 6001 Executive Boulevard, Bethesda,MD 20892-9561, or info@health.org

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By Alberto Carosa
A leading Italian journalist and media expert, who presented a seminal paper
at the HNN conference in Visby in May 2001.Rome. The recent Fifth Global Conference on Drug Prevention, which took place in Rome in late September (Monday 22nd – Friday 26th , 2003) confirmed what was already signalled by the author of this article few years ago, viz. that the Catholic Church is in the forefront in the fight against illicit drugs (see Catholic religious move to the forefront in battle against drugs, in the Wanderer of August 20th, 1998).
Sponsored by the Italian government’s extraordinary commissioner for the co-ordination of anti-narcotics policies, Prefect Pietro Soggiu, in conjunction with the Bureau of International Narcotics and Law Enforcement Affairs of the US Department of State, the conference was spearheaded by a Worldwide Network for the Prevention of Drugs under the co-ordination of an International Organising Committee which included a number of other groups, associations and NGOs. Among these a pivotal role was played by Associazione Casa Rosetta (ACR), a Sicily-based religious-run rehabilitation centre, with its president father Vincenzo Sorce, and the US Florida-based Drug Free America Foundation in the persons of its founder and president, long time anti drug war veteran Betty Sembler, wife to the present US Ambassador to Italy, Melvin Sembler. As a keynote speakers of the opening session, the senior diplomat paid his tribute to the organisers “not only as the United States ambassador to Italy, but also as someone who has been personally involved in trying to help solve the illegal drug issue”.
Father Vincenzo Sorce is a Catholic priest who teaches Pastoral Theology in Sicily at the Palermo-based “S. Giovanni Evangelista” Faculty of Theology and Social Education at the Free “Maria SS Assunta” University in Rome. Journalist and founder of ACR, which is active in 40 centres in Italy and Brazil, he was also the conference moderator in his capacity as chairman of the above International Organising Committee. Father Sorce is also specialising in the training of anti-drug personnel in co-operation with several foreign institutions, including the universities of San Diego and San Francisco in California.
As further proof of the leading role played by Catholic religion, the proceedings were opened and concluded by other two Catholic religious leaders respectively, archbishop Javier Lozano Barragan, president of the Pontifical Council for Pastoral Assistance to Health Care Workers, and Msgr. Paolo Romeo, apostolic nuncio to Italy.
To confirm the relentless and uncompromising stance of the Church in the anti-narcotics fight, Archbishop Barragan, soon to be appointed cardinal in the upcoming concistorium, reminded that in his Magisterium John Paul II dwelt upon the drug issue no less than 360 times, stressing that drug use and /or abuse is never licit because it’s unworthy of a God-created human being, who under no circumstances may renounce his/her dignity as a free and responsible person.

Over 500 delegates from 84 nations in all the continents participated in the event and it would not be possible to mention all of them. Suffice to say that some 60 speakers, from government officials to ambassadors, from scientists (Carmelo Furnari, Eric Voth, Ernst Aeschbach, Gregory K. Pike, Mark S. Gold, David A. Gross, Guillermo Fernandez D’Adam) to jurists (Giuseppe Dalla Torre), media experts (Wade West, Carlos Alberto Di Franco) and NGOs leaders (Stephanie Haynes, Peter Stoker, Calvina Fay, Chavalit Yodmany) offered a wide variety of presentations reflecting cultural, ethical, scientific, medical, social, political and spiritual dimensions of the subjects. Although representing many diverse faiths and beliefs, the participants were united in their support of the following common core principles, as entrenched in their final resolution: the pursuit of a ‘Common Good’ which should define and guide the actions of Society; a ‘Culture of Disapproval’ of drug abuse, namely any use of illegal substances and any inappropriate use of legal substances, to be nurtured in all Society; ‘Moral Imperatives’ for responsible and constructive citizenship, which should be honoured by Society at large; all strategy, policy and action should be informed and underpinned by proper, validated science. Furthermore the participants, who endorsed the resolution by acclamation, pledged “to create value in acknowledgement of the gift of life with which we have been blessed” and confirmed “the superiority of love, in relation to the education and building of our society: a superiority which has become a social, political, cultural and spiritual commitment”.
The Conference resolved also to progress initiatives in support of the above core principles, including opposition to legalisation and other forms of drug law relaxation, and therefore any drives seeking to serve, overtly or covertly, such negative expedience. The fullest support, the final resolution also stated, should be given to the Vienna Declaration, which seeks to unequivocally support the UN convention on drugs, notably by the collection of 25 million supporting signatures by the year 2008, when an overall assessment of the UNGASS results is scheduled to take place. This collection is a natural follow up to a campaign launched in late 2002 by the Sweden-based Hassela Nordic Network, which was able to present over 1.3 million signatures during the midterm review in Vienna last April 2003 for the UN Convention on Drugs to retain its successful “restrictive policies against any legalisation of illicit drugs, including cannabis”. Such legalisation is being pursued by a notorious and powerful trans-national anti-prohibitionist lobby, whose ultimate aim is “getting rid of global treaties against drug” (see also The War on Drugs Takes a New Turn, in the Wanderer of November 28th, 2002).
Besides the above resolutions and pledges, whose impact is generally measured on the medium-long term, the most immediate result produced by the Fifth Global Conference on Drug Prevention was an enormous amount of media coverage which after many days is still far from abating.
A turmoil was apparently unleashed by Italy’s deputy premier Gianfranco Fini, another keynote speaker at the opening sessions of the Conference, when he announced that by Christmas his country would reverse its drug policies with new legislation that would target users of soft drugs and end the legal distinction between possession and trafficking. He said the abolition of the so-called ‘minimum daily dose’ had defanged Italy’s drug laws and prevented police from distinguishing between drug-pushing and personal use.
Apparently a raw nerve was touched, since most of the secular media reacted with hysteria, crying foul and distorting Fini’s stance, whom they accused of wanting to jail all addicts. But the Italian Health Minister Girolamo Sirchia, a prominent haematologist and transplant expert, immediately backed Fini’s message, adding that the Superior Health Council’s decision to classify cannabis as hard was a “strong scientific response which I agree with”. “This puts an end to the pointless and sterile polemics which distort the truth about drug issues,” the minister continued. “There aren’t any drugs that don’t harm the user. These substances are worse than smoking, they harm the brain and cause mental illnesses,” said the 70-year-old minister.
Fini further clarified his vow to clamp down on drugs, speaking of a “zero tolerance” approach as “the most appropriate phrase” which “doesn’t mean handcuffs and police busts but fighting the tendency to underestimate the problem…It is a scientific fact, and one with social costs, that people who use and abuse substances like Ecstasy and amphetamines suffer damage to the brain,” Fini concluded. In other words, “there is no freedom of drug addiction”. Fini is convinced also that, besides traffickers, also what he termed “friendly fire” should be effectively combated, viz. those who foster drug use by disseminating criminal lies and fallacious distinctions between “good” and bad drugs. A real “pro-drug lobby”, as the Executive Director of the UN Office on Drugs and Crimes, Antonio Maria Costa, put it more bluntly in his keynote speech at the Conference the inaugural day. Besides the trans-national lobby referred to above, another typical case in point is the “singing lobby”, so much so that Fini also rebuked rock stars and the drug culture he said was associated with the world of rock. “Rock singers should reflect before saying that drugs are in some way a right, that people should be free to take drugs and that the culture of ‘getting high’ should not be criminalised”. Also Interior Undersecretary Alfredo Mantovano, another keynote speaker on the first Conference day, slammed “pop singers and the media” for encouraging youngsters to smoke pot. In a piqued reaction, 29 major artists published a manifesto to deny these accusations, saying that such words “smack of censorship”, “sound a bit intimidating”, subtly seek “to limit freedom of opinion and speech” and that “new restrictive measures are not needed” (cf. Corriere della Sera, October 1st, 2003).
The Italian media also pulled the emotional chord under another respect, by advocating more rehabilitation efforts rather than jail terms and crackdown policies on both consumers and traffickers. But these very media did ignore what was said at a concomitant joint press conference to present the First UN Report on Amphetamine-type Drugs to the Italian government by the Executive Director of the UN Office on Drugs and Crimes, Antonio Maria Costa, and the Director of the US Office of National Drug Control Policy, John Walters, namely that in the last five years marijuana addiction increased only by 10%, as against that caused by synthetic drugs, which rose by 70%. “Hence my fear”, Costa said, “that these chemical drugs may turn out to be the public enemy No 1”.
As a matter of fact, these chemical substances, like ecstasy and amphetamines, have devastating and irreversible effects on the psyche and body, causing real holes in the brain similar to those suffered by Alzhaimer-hit elderly and thus accelerating the aging process. “Who will assist and pay to support part of a generation mentally and physically crippled by the damages caused by ecstasy?”, Costa wondered. This question might be answered by another question: why shouldn’t the victims or their families sue for damages members and accomplices of the “pro-drug lobby” referred to by Costa, as was the case with tobacco-induced damages?
Should the trend towards irreversible damages continue, therefore, any talk of rehabilitation instead of repression and prevention may soon become sheer platitude, like a hunter who keeps on aiming at a bird even well after it has already flown away from its perch.

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by Peter Stoker: Director, National Drug Prevention Alliance

Simply because this subject is too important to leave to the experts. Parents, even these days, are seen by young people as a key source of information and moral guidance. As an example, try summating the whole life of your child from birth through to age 21. Tabulate all of the hours that they spend in school, or in religious areas, or in community areas, or with you the parent; it is enlightening to then look at the percentage of time the child spends in the various ‘zones of influence’, throughout their youth. The figures are 10% in school, and less than 1% in churches etc. The rest of the time, they are outside the influence of those organisations.

Moreover, the great majority of drug use by young people does not take place in school, nor does the dealing. What does this mean? It clearly means that most of the drug misuse takes place when we are in charge. In the main we have drug free schools; what we don’t have is drug free young people. It follows then, taking the title of this paper, that if we who have longer with the young can communicate and influence effectively with them that we stand a strong chance of making things better. But are we using this time well? Research has shown that on average, a parent spends 15 minutes a day communicating with their child. Of that 15 minutes, 13 minutes are spent in criticism. It is not suggested that parents are the only people who can mobilise to good effect. It is obviously, at the very least, a tripartite effort between home, school and community. But what has been one of the main factors in the deterioration over the past few years, which has let in negative behaviours such as drug misuse, has been the separation of the influence of the home from the diverse and sometimes negative influences young people receive either in school, including the playground; or in the community, including those other ‘playgrounds’. If we are to succeed in prevention, we must recognise that ‘Partnership’ is not just a fashionable buzzword; it is a fundamental.

Can Parents Succeed?

Yes, they certainly can; they have done in other countries, and to some extent they are already succeeding here, but nowhere near enough yet. Before quoting figures from the obvious place that researches so much i.e. America, there is evidence from countries much closer to home: two are Belgium and Sweden. In the Eastern cantons of Belgium, Ernst Servais runs the Social-Psychological Centre which is based in Eupen, and has been working for some 15 or 16 years now on community drug prevention work. Before he got into drug specific community education and prevention work Ernst spent a long time, several years, just developing community networks and using less emotive subjects as a vehicle for bringing people within the community together. He knew the truth of the adage that ~‘Tasks Unite, Issues Divide”. Over 13 years up to 1991 when Ernst published his synthesis called “Before It’s Too Late”, drug use by young people in the area concerned rose by only 3%. If you compare that with the major increase in drug use by surrounding areas, it is truly a remarkable achievement. In the case of Sweden (in the late 1970s), there was a period of relaxed approach and harm-reduction-based policy, particularly around the use of amphetamines. This led to a very large escalation in their use with attendant social, emotional and medical problems. Sweden learnt from this mistake, instituted an exemplary suite of prevention programmes and coupled this with a constructively firm law structure; the prevalence of amphetamine abuse, and indeed of other drugs of abuse in Sweden, has since been pushed back very significantly.

Turning now to America, their experience shows how parents can be truly effective. Nationally, biennially collected data across large numbers of households paints a graphic historical picture (Figure 1). Drug use which had been at a very low level for very many years took off during the 1960s under the dual factors of hippie lifestyles and libertarian philosophies, expediently coupled with protest against the Establishment in the context of the Vietnam War. What did parents do when use first started to grow? Absolutely nothing. This is probably about where Britain is now. The problem had to get much bigger before they woke up, but when they did it was the parents and not the professionals who first started insisting that a more vigorous and constructive approach be taken. And to salutary effect. The results are easy to see. Over a 12-year period from 1980 the USA reduced drug use in all age groups and for all substances by a staggering 60%. 13 million fewer users. If any other Public Health or other kind of behaviour modification exercise had achieved this result people would be screaming from the rooftops what an amazing success it was. Instead, all we heard from a largely libertarian press was that “the war on drugs is failing”. Since 1992, use is climbing rapidly again; a stark lesson that you cannot take your eye off the ball — or take the funds off the programme. Prevention (and health promotion in general) must be revisited in every generation, and constantly reinforced.

So, parents can certainly succeed. But they will only succeed if they work in partnership. Prevention is the proper business of every section of the community, each dovetailed into the other but each addressing the subject in different ways, according to their own setting. It is not only youth who need prevention opportunities; whoever the centre of focus is, there will be some who can exert more influence and others less — but every input is valuable. People who are closer to the focal point are likely to be more influential than the people on the periphery. But all of them have a valuable influence, and all of them should be engaged.

Can Parents Succeed Now?

The chances of success as things stand at the moment with parents in Britain are a lot less than they should be. This is because, as a generalisation, parents are largely on the margins of influence. This marginalisation has occurred through a combination of factors, but is also, to some extent, self-inflicted. Cultural changes, including the elevation of youth to a position of near-autonomy, greater spending power by youth, and youth-centred methods in schools, youth centres etc. have mingled with a seemingly daunting array of issues — sexual behaviour, sexuality, negative role models, libertarian media and entertainment, increased family breakdown as well as reduced family influence, violence and vandalism, and of course alcohol and other drugs. In the face of all this many parents have been tempted to see marginalisation as the route to survival. In the particular context of drugs parents remain behind the ‘brick wall’ of marginalisation, in some cases because they want to be, because it’s safe there. But they’re also behind it because an awful lot of media commentators, professionals of various sorts, and indeed other parents reinforce the view that this is where they should be because they a) don’t know enough about drugs, b) have only one simple function when drugs are mentioned, which is to panic, and c) even if they do get involved they mess up anyway. I want to see this brick wall demolished; and the sooner the better. We will only succeed in prevention if parental communication is brought back from the margins to the place where it belongs, in the very centre of things. And nobody will invite you; you will have to push your way back in.

Where Should Parents Focus Their Effort?

For all but a few parents, who want to take the wider view, the focus should be firmly on one’s own back yard; work with your own family first, and worry about the rest of the world later. Next, as a parent, you do not have to be an expert, any more than others who speak out are (Noel Gallagher and Brian Harvey are certainly no experts). As parents, you know instinctively the behaviour you want to encourage in your children and the behaviour you want to discourage. Focus on that, and all ways of achieving it, and leave the fancy drug technology to other people. You don’t have to ‘know knowledge’, just know where to find it. If you must have an instant drug lecture in thirty seconds, this is it:

All psychoactive substances can be classified under one of three headings: They send you upwards, they send you downwards, or they send you sideways; or some permutation thereof.
(End of lecture)

Your focus needs to be not so much on drug technology but instead be firmly on parenting, and we could all benefit from lessons in this. Indeed, there is an argument for including parenting skills in the school curriculum. Parenting courses unfortunately often tend to be limited to drug knowledge; you need much more breadth and depth than this. One example of a useful model has as its name and emphasis ‘Parenting Skills for Prevention’. It is video and audio based, an 8-week, Adult Education course, proven over more than 10 years operation and developed from the original by NDPA to suit British culture. The 8 modules cover awareness of the subject of drugs, and of you yourself in relation to that subject, how to be ‘pre-event’ and parent assertively; the adolescent’s development and basic drives; and the differences between a child, an adolescent, and an adult. In the second half of the course we look at family systems for QA and QC — Quality Assurance and Quality Control. (Setting behavioural standards and following up to see that they are complied with). The difference between Punishment (which can sometimes mean getting even, or revenge) and Consequences (which are the pre-advised outcomes of unwanted behaviour — and they must be preadvised and consistently applied). The difference between the Needs and Wants of one’s offspring; how the Needs must remain inviolate even in the face of the most extreme behaviour, whilst the Wants can be a focus of any Consequences in response to negative behaviour. We also look at the vital relevance of feelings — adolescents work from their feelings; if your communication is only from the head, their hearts won’t understand. Take a deep breath, and tell them how you feel. Reinforce positives, play down negatives. Arrange your time to allow more real communication with your family. And if all else fails, be aware of where to get help. We have run this 8-week course, sometimes in the evening, sometimes in the day, even in workplace lunch breaks, with several hundred parents. We have received excellent evaluations, and these have been accepted by the Home Office, who funded the early stages of the project.

How Can Parents Be More Effective?

The first thing that parents should do is to exert a positive influence. It is essential that between all of the various people who communicate with a young person that the three key areas of behavioural influence are addressed. This has been termed for short as KAB — Knowledge, Attitude, and Behaviour. Giving knowledge is relatively easy, but it must be valid information. Challenging attitudes, why they exist and why they might be more beneficially changed is also rather better understood than the third component i.e. behavioural modification. We far too often overlook that if we wish to produce positive behaviour we need to encourage it when it occurs. More often our inclination is to challenge or punish negative behaviour when it arises. The plain fact is that if you can introduce an environment of positivity in your home and encourage your children to interact with other children in a more positive way this will have a beneficial effect, and this can spread over a wide area. Studies at Swansea University show that for every peer educator who goes through training programme they beneficially impact, to some extent, around another 200 people. A convenient encapsulation of a parental approach to behaviour is found in a psychologist’s term, which is to say that you need to practice “loving control”, being neither too authoritarian nor too lax. Again, research shows that this produces overall the best results, including a marked decrease of prevalence of drug misuse.

A current educationist fashion is to speak of facilitating ‘Informed Choices’ by young people. (Regrettably, the people doing the informing rarely encourage consideration of anyone other than the individual; self-actualisation -Maslow style- is the governing force.) Choice per se is of course a part of healthy development, but when it comes to the use of illegal drugs (or age limits for legal drugs), choice has no part to play. We do not ask children to choose whether to steal or assault; we Just Say No.

Disapproval is still a strong impactor, as a 17-year analysis of USA nation-wide drug-related behaviour shows (Figure 3). Throughout the 17 year period (1974 — 1991) there is a perfect inverse correlation between prevalence of use and perception of disapproval by others, as well as perception of harmfulness of use. You can exert positive influence by setting out clear values and boundaries for behaviour in the home, and setting out what the consequences will be of crossing those boundaries. And, most importantly, sticking to those consequences without wavering if any transgression occurs. Parents can also set an example and show integrity in what they’re saying, even though sometimes they may be decoyed by arguments such as ‘you smoke tobacco’ or ‘you drink alcohol; those are your drugs, so why are you criticising mine?’ The short but valid answer to this is ‘two wrongs don’t make a right’. The alternative short answer is for you not to smoke and not abuse alcohol. (Abuse of alcohol may, stereotypically, include using it as a drug instead of as a beverage). The longer answer is that if you do smoke you probably became hooked when the level of knowledge was well below what it is now, and if you had known what is known now, you probably wouldn’t have started. If you are a smoker, both for the example you set and for your own health, it would do you no harm to give it up. As for alcohol, the least you could think about is keeping the levels well below the health limits and never say “I need a drink” — this is a suicidal parental message! If you want to introduce a healthy form of taking substances in your home, here’s a radical idea: try and eat together as a family now and again; a big challenge, I know, but you can do it if you try!

If you are going to get ahead of the game you need to stay very aware of youth culture, and in particular the youth culture that exists in your own home. Here’s another radical idea: Every now and again, check how your young person decorates his or her room. What records do they listen to? What set of people do they hang out with? What kind of language do they use? Are there any marked changes in their attitude towards you and respect for you? What magazines and newspapers do they read? What films and videos do they watch? Do you know which musical groups and which films promote or give apologia for drug use? If not, why not? This kind of upstream marker is a lot more valuable than the kind of “signs and symptoms of drug abuse” that are so often peddled in parental advice articles. Frankly, if you’re looking for signs and symptoms of use you are already too late.

Another thing that you can do as a parent, and you have the right to do it, is to check out your school. Do they have drug policy, and does it start with the aims of the school and how to achieve these through prevention and education, or is the policy no more than a list of damage limitation, reaction and repair once drug use has been discovered (“stable door — instructions for bolting” etc.)? What lessons are they delivering that have to do with social behaviours and personal development? What philosophies are they following? Who is funding this aspect of their education, directly or indirectly? What materials are they using and what agendae inform the materials? What messages, overt and covert, are being given out? And if you don’t like the answers you find, what are you doing about it? (Then repeat the dose for everyone else in the community who communicates with your offspring. politicians, media, health workers, social workers-above all check out people like me, who claim to specialise in the drugs field. Where are we coming from? Is reduction of drug misuse our driving force? (The answer from some within the above disciplines may surprise you!)

Tackling the drug problem in our society is one of the toughest yet potentially most rewarding tasks facing us all today. ‘Tackling Drugs Together’ is today’s maxim but is a good way short of being today’s reality. To reverse the trend (and thereby ‘to Build a Better Britain’) will take nothing less than a major change in the culture of our whole society. Mission Impossible? Hardly. The culture changes which brought us to where we are now have all taken place in the lifetime of many of us who are now parents. What has been done can be undone, and the longest journey begins with a single step. That first step could, and indeed should be taken by you, the parent. Safe journey!

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Filed under: Prevention (Papers) :

NDPA started in a modest way in early 1993, after a year of exploratory work. Of course nobody was standing idly waiting for NDPA to appear, and the value of the initiative had to satisfy hard-nosed, already overworked agencies and individuals. By May 93 the clear need for NDPA was acknowledged, and the first formal meeting of the Executive got things moving.Attendees included Life Education Centres, Hope UK, prevention specialists Positive Prevention Plus, Ben’s friends (named for Ben Wood who died from ecstasy use), health promotion specialist Anthony Johnson, and other concerned individuals. From these small but substantial beginnings the Alliance has extended to the point where its ‘constituency’ now conservatively numbers more than ten million people.

As well as entities in the four ‘home nations’ and the Irish Republic, major groups like Life Education Centres and DARE UK, and high-profile campaigners like Jan and Paul Betts, we now have links with an even more diverse range of interests groups. Mrs Frances Lawrence, widow of murdered headteacher Phillip Lawrence and Anne Pearston of Dunblane’s ‘Snowdrop’ campaign are but two examples. Why would they be interested in the NDPA? Because they recognise, as do we, that drug misuse is part of a much wider picture of social behaviour in which we must all strive (as our general leaflet title says) for
‘a prospect of something better’.

The Executive has met at least four times a year every year since then, and the many and varied outcomes are touched on in this brief paper. The detail of our activities fills several filing cabinets and not a few floppies and zips. The most expedient way for you to find out more, if you want, is to contact us personally; we will be very pleased to assist you.

ACHIEVEMENTS SO FAR.

NDPA’s formal ‘birth’ coincided with the first drafting of ‘Tackling Drugs Together’. We were asked by then – Minister David Maclean to meet with Sue Street, director of the Central Drugs Coordination Unit (CDCU) in Whitehall. We made a good impression by the calibre of our input, and the eventual publication gave us much grounds for encouragement. From that time on we have sustained a good working relationship with the CDCU under Stephen Rimmer, and now in its new existence as the office of the UK Anti-Drugs Co-Ordinator, Keith Hellawell (and his deputy, Mike Trace).

NDPA is increasingly in demand for conference appearances, including the Scottish National Drugs Conference, the Irish Drug Squad (Garda), ‘Frank Talks’ (Belfast), DARE Graduation, Isle of Man Life Education, Scottish Chief Police Officers, several international presentations, and many more. Trainings have been held in Glasgow, Lake District, Cambridgeshire, Hertfordshire and of course the Metropolitan area, where several have occurred. Several police forces continue to use our consultancy resources.

As well as technical papers for ‘Tackling Drugs Together’ (TDT) and its successor ‘To Build a Better Britain’ , NDPA has produced a great many others, including papers for the three main political parties. These and other papers covered such subjects as drug strategy and philosophy, prevention technology, educational techniques, enforcement approaches, constructive/rehabilitative justice systems, drug information, and more. Two leaflets summarising cannabis research (one for youth, one for parents) have been reprinted twice already, their content having been validated in ongoing meetings with Professor John Henry and Professor Heather Ashton.

Very little of this would have been possible without the National Lottery Charities Board (NLCB) grant. Coming in summer 1997 the grant was worth just under £150,000 over three years, and we volunteered to put in another £50,000. Companies House rigorously screened us before allowing our definition as ‘National’. NLCB also vetted us closely, because NDPA was an unknown quantity, but their analysis proved positive; they put their faith in us and for that we are eternally grateful.

A NEW FOCUS ON PREVENTION

Our opening comments on ‘TDT’ still hold good today and indeed were strongly echoed in our imput to ‘BBB’, which came in two slices – a four page summary called ‘Adjusting the Focus’ and, in January 98, a 28 – page formal proposal.

The main thrust was that Britain’s strategy needed to be strongly focussed on primary prevention, buttressed by sensible but unequivocal legal structures. Our words were ‘Prevention coupled with firm but fair laws’. When BBB came out it called for ‘Firm laws plus prevention’ – not a million miles away, it would seem.

Inculcating cultural changes in favour of healthy lifestyles.
Constructive justice system.
Workplace prevention.
Harm reduction kept in perspective.

AD NAUSEAM

A perennial bugbear of our work is the legalisation lobby. This has taken us to formal/informal debates at Cambridge, Oxford, Colchester, even Westminster. Several reams of paper have gone into technical presentations. Our extensive international links help greatly on this and other subjects. The Media regard us as ‘first port of call’ on this subject, and we have featured on BBC World Service (130 million listeners) BBC TV, Channel 4, Readers Digest (5 million readers), The Guardian, and on. And on. We have faced up to drug smuggler Howard Marks, ‘heroin doctor’ John Marks (no relation). The Government seem to hope that their unequivocal stance against law relaxation (for which, much thanks) will make all the legalisers shut up and go away. Far from it.

YOUTH DEVELOPMENT

The main focus of our work is on youth, and services to skill them, to enable them to resist drug misuse. We were taught a long time ago by a wise old trainer that “we rarely succeed at anything unless we have fun doing it”. This remains a mainstay of our youth work, and probably accounts for the fact that so many of our youth participants stay with us for so long. Another guiding principle is Youth Empowerment, through the medium of Peer Prevention (which is like Peer Education, but much wider in scope). We now have a Youth Training Team which is capable of organising and delivering prevention programmes, and prepared to travel anywhere – expenses permitting.

Besides the Teenex programme, which looks set to spread into Wales before too long, there is the excellent Youth Trust in Devon which is currently planning to expand into after – school services for ‘latchkey’ youth. Meanwhile services to the younger set are impeccably provided by such as Life Education and DARE. For the latter we recently completed a meta-analysis and synthesis of international evaluative research which is now aiding their development programme.

THE FUTURE – THAT ‘BETTER PROSPECT’

‘To Build a Better Britain’ is a 10 year strategy with regular interim reviews; we have met Keith Hellawell and Mike Trace several times, and will sustain this dialogue. We have just started two research studies, in hand at Brunel University, to run over 3 years. Our existing parliamentary contacts need increasing, and likewise the media work is bound to step up – with fierce demands every time someone else says something libertarian or outrageous (or both). The legalisation/decriminalisation/’harm reduction + no prevention’ lobby will remain vocal. There is also the small matter of funding NDPA for the next decade. Above all we need to ensure two things: greater union (a stronger voice) amongst prevention agencies and supporters across the community; and greater efforts to lift quality (and prove this quality by evidence–based evaluation). Should keep us busy for a while……………

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Australia and Sweden have taken different paths in the battle against illicit drugs.
Dr Lucy Sullivan examines the results.

A comparison of drug policies in Sweden and Australia. and of drug usage and associated problems, is highly suggestive of which country has chosen the more effective approach.

Sweden:

After beginning with a legal approach to illicit drugs, Sweden executed a volte face in response to escalating drug use in the population. Policy now aims at a drug-free society.

Coercive care of adult drug abusers was introduced in 1982: Swedish courts can order treatment instead of punishment if the offence carries no more than one year of imprisonment.

Drug use was criminalised in 1988, and a maximum penalty of six months’ imprisonment for illicit drug use was introduced in 1993, Possession of small quantities of cannabis or amphetamines may result in only a fine, but possession of heroin or cocaine receives a strict term of imprisonment. Drug trafficking maybe punished by 20 years imprisonment. Methadone assisted rehabilitation of drug addicts has been implemented.

Schools and municipal social services provide extensive education against drug use. Harm minimization, as a policy approach, and needle exchange have not been adopted, on the grounds that they would convey an ambiguous message against society’s attitude to drug abuse.

Australia:

In Australia generally, the maximum penalty for possession of small amounts of cannabis is two years imprisonment. In South Australia and the Australian Capital Territory, however, possession of small amounts of cannabis has been decriminalised. Trafficking in illegal drugs may be punished with life imprisonment.

Despite the legal position, Australia’s National Drug Strategy since the late 1980s has been one of ‘harm minimisation’, rather than prevention or a drug-free society. Through the late ‘80s and most of the ‘90s, there has been a movement in the allocation of funding, from law enforcement to education.

As an educational policy, harm minimisation is defined as teaching safe use of drugs, abstinence is not seriously addressed. Other features of Australia’s harm minimisation policy are an extensive free needle exchange programme and free methadone maintenance for heroin addicts.

Sweden Australia
Lifetime prevalence of drug use in
16-29 year olds (Sweden) and 14-25 year olds (Australia) 9% 52%
Use in the previous year, as above 2% 33%
Estimated dependent heroin users per million population 500 5-6000
Percentage of dependent users aged under 20 1.5% 8.2%
Methadone patients per million population 50 940
Drug-related deaths per million population 23 48
Percentage of all deaths at age under 25 1.5% 3.7%

Drug offences per million population –
Sweden = arrests; Australia = convictions 3100 1000
Average months in prison per drug offence 20 5
Property crimes per million population 51,000 57,000
Cumulative AIDS cases per million population 150 330

Outcomes:

The accompanying table shows comparative figures on drug abuse and related factors for Sweden and Australia as presented in the United Nations World Drug Report 1997 (adjusted where necessary to a rate basis).

The comparative figures for drug use in Sweden and Australia, taken in conjunction with education policies which promote abstinence versus safe usage, suggest that Australia’s policy of harm minimisation has induced widespread drug usage – 52% lifetime usage (i.e., used at least once) in Australia compared with 9% in Sweden.

Further data indicate that the change from the liberal to prohibitive in Swedish policy has been effective in reducing the initiation of young users, whereas usage by young people in Australia has been rising over the same period.

The highest prevalence of lifetime usage in Sweden occurs in the 30-49 years age group. In Australia, the rates of usage are minimal above age 40, while the greatest increase in use has occurred in the 14-24 years age group. This demonstrates the success of education in harm minimisation in encouraging drug use, particularly in the age group most exposed to drug education – school children.

Only 1.5% of Swedish young people (aged under 20) are drug dependent, compared with 8.2% of Australians in the same age group.

The information conveyed in harm minimisation education is clearly unable to counteract the effect of higher usage rates. Drug-related death rates are twice as high in Australia as in Sweden – 46 versus 23 per million population. Moreover, the share of under 25 year-olds in drug-related deaths in Sweden is very low – only 3.6%. The Australian figure in this category was not available, but the percentage of all deaths at age under 25 (3.7% compared with 1.5% in Sweden) indicates a higher presence of trauma for Australian young people, of which drug taking is likely to form a part. Free needle distribution in Australia does not appear to have resulted in better control of the AIDS epidemic here, with our cumulative AIDS rate more than twice that of Sweden. While the proportion of methadone patients to heroin addicts is similar in the two countries, one may conjecture that the use of methadone for rehabilitation in Sweden, rather than for maintenance as in Australia, contributes to the dramatically lower rate of heroin addiction there (less by a factor of at least 10).

The higher rate of illegal drug use in Australia is the more remarkable in that Australians are roughly as law-abiding as Swedes in relation to property crime, and far less violent. The lower ratio of convictions to usage rates in Australia may well encourage contempt of the law.

The proponents of the harm minimisation strategy in Australia claim that Australia is leading the world in the public health of drug abuse.

These figures suggest, rather, that it is leading us in the opposite direction, and that a policy like Sweden’s, which addresses its goals straightforwardly and unambiguously, rather than deviously, is more successful in practice.

News Weekly, August 28 1999 Page 8
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Evidence for prevention
Prevention outweighs permissive policy for social benefit to the individual and to societyEd Jurith is currently temporarily occupying the desk of the USA’s ‘drug czar’ while President Bush decides whose name is ‘permanently’ painted on the door. Close to the end of his Atlantic Fellowship in England, Ed gave a talk in London to drug workers. He proposed and answered the rhetorical question: ‘What is the goal of US drug policy ? – A drug-free America’.

I watched his audience stiffen, then relax as he went on: ‘None of us expect 100% success, but as a goal to work towards, it’s not that bad.’

It is a mistake to assume that all the zealots are anti-drugs, any more than all the sacred cows are on one side of the fence. We all have our share of both.

The governing goal in our national strategy is to work towards the irreducible minimum of drug users. This is a common theme in both the current drugs strategy and its 1995 predecessor (its Appendix C has one of the most helpful definitions of the role of harm reduction).

When asked to identify the main tool to achieve this goal, most people choose ‘education’. But this is only one component – and by some accounts a deliberately ‘aimless’ one.1 You could, from this basis, educate a ‘drug fancier’ but the outcome at best would be an educated drug fancier.

Prevention differs from education by setting goals and boundaries and working within the social context. Prevention fosters a culture in which the desired situation is more likely to occur, more likely to be willingly chosen. The then Chief Executive, Council on Addiction for Northamptonshire, Robin Burgess, underscored this very even-handedly in Druglink, March/April 1996.2

Prevention must engage the whole society. This requires a substantial shift in attitude for several professions, given we are by nature symptom-focused and reactive. Suggesting, for example, that prevention should be limited to those ‘at risk’ is like limiting contraception to the pregnant.

Lofquist, in his classic text says: ‘We must get beyond the notion that prevention is merely stopping something happening, to a more positive approach that creates conditions which promote the well-being of people’.3

In simple terms to prevent we must be working ‘pre-event’. School or workplace drugs policies that only intervene when drug use is observed need extra front-end chapters to cover this.

What is the value of the law in prevention and health promotion? It spells out the boundaries and at least some of the consequences of breaching them. It also undoubtedly acts as a discouragement for some – hence the increase in use seen universally when laws are relaxed.

Intervention by the law, whether by Caution or Court, is credited by many in my experience with having decided them to avoid or turn away from drugs. In the USA the criminal justice system remains the top referral source for rehabilitation.

There is great potential for more constructive systems: for example, the National Drug Prevention Alliance advocates an extended caution applied to minor drugs offences, with a preventive aim (a working title might be ‘PreCaution’).

The principle is to offer a caution – or deferred sentence – with the condition of attendance at drug prevention training sessions, analogous to what happens now with drink driving cases. Failure to attend would constitute a breach and thus appearance in court. Costs could be limited by cooperation with the voluntary sector.

Law and criminal justice are parts of the interlocking structure of social agents that deal with positive and negative life issues to foster a healthy society. The problem with such structures is that removal of any part can lead to collapse. The ‘legal’ element may be easier to dislodge than many, starting with mislabelling it.

‘Prohibition’ conjures up images of a rejected policy and an American policy at that – very handy derogatory terms. The Australian Parliamentary Group for Drug Law Reform certainly believed so, to the extent that they deployed ‘ conscious manipulation of the language and debate ‘ – their words, not mine, ‘ labelling those who oppose drug law reform as ‘prohibitionists’ and those who seek it as ‘reformers’’.4

For equity, instead of prohibition I suggest ‘preventive policies’ – a less calculated term, less likely to promote a particular viewpoint. It also fairly balances the term for the opposite approach ‘permissive policies’. From this start point, let’s climb over the fence and vet some of the sacred cows in the ‘permissive’ herd:

Culling ?

‘US Prohibition equals UK drug policy’ – US tried to suppress what was until then a legal substance (alcohol), used by the majority of, and generally accepted by the public. The inverse of these parameters is true of our drug laws. No comparison.

‘US policy spectacularly unsuccessful’ – the US sustained drug prevention for 12 years from 1980–92, achieving a 60% drop, about 13 million fewer users.5 Things slipped thereafter as government and parents took their eyes off the ball, but prevalence is now declining again. This is despite ‘law-weakeners’ like George Soros investing huge amounts of money in permissive campaigning – he puts his personal input at $90 million (so far).6

‘Hundreds of thousands jailed in US for simple possession’ – sentencing for all offences, including drugs, has declined and is now at half the 1997 level. The average amount of cannabis per incarceration is 4,500 lbs. In 1998 alone 1.7 million pounds of cannabis were seized. Under 0.1% of those jailed are non-violent, first-time cannabis offenders.7

‘US incarceration policy is racist’ – demographic analysis belies this. In Northeast and Northwest regions sentencing black/white is equal, while in the Midwest whites do worse. Average sentences for the South are 1 month longer for blacks but, crucially, in this region all races are more likely to be convicted, and imprisoned for longer. This factor alone explains the differences.7

‘We are at surrender stage in the UK’ – despite the current World Health Organisation (WHO) European School Survey Project on Alcohol and other Drugs (EASAD) report, the white flag can stay in the locker for a long time yet. The UK Anti-Drugs Coordination Unit confirm that more than 80% of young people either never use at all (50%) or else give up after one or two tentative tries, a figure which has been growing for at least the last three years.

‘Just Say No doesn’t work’ – unsupported sloganeering certainly doesn’t work but the US programme of this name was much more. It was a comprehensive personal and social development process and one of the key factors in the prevention gains from 1980-92.

Undoubtedly some re-visit the slogan as a coded message implying prevention as a whole doesn’t work, but there is a growing body of evidence to rebut this slander. The work of experts such as Kumpfer8, Tobler9 and Benard10 relates to large numbers of successful initiatives.

But Joan Smith does have a point (Druglink Jan/Feb 2001 p.14). Latin America is certainly in a mess. Nowhere more so than Colombia under President Pastrana, a man who demonstrates his readiness to ‘milk the cow from both sides’ – sacred or not. Bellicose presidential anti-drug proclamations have been accompanied by awarding the drug-financed guerrilla forces a ‘police and army-free’ slice of Colombia the size of Switzerland.

Mexico is more encouraging. On a visit there recently George Bush said the time was past for Americans to blame Mexicans for a problem substantially derived from the demands of American youth. He said that priority should be given to ensure the effectiveness of prevention programmes, and that jailing first-time drug offenders: ‘may not be the best use of jail space, or the best way to free them from their disease.’

Danny Kushlik defines drug policy parameters (Druglink Jan/Feb 2001, p.20), but ends up with some dubious correlations. A more sound method is to look at the experience of countries that have tried to unravel their drug laws.11

Holland and Switzerland are glorified by some but there are enough negative reports, despite the predominantly libertarian media, to give cause for serious doubt.

Journalist and writer Larry Collins?12 is not impressed by the proposal to go Dutch. WHO and INCB experts have combined13 to condemn the Swiss experience as a questionable model – not to be followed by other countries.

Spain in the early 80s relaxed laws for cannabis, cocaine and heroin until parents shamed the government into a tougher stance. Italy in the late 80s rescinded lax heroin laws after record levels of addiction and death. Japan cut record abuse levels of amphetamines and heroin by applying firm laws with mandatory rehabilitation. In the distant past China found it necessary to apply stricter laws and education/rehabilitation to recover from damage by British-marketed opium.

Closer to home the ‘British experiment’ of heroin on prescription was revoked after it led to ‘leakage’ on to the street and record levels of youth addiction. Those European countries now approaching law relaxation may find themselves living through a previously-observed cycle – the three Rs: relax, repent, repeal.

In 1975 Alaska caved in to a well-orchestrated campaign for decriminalisation. The grounds for decriminalisation of cannabis were that this would not increase casual or chronic use as there was already lots of both about. It would not boost use of other drugs as cannabis as a gateway to other drug use is a myth. Crime would go down due to no possession charges and streets full of peaceful cannabis smokers.

More than a decade’s experience and observation convinced the Alaskan Supreme
Court that exactly the opposite had happened, and in 1990 the decriminalisation was rescinded.

Perhaps the most instructive example comes from Sweden.14 In the mid-50s Sweden found itself facing increased amphetamine use. Its natural instinct was to seek a liberal accommodation. Accordingly, the use of amphetamines was decriminalised while social/medical systems were put in place to accommodate the behaviour and minimise the harm.

Within 15 years the Swedes found amphetamine use had soared to enormous levels and with it social and medical costs. A new plan was introduce with the incremental introduction of firm laws plus mandatory treatment schemes. Today Sweden has prevalence levels a fraction of the rest of Europe.

Recent moves to relax the policy have been emphatically rejected, and Sweden stays with their preventive approach, which they characterise as ‘a vision expressing optimism and a positive view of humanity.’ The contrast between Sweden and, for example, Australia is, as researcher Dr Lucy Sullivan15 says ‘highly suggestive of which country has chosen the more effective approach’ (see table). (Full Drug Policy comparison article)

	Sweden	Australia
Lifetime prevalence of drug use in 16-29 year olds (Sweden) and 14-25 year olds (Australia)	9%	52%
Use in the previous year, as above	2%	33%
Estimated dependent heroin users per million population	500	5-6000
Percentage of dependent users aged under 20	1.5%	8.2%
Methadone patients per million population	50	940
Drug-related deaths per million population	23	48
Percentage of all deaths at age under 25	1.5%	3.7%

Drug offences per million population – Sweden = arrests; Australia = convictions	3100	1000
Average months in prison per drug offence	20	5
Property crimes per million population	51,000	57,000
Cumulative AIDS cases per million population

Culture

The culture in which decisions on life issues are taken is all-important, whatever the country.

In the case of youth and drug use in the UK, recent decades have seen many cultural developments: more drugs at lower real prices, a shift from community orientation to individualism, a search for rapid gratification, less guidance from (and faith in) religion, a pill for every ill, marching for rights but never for responsibilities. This comes with an increase in youth autonomy and spending power simultaneous with a decrease in traditional authority from parents, teachers and other civic/social agencies.

This may help to understand how the UK comes top of the European league for self-indulgence but it misses one important factor – what contribution have we, the relevant professionals in health, education and social fields, made to all this?

The answer is not flattering.16 There has been too much striving for acceptance by youth, too much selling out. We try to identify with youth and too often we over-identify. The result has been sizeable sections of youth who have scant respect for others, or for society’s boundaries. In effect they sign up for the (Rogerian) gospel of Values Clarification – a do-it-yourself morality kit.17 This is not education, it is abdication.

Steering the educationist juggernaut will be one of the biggest challenges to Keith Hellawell, our UK Anti-Drug Coordinator (many fail the driving test). It will require him to put some flesh on the bones of his rhetoric – however sincere.

Keith Hellawell is personally commited to minimising drug use, affirms that he is convinced of the significantly damaging effects of cannabis – physiological, social, emotional and intellectual. He says that he has ‘never been a just say no person, but is a say no for these reasons person’.

He rejects an educational approach that is relaxed about drug use, which replaces behaviour boundaries with harm reduction. But if prevention is ever to become more than a slogan he needs to put the Government’s money where his mouth is.

Prevention outweighs permissive policy every time in terms of social benefit to the individual and to society. And yet, when the sacred cows come home and when the relative strengths of our friends and our adversaries are weighed in the balance, we probably get the society we deserve.

References:

1. O’ Connor et al. (1999) ‘Drug Education in Schools.’ Roehampton Institute.

2. Burgess, R. (1996) ‘What’s Wrong with Prevention?’ Druglink, March/April .

3. Lofquist W. (1983) ‘Discovering the Meaning of Prevention’. AYD Publications.

4. ‘A Push for National Drug Law Reform’. Connexions News Oct/Nov 1994.

5. US Biennial Household Surveys, correlated with Michigan Schools System

6. AP wire, 25 Aug 1997: George Soros quoted in ‘Time’ magazine that he has spent ‘more than $90 million in recent years to weaken drug laws’.

7. Peterson, R. E. (1997) ‘Drug Enforcement Works’. PAE Consultants.

8. Kumpfer, K. (1990) ‘ Challenges to Prevention Programmes in Schools’. OSAP.

9. Tobler, N.S. (1986) ‘Meta-Analysis of 143 Adolescent Drug Prevention Programmes’ Journal of Drug Issues

10. Benard, B. (1987) ‘Characteristics of Effective Prevention Programmes’.ITI and NIDA

11. Peterson, R E. (1991) ‘Legalisation – the Myth Exposed’. Narc Officer.

12. Collins, L. (1999) ‘Holland’s Half-Baked Drug Experiment’. Foreign Affairs.

13. (1999) ‘International Criticism of the Swiss Heroin Trials’ AIDS-Aufklarung Schweiz and Schweizer Aerzte gegen Drogen.

14. Swedish National Institute of Public Health. (1995) ‘Drug Policy – the Swedish Experience’.
15. Sullivan, Dr. L. (1999) ‘Drug Policy: A Tale of Two Countries’ News Weekly

16. Dennis, Prof N. (1997) ‘Social Irresponsibility.’ Christian Institute.

17. Stoker, P. (1999) ‘Early years drug prevention and education – getting back on track’ Early Child Development and Care, Vol 158, .

Filed under: Prevention (Papers) :

A framework for the future of British drugs strategy

‘Tackling Drugs Together’, a strategy for 1995-98 came from joint action by all relevant government departments and with support from all major political parties. Specialist agencies, including NDPA, contributed to its production. Much positive progress has been made. The Drug Action Team/Drug Reference Group structure has concentrated minds. The ensuing review of prevention, intervention, treatment and rehabilitation services has pointed up areas for improvement. Above all, the commitment to more and better primary prevention (including education) has galvanised action across the field.

Three years is little enough to establish a structure, let alone deliver on it. There must be a corresponding strategy beyond 1998 and into the next millenium. This will always be a ‘long game’. This Paper suggests how an improved strategy could develop.

Drug strategy is always prey to ideology and negative agendae. A firm hand on the tiller is essential. In summary NDPA would wish to see a system which promotes total rather than just physical health; instead of reactively responding to sickness, it validates and encourages non-users, minimises the number who start, facilitates users to stop, and uses the tools – including the justice system – constructively; with firmness melded with sensitivity.

A Total Health

The World Health Organisation (and many others before them) have defined Health as having six components: physical, mental-intellectual, emotional, social, spiritual, and environmental. Far too much of drug related work to date has ignored all but the physical element. Real progress awaits this fundamental widening of vision.

B Education is not equal to Prevention

A common misunderstanding is that Education = Prevention. Section C (below) exposes the fallacy of this; education is an important part, but far from being the whole. This flaw is compounded by overviews of work in Britain, much of which has indeed been limited to education, and has in consequence been of limited efficacy. This has had much to do with the unusually pessimistic attitude towards Prevention of many British drug workers. Ample evidence of success exists in other countries, and cultural transferability has already been demonstrated to the satisfaction of all except those with the telescope to their blind eye.

The vital techniques of persuasion; vocabulary, semantics, images, psychology and ‘thinkspeak’ are well understood by those who seek to replace ‘Tackling Drugs Together’ with more acquiescent strategies. It is palpably true that those who support the strategy are sadly not so well versed. Until this disadvantage is removed the struggle will always be uneven.

C A Community Affair

We live in a symptom-focussed society, with separated response systems for such as health, social services, justice. Painful experience has shown that this ‘segmental’ attitude seriously hampers effective prevention – the correct approach must be to engage the whole of society, albeit in different ways. We must grow beyond the notion that prevention is merely ‘stopping something happening’ into promoting and enriching the wellbeing of people. Some examples of action within the community are:

• Government – Specify, resource, manage, evaluate
• Health – Cover all health elements
• Schools – Health promoting policies
• Colleges – train teachers/youth workers in prevention
• Peers – Utilise potential
• Parents – de-marginalise, train, resource, support
• Religion – spiritual lead, network
• Pharmacists – Pro-active, prevent, reduce harm
• Businesses – Employee Assistance (EAP), testing
• Media – Educate staff, avoid mixed messages
• Vol. Sector – Network and engage
• Sport – Pro-active prevention
• Drug services – Encourage plurality

D Long, wide and deep

Environmental and nurture factors around the child which may precede drug misuse start very early; even in the nursery. Factors increasing propensity for use are many and varied, and can be profound. Prevention systems must therefore be ‘long, wide and deep’.

There is a flavour permeating from some quarters that exploratory use (otherwise euphemistically named ‘experimental’ use) is of relatively little concern. This is not only untrue, it reveals a fundamental misunderstanding of the process. Community-wide primary prevention for all age groups, especially the young, needs very substantial development above the present very limited levels. Beyond this there is also scope for focussed interventions, such as ‘mentoring, with those young people identified as more ‘at risk’ than others.

Parents are a key resource in prevention, a resource largely ignored thus far. Their marginalisation and disenfranchisement must be reversed, and they need support and training to cope with the greater demands on parents in this area.

E Social Foundation

Cutting-edge prevention technology recognises that wide focus is fundamental. Whilst social factors such as deprivation, unemployment or homelessness are not necessarily causal to drug misuse, they certainly correlate. Rhetoric around ‘return to full employment’ helps no one; if life after the microchip means ‘less than full’ employment, the social strategy should own up to this and address it constructively.

Support systems in ‘deprived’ areas should not presume all residents are drug users. If anything these areas need more primary prevention resources, not less.

F Justice potential

NDPA has identified ways of improving the application of the justice system. but surrendering to the drug problem is not one of them. Research has shown that justice systems which are firm but fair and coupled with quality drug prevention produce the best results. There is certainly more scope for diversion to treatment or counselling, (such as the TASC system in America), but by no means everyone is far enough into ‘a drug career’ for this to be relevant; in earlier stages some other intervention – perhaps developed upwards from Reparative Cautioning – should be explored.

Throughout the justice system (and without denying the just application of punishment and retribution, which are matters outside the scope of this Paper) the focus should firmly be on whatever methods are needed to produce voluntary non-offending in future. The deterrent effect of the sentencing structure will only be one part of this. There is good evidence to suggest that Drug Courts can be a helpful introduction; expediting cases and hearing them before knowledgeable judges and court officials is welcomed, even by the defendants.

G No debate needed

For drug apologists still pathetically struggling, thirty years on, to justify their cause, a common ploy is to refer to “the current debate on drugs”. Just keeping the subject on the agenda is a tactical victory. The next step is to continually plead until exhaustion in the listeners yields some compromise. The truth is that outside of this minority and a strangely supportive media there is no debate. Parents and other citizens do not want their children to misuse drugs – legal or otherwise. Some groups, including NDPA, feel obliged to respond, but do so unwillingly. Many MP’s have made it clear they reject calls for a Royal Commission since this would send an erroneous signal to the public that the law might change, when there is no such intention. NDPA strongly supports this stance. Mixed messages are confusing, especially to our young people.

H The public and the media

Engaging with the community at several levels and in several ways is the lifeblood of democracy, if a little anaemic at times.

With the drugs issue, the task is hampered by accidental or calculated misinformation, the use of out of date materials and by the personal agendae of those delivering the information – be they media personnel, drugs professionals, or others in the community. A whole vocabulary of ‘weasel words’ has been developed by a well-financed international pro-drug lobby, to confuse and seduce our policy makers and the public at large.

For ‘realism’ read ‘surrender’; for ‘informed choices’ read ‘laissez-faire’, for ‘normalisation’ read ‘decriminalisation’, for ‘prohibition’ read ‘the current laws almost all of us support’; for ‘harm reduction’ read ‘legalisation’, and so on.

NDPA finds the metaphor ‘War on Drugs’ inexact and unhelpful, but rumours of its death are greatly exaggerated. Some pro-drug campaigners suggest this is a ‘Civil War’, with the public as innocent victims – if this be so, then these campaigners are to the drug barons as collaborators are to an invasion force.

Government could do the whole process a great service, and increase the chances of its strategy succeeding, by tackling this issue assertively. The fact is that over at least the last ten years far too much succour has been given to those who seek to undermine the governments’, strategies; despite people of the calibre of Anna Bradley – ISDD Director, making it clear that “there is no research base for Harm Reduction”. The received wisdom of Harm Reduction has been widely applied whilst Prevention of any merit has either been undercut or excluded altogether. Ironically, in the face of increasing use over this period the protagonists of Harm Reduction audaciously claim that this is evidence that Prevention is failing! Government attempted to put Harm Reduction in proper perspective when producing ‘Tackling Drugs Together’, but old ideology dies hard. A good start would be to correct the definition of ‘Prevention’: to prevent should mean to be pre-event; anything during or after the event is damage limitation (harm reduction) or repair (treatment/rehab.)

(NDPA wishes to make it plain that the above relates to the ‘abuse’ of Harm Reduction as a ‘Trojan Horse’ for legalisation or decriminalisation, in the guise of a broad policy for non-users and users alike. In the quite separate and more traditional application of Harm Reduction (or damage limitation) to mitigate the effects on actual users, NDPA is supportive.)

J More support needed

The structure for ‘Quality Assurance and Quality Control’ in delivering the national strategy needs strengthening. At present there is a system (CDCU/DAT/DRG) for communicating up and down. but the level of ‘specifying’ and ‘compliance control’ is less than desirable.

In essence, the government should be able to verify that its strategy is reflected in local policy and action; and if not, why not. The obvious control mechanism would be funding, which should be prospectively and retrospectively tied to compliance (as well as to effectiveness). Funding of all aspects (prevention, intervention and treatment/rehab.) is well below where it should be. Moreover, within this funding structure prevention is very much the ‘Cinderella’ service. If compliance is given its due importance, it follows that it must be underpinned with appropriate ‘good practice’ training mechanisms.

Training should not be confined to the professions directly concerned with drugs services but should cover others of secondary and tertiary relevance; it must also cover the Voluntary Sector. In the case of any future regulating/accreditation systems for this field, it is essential that this is done by an independent body able to take a detached and balanced view of the whole process. Those working in intervention and treatment may well come under the purview of the Dept. of Health but for those at the Primary Prevention end a body such as America’s CSAP (Center for Substance Abuse Prevention) would be more appropriate.

Whilst sound arguments exist for having lengthier funding for proven schemes, there is also sound argument for seed-funding new initiatives, in order to judge their effectiveness. Evaluation budgets tend to ignore or under-resource newer, smaller initiatives; the reverse should be the case if value for money is to be achieved.

K Drug Information

Research, surveys and observation will continue to be vital to the success of prevention. There is a regrettable degree of xenophobia (towards overseas research and practice) in the drugs field which may have more to do with ‘ownership/control’ fixations, or excluding that which does not fit certain agendas; these factors often seem to hold more sway than the technical merits of the material. NDPA strongly recommend increased interchange with other countries on all aspects of drug-related work, particularly primary prevention, where there is so much that we can learn.

An almost unheralded reduction, in the USA of 60% over twelve years in the use of all drugs at all ages led Neil Dixon, BBC Social Affairs Editor to describe it as “America’s best kept secret”. The misuse of drugs is a global problem and we should be more willing to share international successes as well as failures.

It is fashionable to decry painful facts about drugs and their misuse; these should, it is argued, be excluded on the grounds that all “shock-horror” input is counter productive. A grain of common sense would not come amiss here; certainly hyperbole should be avoided, but rational facts set into context about the personal and social harm which can ensue should not be shirked. Leaving them out gives a falsely rosy picture of drug misuse. Prescribed drugs packaging contains information on all the possible harm – even though it is unlikely to affect more than a few people using the medicine.

L And in conclusion…

Current vogue in youth education speaks of ‘Informed Choices’. ‘Choice’ implies there are two or more valid options for selection. In the case of illegal drug use there is no option. In what other area of illegal behaviour – theft, violence. etc. do we permit choice? Moreover, the educationist vogue is to say this is ‘your choice’ – implying that the many other people consequentially impacted by that choice feature little if at all in the process. This is another area of training our young for life which needs rapid rectification.

Though the prevalence of drug use, especially by young people seems to be worsening, there is no need for fatalism. Others have succeeded, and if we improve our ways of tackling this together -not hoping for that mythical ‘silver bullet’ but instead co-operating in a pluralist approach, there is a bright future ahead. In this era of unemployment the word “redundancy” has become tainted, but there is one redundancy we can all welcome…

…we don’t need drugs!

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The overlap in technologies between drug prevention, delinquency prevention, and behavioural modification within the Social Services context (as described at the beginning of this chapter) was an exciting discovery for this author. However, rather like being the second into the bathtub after Archimedes, it was found to be not a new discovery. In 1983 Bill W. Lofquist in the foreword to his classic book, had made the following key statement:
‘We have organised human services around symptoms, building entire systems that work in relative isolation from one another. Juvenile and criminal justice, education, health, public welfare, recreation and many other services function in separate spheres and there is often isolation of components even within these systems….

Prevention is another matter. When I have told people I have been working on a book about prevention, the immediate question has often been prevention of what?’ That is a logical question in a symptom-focused, remedial, reactive world. I have purposefully left any mention of symptoms out of the title of the book. One reason is the awareness that a wide variety of symptoms are the result of some common conditions. Designing separate systems for remedial work may make some sense, but addressing the common conditions which promote those systems calls for a different approach. If we can get beyond the notion that prevention is only “stopping something from happening” to a more positive approach, that creates conditions which promote the well-being of people, we can begin to view human services quite differently. This, in turn, can transform and enrich our approaches to helping people and building communities that are relatively free of the symptoms we have designed the services around.

The wider significance and potential of this finding is enormous. It means that if we can only produce and effect truly comprehensive prevention strategies there is the promise of society empowering itself to achieve improvements across a broad spectrum. Nothing solves everything, of course, and like many good strategies it is likely to fall foul of such factors as professional and/or parochial jealousies, myopic policies, etc. Prevention workers are therefore unlikely to need to plan a fresh career for some time to come.

Taken from “Drug Prevention – Just Say NOW”, by Peter Stoker
David Fulton Publishers, London 1992.

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THE CANNABIS DEBATE
Re-printed from the Daily Mail Monday 30th July 2001
by David JonesSenior politicians have suggested the laws on cannabis should be revised after a new survey for the department of Health shows drug use among children is soaring. But should cannabis be legalised? On Saturday in the Mail we asked people from all walks of life for their opinion – and intriguingly it was those in medicine and law enforcement who warned against liberalisation. Today, we publish a special investigation comparing two very different policies on drug use in two European countries to see which is most effective.

The unmarked police patrol van suddenly brakes and two plain clothes officers step briskly on to the pavement, blocking the path of a group of teenagers wandering, apparently innocently, through their leafy suburban housing estate. “Hi, kids, how are things going?” begins Inspector Alex Hermansson. His tone is affable, but the youths, aged between 15 and 18, are apprehensive, for they know full well that this is more than a friendly chat. As Hermansson engages them in conversation, his colleague, Lars-Hakan Lindolm, checks each one for signs of drug abuse. First he looks into their eyes. Are the pupils dilated? Then he examines their jaws: is anyone chewing excessively – a classic symptom of Ecstasy use – or grinding their teeth, as amphetamine takers often do? This time, all the friends appear ‘clean’ and within a few minutes they are allowed to walk on. Yet the merest hint that they had taken any drug would have seen them arrested, their urine or blood tested, and brought before the courts.

Contrast this scene with another, which I had witnessed a few days earlier, in an equally respectable looking residential area only a few hundred miles away. It was a warm summer’s evening and children were playing in the streets, but all around the Lucky Luke ‘coffee shop’ the air was redolent of sticky sweet marijuana fumes. In theory, the people who go there to get legally stoned or buy their takeaway cannabis supplies – characters ranging from jobless hippies to smart business executives – are not supposed to smoke their reefers out of doors.

However, in practice, several of the licensed dope den’s customers casually lit joints, knowing the police would admonish them at worst, but would more likely smile and wave them on their way.

This is a tale of two countries whose attitude towards drugs could not be farther apart.

The first, Sweden, is hell-bent on creating a drug-free society. Its relentless pursuit of this seemingly unattainable ideal is taking the fight against drugs to tough new levels, unprecedented in the Western World. The second, Holland, has – willingly or not – won a reputation as Europe’s drugs capital. Hordes of tourists go there to take advantage of its liberal cannabis laws, which could soon be relaxed still more to allow production and bulk sales, as well as personal use.

In recent weeks, Britain has been lurching ever closer towards the Dutch model, with politicians to the left and right supporting the growing clamour to legalise cannabis. The question is: Which of these two contrasting societies would you prefer to live in?

The statistics might help you to make up your mind. In Sweden, only 2 of every 100 people aged between 15 and 25 are likely to have smoked cannabis in the past year; in Holland it is about seven times more (and a staggering eight times more in Britain).

Surely not coincidentally, the use of hard drugs, such as heroin, cocain, ecstasy and amphetamines, is appreciably lower in Sweden, too. So is the prevalence of drugs-related crime, though this is rising in both countries.

In Sweden, the mass production of drugs remains negligible, while Holland – which churns out up to 80% of the worlds ecstasy and truckloads of powerful ‘Nederweed’ cannabis – has been branded the drug baron of Europe. Despite these alarming facts, I leaned towards legalisation before embarking on this comparative study. The prospect of a few hash cafes seemed unlikely to threaten the fabric of society. And the casual use of cannabis is imbued so deeply in British youth culture that decriminalisation seemed, if not desirable, wearily inevitable. Ten days touring Holland and Sweden has changed my thinking completely.

The trail began with Amsterdam and the Grasshopper, a vast neon-lit dope-fiends’ mecca that shimmers invitingly in the vice-ridden part of the city. As I arrived, I was instantly disabused of the myth trotted out by Dutch drugs policy apologists. If we listen to them, the tolerance of cannabis in a controlled environment has succeeded in separating the hard and soft drugs market.

When you buy hashish in a ‘coffee shop’, the accepted wisdom runs, at least you’re not being hassled to buy something worse, such as heroin. This is nonsense. Even before I had paid my taxi driver I was being harassed by a scruffy Middle Eastern pusher who tried to press sugar-cube sized rocks of crack cocaine into my hand – something that has never happened to me in Leicester Square or Piccadilly. Such dealers target the major cannabis cafes, where stoned youths provide easy pickings.

Away from the squalid red light area, smaller coffee shops such as Dutch Flowers, a quaint canal-side establishment, can mislead the first-time visitor into thinking Holland’s dope houses are no more dangerous than the Rovers Return. As I perused a menu, featuring Spirit of Amsterdam (a Dutch grown favourite) and Morocco Unique (a medal winner in the annual cannabis cup), Marcel, the friendly manager, smoked the profits and extolled the virtues of Holland’s approach.

The cafes were largely peaceful and well run, he said. Bosses such as his own, who runs four coffee shops, upheld strict licensing laws that banned anyone under 18 and restricted the amount a customer could buy to five grams – sufficient for perhaps five strong joints. Listening to Marcel talk, and watching his young customers – some British dope tourists – quietly smoke themselves into a stupor, it all seemed rather harmless. But then, as the weed loosened his tongue, a darker picture began to emerge.

The law states that the cafes can keep only a kilogram of cannabis on their premises at any time. On busy days, this stash can run out several times. But the production and large scale supply of cannabis remains illegal – so where did replenishment come from?

“It’s a real back-door story,” Marcel said, lowering his voice. “Mostly we buy from middle men. Much of it is smuggled in from Morocco or Afghanistan. Let’s just say we have to be very discrete.”

The ‘back-door story’ has been one of Europe’s great untold scandals since Holland relaxed its cannabis laws more than 25 years ago. Ridiculously, the country allows cannabis to be sold in approved outlets (currently, 800 are licensed by local authorities), yet everything else to do with the drug is illegal – from growing it to importing it. Anyone who cultivates or imports cannabis is committing a criminal offence. This double standard has been exercising the Dutch parliament, and MPs recently voted to end the hypocrisy by regulating the entire cannabis market, from plant to pipe.

So far, however, the government refuses to sanction these proposals. Even it is not sufficiently laid back to risk the international outcry that would result. While the debate goes on, the shadowy figures who control the Dutch trade thrive.

The following day, I discovered just how easily they make their fortunes, right under the noses of the authorities, when I crossed the famous wartime ‘Bridge too Far’ and entered Arnhem. There, at the Lucky Loop coffee shop, I met an amiable, attractive couple, both 21, Denis Holdyk and Krysta Slykhuis.

Though they shared the strongest joint on offer – the mind-blowing White Widow – they remained remarkably lucid, their tolerance bolsted by smoking cannabis almost every day since they were 13.

Somewhat recklessly, Holdyk soon disclosed that he was one of around 500 cannabis growers who supply the cafes in and around the city. He began business three years ago, with five plants, but was now renting two apartments as cannabis nurseries, and reckoned to make around £80,000 a year. One day, he said, he would leave Holland and launder the money. “Then I will retire to my yacht and get high all day,” he smiled.

My first reaction, I confess, was one of muted admiration. After all, here was a young man who seemed to believe in what he was doing, and had turned a small (albeit illegal) business into a roaring success.

As the evening wore on, however, I realised that Holdyk and his girl friend were not the earnest, untroubled entrepreneurial couple they presented. Both suffered recurring psychiatric problems, and it was impossible to believe their blind insistence that smoking huge quantities of cannabis (and, in Krysta’s case, taking almost every other drug) was not to blame. They also boasted of helping a jailed associate to smuggle drugs into prison.

“We wrapped a big piece of hash inside some silver paper and he swallowed it,” said Holdyk. “that man became the richest guy in the prison”.

If I still needed proof that the great Dutch drugs experiment has failed, I found it in the Southern frontier town of Venlo. Two decades ago, this 90,000 strong community supported just one licensed coffee shop selling cannabis. Today, there are more than 60, but of that number only five have licenses – the rest are illegal.

And, to the horror of its citizens, Venlo has become a drugs cash-and-carry for droves of German shoppers, who need to drive only three miles across the border. To stroll along the River Maas, even at lunchtime, is like stepping into some oriental opium bazaar. The peddlers, almost exclusively Turkish, urge you inside seedy shops selling cannabis paraphernalia. But many offer harder drugs, too.

Parking my car opposite these dubious shops, I glanced through the window of a grubby, white van. Inside, a middle-aged man was smoking heroin from silver foil. Small wonder that most parents have banned their children from walking beside the river.

Belatedly, the burghers of Venlo are endeavouring to reclaim their once safe town. With the backing of the Dutch government, they have launched Operation Hector, a £25 million project aimed at shutting down the drugs denizens.

Andre Rouvoet, an MP for the small Christian Unison party, is among the small number of Dutch politicians who wish they could turn back the clock. Asked what he thought might happen if Britain were to legalise cannabis, he said:”Let me give you some good advice. Don’t. Just don’t.”

And so to Sweden. A generation ago, this fiercely independent nation of nine million souls might easily have gone the way of Amsterdam, but at the height of the bohemian Sixties, something went wrong. The Swedish government had empowered certain named doctors to prescribe narcotics to anyone claiming to be addicted.

The system was widely abused and one of the junkies supplied an overdose to his fiancée, who died. The story caused a national scandal. At roughly the same time, a Swedish professor, Nils Begerot, published a major study of drug misuse. He concluded that soft drugs invariably let to harder ones and that abuse was akin to an epidemic, which spread inexorably through the population.

Thus was Sweden’s hardline policy born. The first laws were drafted in 1968, but they have been sharpened over the years, so that now all narcotics, from cannabis upwards, are regarded seriously, and even their presence in the bloodstream is punishable with prison.

The police camp on the doorsteps of known drug sellers and users, continually stopping and searching them. No drugs offence, however petty, is overlooked. Even small-time cannabis smokers can expect to be arrested and fined, over and over again. If they don’t kick the habit, they might be sent for compulsory treatment in an addiction centre. Some are jailed.

Constantly badgered like this, even hardened habitual offenders throw in the towel. In Malmo’s central prison I spoke to Faruk Haliti, 25, who started using drugs at 14 and later joined a notorious, violent Gothenburg gang. Tired of being hounded, he has opted to end his latest sentence – two years for possessing a machine gun and cocaine – in a therapy unit.

“I’ve been in prison maybe ten times and I’ve had enough,” he said “I’m going to try to straighten myself out.”

The Swedes are determined to prevent more children from growing up like Haliti. To that end, school pupils are required to fill in questionnaires about their drug habits, and where there is evidence of abuse, action is swiftly taken. I saw the evidence of the programme’s efficacy when I ventured into Rosegarde, Malmo, one of Sweden’s toughest high-rise estates, where 70% of its largely immigrant population are jobless.

If this were Peckham, say, or Moss Side, a smorgasbord of drugs would have been on offer. Yet all the teenagers I spoke to there were horrified when I asked whether they smoked cannabis to ease their boredom. “None of our friends takes anything like that,” said Petric Takiri, 15, a Kosovan. “We value our health”.

Whether the Swedish model could ever succeed in Britain is open to question. It would demand huge resources and require a monumental cultural shift. According to Malmo police chief Thomas Servin, it is already too late. “I would like Britain and all the EU countries to follow our example, but I don’t think it will happen,” he said.

“In your country the attitude is different. They sell cannabis openly, and you have this liberal view.” Perhaps he is right, but I have returned home convinced that we should seriously consider giving Swedish-style zero tolerance a try.

Because, faced with the choice of raising my children in dope-fugged Holland or squeaky clean Sweden, I know which country I would choose.

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Editorial Comment on British government’s New Media strategy for drugs

NEW BRITISH MEDIA DRUG CAMPAIGN HAS SCHIZOID TENDENCIES

Late May saw the public launch, on satellite and terrestrial channels, of the British Government’s latest strategy concerning drug misuse. The strategy includes an array of TV and radio announcements, a new web page ( www.talktofrank.com ), a new telephone help line (to replace the National Drugs Helpline), an email help line, and a collection of CD Rom or print based materials, which local agencies are encouraged to use to promote the campaign and to generate activities with the public. The budget for this campaign is set at £3 million a year for the next three years.

The strategy has been given the brand name of ‘Frank’ – this was chosen after much internal contemplation and focus group dialogue. The organizers perceive this brand name to convey an image which is non-judgmental, honest, down-to-earth, entertaining and always there for you – maybe something like an older uncle … that kind of relative whom young people would feel more comfortable speaking with than they would with their own parents.

The most usual dictionary definition of the word ‘FRANK’ is “open, honest and direct, especially when dealing with unpalatable matters ” … but another definition – intriguingly – is the “stamping of an official mark on a communication”. Moreover, the original Franks were a people that controlled much of Western Europe for several centuries … the choice of name for this campaign might therefore achieve a certain resonance in Downing Street. (as an ‘aspirational target’, anyway).

It would be quite wrong to be unremittingly carping about Frank; there are aspects which deserve commendation and encouragement. Paul Betts, father of the late Leah Betts, whose death from ecstasy sparked off a major media campaign, expressed himself encouraged by some of the content, and by the principle of ‘talking with’ rather than ‘talking at’ the young (not a new practice, but certainly a good one) At the same time any campaign which sets itself up as being ‘open, honest and direct’ must expect commentary upon it to be likewise. An overview, therefore, would conclude that there is a mix of the good and the bad; a mix of the sophisticated and the naive – and, above all, Frank seems to be suffering from schizophrenia when he contemplates his goals.

This last point is most evident when Frank addresses drugs other than his ‘betes noire’ (heroin and cocaine) – the strategy is said to dovetail with the overall drug strategy, which has, as one of its main aims, “… helping young people resist drug misuse in order to achieve their full potential in society”. The official press release for Frank backs this up by saying that “A key priority of the drugs strategy is to educate young people and prevent them becoming involved in drugs”. These are aims which would find favour with all but the most libertarian zealots. Sadly, the actual detail of what Frank will get up to is all but invisible in respect of prevention, and seems, more often than not, to be written in terms of fatalism about drug use and thereafter acceptance of drug-using behaviour. Much is made – especially in the adverts – of the assertion that “… as many as one in three people have taken drugs …” without clarifying that this figure is for any use at all throughout one’s lifetime, and the majority of these ‘users’ never do more than ‘dabble’ once or twice before giving up. Even for the higher use group which is young people, the number who use more than twice is as low as one in six, with the figures for regular or for problematic use being very much lower than this.

If Frank intends to be “honest and direct” about “preventing them becoming involved in drugs” then why does the campaign say it will “… focus on the most vulnerable young people … (and) … will focus on cocaine and heroin “? The answer seems to rest in some of the remarks from the rostrum, to professionals and to the Press, at their respective launches. Once again the assertion was made that cocaine and heroin do more harm to society than other drugs, an assertion based on a narrow, user-centric definition of ‘harm’ which ignores significant categories of damage such as intellectual, social and emotional impacts, and which scarcely touches on the damage to people other than the user. Yet again there came the mantra: “The Just Say No approach does not work” – leaving aside the factually contentious (and sometimes tendentious) nature of this claim, there was a noticeable absence of reference to the many other varieties of primary prevention, where the reduction in use that comes from such initiatives is well documented. (A more cynical observer might conclude that the underlying agenda is to neuter all primary prevention). So, Just Say No is a no-no … and yet, referring to the fact sheet for the drug ecstasy, the unequivocal statement is made that “When you buy ecstasy you have no way of knowing what is in it, so the safest thing to take is nothing” – in other words, just say no.

The adverts, both TV and radio, will be found humorous by all but the most determinedly morose, and they have a fast-moving style which should appeal to young people – and to many of their parents. There is a debate to be had about underlying messages in the depictions, particularly of adults and of drug users, but this is for the future. Similarly, the language chosen for the fact sheets on specific drugs is simplified and boiled down in order to be more accessible to the lay reader, even though this risks people misconstruing what they perceive – and gives the more pedantic professionals something to get their teeth into. The risk of people picking up the wrong message is a key aspect – reservations have been expressed by several field workers. Picking up the wrong message is almost an Olympic sport amongst young people, and as one seasoned youth worker once observed “There’s nothing wrong with an adolescent, that reasoning with him won’t aggravate”.

Several professionals had things to say on this front. Alistair Lang, the chief executive of DARE (Drug Abuse Resistance Education) said “There is no harm in having information about drugs in the right places, but this sounds a bit like a ‘Which? Guide to mobile phones’. From the government you want to hear a categorical health warning, of the sort you get on cigarette packets, that drugs can harm – or even kill you”. Oliver Letwin, the Shadow Home Secretary, said it was “… highly questionable for taxpayers’ money to be spent on telling young people that Ecstasy gave them a buzz”.

Mail on Sunday senior columnist Peter Hitchens was trenchant in his criticisms of Frank; in his column on 1st June he urged parents to visit the website ( www.talktofrank.com ) and see for themselves the sort of advice being given out. [HNN website readers are encouraged to do the same – Ed.] Hitchens quoted this disturbing item: “If only illegal drugs came in packets with instructions … we’d all know what the drug would do, how much is too much and what other drugs are to be avoided at the same time”. Hitchens hammers the implications of this kind of presentation, which are that the law is bound to be ignored, and – even more dangerously, that there are safe ways to do drugs. Hitchens took up the website’s invitation to ask questions, and asked two simple ones: “Is it wrong to take drugs?” and “Is it ever safe to take drugs?”. The website was unable to offer a reply to Peter Hitchens, who concluded his article by wondering whether the Home Secretary David Blunkett could answer those simple questions, and added another question – ‘ Will the Home Secretary shut this site down?’ … an answer is unlikely.

Home Office ‘drugs minister’ Bob Ainsworth claimed that “this is the first time the government has tried to reach out to parents and carers as well as children … ” which will be viewed with surprise by those drug professionals whose shelves are sagging under the weight of previous government-sponsored material doing just that. Hazel Blears, Public Health minister, came in for some heavy media criticism when she said, “in many cases people do take drugs because it’s a pleasurable thing to do”. The outcry says more about the critics than about the issue; anyone who does not know that one of the primary motivations for drug abuse is pleasure needs to revisit their textbooks. Where the minister misfired was in not making it clear that pleasure from drugs up is artificial, short-lived, and ultimately empty experience, and therefore that the (legitimate) human pursuit of pleasure should be fulfilled via other routes – which a Public Health minister might be expected to not only be aware of, but to advocate. She compounded the felony by paraphrasing the attack on ‘Just Say No’ approaches, which makes one speculate whether her own ‘aspirational target’ is to render her post redundant! (Just say Go?).

Not all the critics of the Frank Campaign came from the prevention side of the field. Danny Kushlik, director of the ‘legalise everything’ Transform Drugs Policy Institute branded Frank a “wasted opportunity” because it offered no advice on ‘Harm Reduction’. He went on to emote “The campaign is crap. It focuses entirely on illegality. It looks like it’s been designed by some official at the Home Office” (hardly a breathtaking deduction). Even Release, the longtime cannabis legalisation campaigners, were unhappy; “Talk to Frank conjures up an image of a white older man” (Release has, for several years, itself been managed by a white older man …). Of all the liberalist groups, only DrugScope seemed content – less than surprising to those who can see DrugScope’s fingerprints all over this product.

The fact sheets are certainly written in easy-to-read language, including slang, but some of the statements are a cause for serious concern. Amphetamines receive the admonition: “too much, too often can make people depressed and paranoid”. – the implication being that lesser consumption is of no concern. Regular users of cocaine or crack can, it is said, develop “a regular habit” (is there such a thing as a ‘irregular habit’?) – but there is no mention of cocaine or crack addiction. With Ecstasy, “some of those who died did so from heat stroke” – but what of the others? Although, with Ecstasy, the uncertainty of what you are being sold leads Frank to recommend that you avoid it, a similar concern about uncertainty as to what you’re sold when it comes to heroin is not accompanied by any similar recommendation to just say no.

As might be expected, the fact sheet on cannabis is the biggest disappointment; and it receives fire from both sides. The UKCIA (UK Cannabis Information Agency) is incensed by what it sees as avoidance of its version of the truth; understandably enough, given their faith in the weed. Prevention professionals have also expressed serious reservations, but on the basis of research rather than faith. The extraordinary increase in strength in recent years, with the consequent major increased risks of psychoses, is brushed aside by the statement: “Some types are very mild. Some are very strong.”. There is a blunt and erroneous statement that “It is very unlikely that any one will become physically dependent on cannabis…” and this is reiterated later in the same fact sheet, albeit with psychological dependency acknowledged – yet in a phrasing that suggests this is somehow less of an issue – which any drug worker worth their salt will know is far from the case. Another misleading statement is that “some people use it for medical reasons – MS, glaucoma, (etc) …” – the more correct statement would have been “some people use it in the belief that it has medical benefit”; some people will see this statement as governmental acceptance of a position which – in respect of ‘raw’ (as-grown) cannabis – remains more likely to be scientifically rejected than accepted. Frank goes on to say “medicinal types of cannabis are being researched” – this is unforgivably sloppy writing; it is extracts of cannabis which are being researched, and then only for ingestion by means excluding smoking; there is no suggestion in the research that smoking cannabis joints is on the research or government agenda. Once again this sloppiness gives credence where none is justified, and unjustified succour to lobbies who are quite capable of making up their own fantasies without the help of the government writers.

At the launch for drugs professionals, first up to introduce Frank was Cathy Hamlyn – Head of Sexual Health and Substance Abuse at the Department of Health. Referring to an increased spend by her department, up from £236 million to £296 million per year (which makes for interesting comparison with just £3 million per year for Frank. One wonders where all the rest is going).She gave the overall aim of Frank as “helping young people understand the risks and the sources of help” (no mention of prevention there) and to “give parents more confidence”. The target age range for Frank was stated as “young people from 11-21 years and for parents of 11 to 18 year-olds”; this is probably a rational age bracket for those receiving or reading the Frank materials, even though there is some incidence of drug abuse below this age.

Next to speak was Katie Aston of the Home Office, who gave an interesting slant on one goal, which she verbalized as “… to reduce use of class A drugs and to reduce the frequent use of illicit drugs” – presumably infrequent use of illicit drugs is OK by Frank. She went on to say that one expectation was that there would be “… a shift in attitudes on specific drugs”, and she gave the example of “modifying the perception of heroin use as being linked with failure”. Quite what the advantage would be, and for whom, in this kind of ‘rehabilitation’ in the characterization of heroin use, is unclear. Equally unsettling was the stated intention, of “… starting the process of destigmatisation of drug abuse”. One can see the advantage, within a therapeutic process (of counseling or treatment) of the client’s attitude not being clouded by such characterisations; but this is a world away from some general kind of normalisation across society, and with it the risk of suggesting an active acceptance of drug misuse. Home Office urgently needs to get its act together on these issues – assuming, charitably, that they have not already done so.

Also on the rostrum was Sarah Maclean, representing the Department for Education and Skills; she told the professionals that Frank will support schools (and young workers) through drug education advisers, and that this will involve the Drug Education Forum – not the best news for those drug educators who pursue a preventive approach; the DEF has long been dominated by a ‘harm reduction and personal choice’ model … it remains to be seen whether it changes its direction under its new chairman, Eric Carlin, who is UK chief executive of Mentor, the prevention body which has such diverse board members as HM the Queen of Sweden, and George Soros, as well as Lord Mancroft, a Tory peer with a penchant for relaxing drug laws.

A question about the absence of reference to gun crimes and turf wars, and there being only fleeting reference to crack cocaine, brought the response that Frank did not want to generate worry across the nation about specific drug problems which were more regionally concentrated. Questions about the absence of black people in the adverts threw the panel into a confusion of hand-wringing, with protestations that this was only the beginning, and that all ideas from the public and professions, for modifying the campaign will be entertained with enthusiasm. This remains to be seen.

Overall, then, there are things about Frank that are worthy of encouragement, but he has some worrying traits, and he seems to be facing in several directions when it comes to what he is trying to achieve; almost schizophrenic. Being all things to all men may seem a good strategy for a politician, but for a communicator with young people, parents and carers, Frank needs to be more than ‘open and non-judgmental’ – valuable though these values are. Young people can smell hypocrisy a mile off, and can tell when someone is pandering to them in an attempt to be ‘cool’ or to buy ‘cred’. Frank could usefully mature a little, pluck up his courage, and move beyond mere distribution of information – as a caring ‘older uncle’ might well do. Frank speaking about society’s goals does not have to be off-putting, nor does it have to stray into authoritarian mandates. If Frank can help the young and their parents understand – not only what drugs do, but also why it makes sense to avoid them – in the interest of other people, not just the user – then this would be a real leap forward … far beyond just saying ‘No’, and into a truly honest dialogue worth having, in the interests of all of us.

_______________________

Website: www.talktofrank.com email: FRANK@homeoffice.gsi.gov.uk
FRANK Hotline: 0800 77 66 00

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Where school-based prevention programmes disappoint, family interventions have a better record. According to an authoritative review, the one with the best record of all is the US Families Programme now being tried in Britain. Where does it come from, and what is the evidence? Karol Kumpfer originated the programme.

The Strengthening Families Programmei is one of the few whose substance use prevention credentials have survived rigorous inspection by independent scholars, in this case a British team who singled it out as the most promising “effective intervention over the longer-term for the primary prevention of alcohol misuse”.Their judgement carries considerable weight because it was based on one of the scrupulously scientific Cochrane reviews. An added attraction is that Strengthening Families’ benefits potentially extend to youth crime and anti-social behaviour, educational attainment, and child welfare, consistent with advice that family interventions should not deal with drugs in isolation. Though the programme and most of the research are US-based, at least one British centre is using it to gain these broader benefits ( The British experience) and at another an evaluation is under way ( Accolade from Cochrane review).

Roots: drug using families and primary school children

The study which caught the Cochrane reviewers’ eyes involved a version of the programme designed to be universally applicable to the families of secondary school children and tested on mainly rural, white, intact families. However, its origins were in an attempt to help drug using parents do the best for their primary-school age children.5 Patients at a methadone clinic in Salt Lake City provided the impetus. By improving their parenting, they hoped to help their children avoid replicating their own fates and to achieve happiness and success. In response Karol Kumpfer, a developmental psychologist at the University of Utah, created an intervention to reduce the chances that the 6–10-year-old children of problem drug users would themselves later develop drug problems. She planned to achieve this by “improving parent-child relationships … We try to change the family dynamics, to create a more democratic family where they actually have family meetings, talk together, and plan activities together.”

Careful construction

Work started in 1983 with a review of research on how drug problems and of existing family programmes which might divert this trajectory. Based largely on the Utah team’s own research, a careful unpicking of how the drug problems of parents affect their children established that disorganised stress in the household often results in a lack of consistent and responsible parenting.7 Parents spend relatively little time with their children, particularly ‘quality time’ enjoying joint activities. Stigma and fear of exposure lead to the social isolation of the family and of the child. To their peers, children from these families can seem ‘strange’, unable to engage in the normal give and take of social interaction or to share their homes and their families with their friends.ii The result is an impoverished social environment which lacks adult supports. Family dysfunction takes its toll on the child in the form of emotional stress, low self-esteem, under-achievement at school, conflict at home, and avoidance of intimate relationships. To meet these needs elements were adapted and blended from existing approaches.8 Despite the achievements of some parent-only approaches, Dr Kumpfer believed that the best response would involve the whole family – parents and children. Ironically given its later transformation into an across-the board (‘universal’) prevention programme, she was also convinced that there was a “qualitative difference” between trying to prevent drug abuse in these high-risk families and preventing recreational and experimental drug use by the children of more typical families. What emerged was the first Strengthening Families Programme. Its basic format has remained unaltered. The weekly sessions last two to three hours. For about an hour parallel groups of children and parents from four to 14 families develop their understandings and skills led by two parent and two child trainers. In a second hour parents and children come together as individual family units to practice the principles they have learned.9 The remaining time is spent in logistics, meals, and enjoyable family activities.5 Its tripartite nature (parents only, children only, then the whole family) departed from previous approaches as did the fact that parents put their learning into effect during the 14 sessions – an opportunity to receive immediate feedback from the trainers.8 During parent-child play sessions parents are coached in how to enjoy their children and to reinforce good behaviour. At first the accent is on building up the positives before tackling the more incendiary issues of limit setting and discipline. The programme is highly structured with detailed manuals, videos and activities, but also highly interactive and designed to be adapted sensitively to the participating families.

The first test: parents in drug treatment

The approach was first trialled in Salt Lake City on 90 families with parents in outpatient substance abuse treatment. Though its findings were convincing enough to generate further federal funding, the study was never fully reported in a scientific journal 10 and the accounts we have seem inconsistent. Many studies followed but this remains one of the few to have randomised families to the programme, eliminating the risk that the apparent benefits arose simply because families who opted to undergo it differed from those who did not. Thirty families were randomly allocated to continue with the parent’s normal substance abuse treatment (the controls)9 while 20 each additionally received the Strengthening Families parents’ sessions, these plus the children’s sessions, or the full programme including the parent-child family sessions1 At issue was which approach would generate the greatest before–after improvements. The clear answer was the full programme. Compared to controls, families offered the full intervention improved in parenting, children’s social skills and family relationships. Parents became less depressed and cut their drug use. Children became less aggressive, better behaved, said relationships with other children had improved, and felt more able to express themselves. Among older children could be seen a reduction in the use of tobacco, drugs, and alcohol. The differences were usually substantial and statistically significant. Without family sessions there had been gains in parenting and child social skills but these had not gelled into improved family relationships. It was the package ‘wrapped up’ by parents and children coming together which had made the difference.

Adapted for new populations

A series of trials followed in which Strengthening Families was adapted for and tested on high-risk families with pre-teenage children from disparate backgrounds.Except for two as yet unpublished studies, none were randomised and only one has been published in a scientific journal.Results from one of the randomised studies are still being analysed. It involved not just US but also Canadian families, probably culturally closer to Britain. Participants were families with children aged 9–12 one of whose parents had a drink problem. They were randomly assigned to a minimal contact control group or to Strengthening Families. An initial report on 365 families who completed before-and-after interviews found significant extra parenting gains in the Strengthening Families group, particularly when the child was a boy. One of the largest of the non-randomised studies involved a mainly poor, multi-ethnic sample of 421 parents and their 703 youngsters aged 6–13. Strengthening Families was compared with a local variant which omitted the joint parent-child sessions found so important in the original study. Again their importance was shown when the full programme led to significantly better family environment, parenting, and child behaviour/emotion outcomes. A five-year follow-up of just the Strengthening Families sample found that the gains had largely persisted, but without a control group this finding can only be considered suggestive. In Hawaii an attempt was made to disseminate the programme throughout schools, churches, and public service organisations. Though multiply flawed, a local evaluation which compared a longer ‘culturally appropriate’ version against the original came up with the interesting finding that the customised version was less beneficial – a warning that though they improve recruitment, such modifications can also undermine the programme by departing from core content or principles. In this case a shift from behavioural training to ‘family values’ sessions could have been the culprit. Hawaii also demonstrated that the prospect of multiple benefits can stimulate support from disparate agencies, enabling large-scale implementation. It also underlined the importance of skilled trainers, these big families numbers were best kept low) if drop-out is to be minimised.

Rural black mothers benefit

For America with its large black drug treatment caseload, whether the programme would work with these families was a major issue. An adapted Strengthening Families’ 14-session version has been tested mainly on high-risk families with primary school children, the seven-session version as a universal substance use prevention programme for secondary school children, but both have been used in other roles. For both there is evidence of improved family, parental and child functioning and of a retardation in the uptake of substance use and a reduction in its severity. For drinking in particular, the seven-session programme is considered the most promising approach we have, but research on this version is confined to a few studies in US rural communities, while most research on the 14-session version has consisted of uncontrolled studies. Nevertheless the consistency and bulk of positive findings warrants serious consideration of the approach not just for substance use prevention but as a means of promoting pro-social child development in general. It is feasible to implement in Britain and a formal evaluation is under way. A version was tested on 62 black, single-mother families in rural Alabama in a study which featured a one-year follow-up.Four results echo other work on the programme. First, recruitment beyond women already in treatment at a mental health centre proved difficult. The solution was to employ a recruiter from the same background who enrolled participants from venues such as housing estates, churches, and classes for problem children. ‘Indigenous’ recruiters also proved valuable in later trials. Secondly, over 80% of the recruited families virtually completed the 14 sessions, typical (perhaps after teething problems) of the programme. Thirdly, the most at-risk families made the greatest gains – in this case mothers who used illicit drugs as well as alcohol. Here there was more scope to normalise the children’s and the parents’ functioning, including their drug use. Children of less at-risk families improved only in the areas where they happened to be problematic in the first place. The implication is that the programme works by helping families with relatively severe problems move closer to the normal range. For those already within this range, it makes less difference. Lastly, the degree to which parents spoke up in the group sessions made no difference to how much they and their children profited from them – a finding later replicated.

Black drug using fathers queue up to join

The replication came in research on black fathers with 6–12-year-old children. In preparation the Alabama manual was tailored for the inner city and renamed the ‘Safe Haven Programme’. It was trialed on the residents of a Salvation Army drug treatment centre in Detroit, using drug counsellors as leaders. Again the recruiting agent was crucial, a charismatic ex-addict drug counsellor. Another typical feature was the integration of the programme into the life of ordinary community venues (local churches at night), destigmatising participation and enhancing sustainability. Also typical was the provision of child care, meals, transport, and other basic supports, much from church members or the treatment agency. These promoted recruitment and retention as did the advent of the specially tailored programme.vii At first low, the retention rate rose to 80% where it remained for four years as applicants came to exceed capacity. Within two years, 88 families had entered the programme. Most had below-poverty incomes and half the children had fallen seriously behind at school, but still 58 families came to at least 10 of the 12 sessions.For the analysis they were split into families whose adults (not just the father) consumed higher versus lower amounts of alcohol and illicit drugs. Before-to-after gains were concentrated in the high drug use families where there were substantial improvements in family and parental illicit drug use, parental depression, confidence in parenting ability, time spent with the children, in the childrens’ delinquency, aggression, and withdrawn or compulsive behaviour, and some improvements in family ‘atmosphere’. Parents also reported significant improvements in their child’s relationship with school.

Feel the weight

Though encouraging, in both studies of black families parents chose to commit to the sessions,viii giving the intervention a head start by selecting out less committed families, and neither had a control group who did not go through the programme. Without this we cannot know whether in these families the improvements would have occurred anyway Practice points from this article This systematic review points to the potential value of the Strengthening Families Program … for the primary prevention of alcohol misuse.

Accolade from Cochrane review Strengthening Families received a boost when a Cochrane review team led by Professor David Foxcroft singled it out as the most promising “effective intervention over the longer-term for the primary prevention of alcohol misuse”. Foxcroft’s team examined over 600 reports of studies of psychosocial or educational interventions intended to prevent alcohol use or misuse by young people. Just 56 were relevant and rigorous enough to be included in the review, and just three reported alcohol use or misuse reductions which persisted over a follow-up period of at least three years. One was the seriously flawed study of Life Skills Training analysed previously in and another investigated an approach tailored for Native Americans. That left Strengthening Families, specifically the study in Iowa where the seven session version was offered across the board to families with children in the early years of secondary school. This featured a “strong design, and … a consistent pattern of effectiveness across the three drinking behaviour variables”. Unusually, its effectiveness“seemed to increase over time,reflecting the developmentally orientated …model on which the intervention is based”. To the original analysis David Foxcroft added one accounting for children not reinterviewed at the last follow-up. This assumed that their behaviour matched that of children from control group families. The result was an estimate that for every nine children whose families had been offered the Iowa programme, one was prevented from starting to drink, to drink without permission, or getting drunk; the last two were statistically significant. These ratios were around twice as good as those for the other two programmes and more consistent across different drinking measures. It was enough to persuade Professor Foxcroft to call for a project to “translate, develop and pilot the Strengthening Families Programme in the United Kingdom”. One such trial is under way, but using it to help troubled families rather than as a universal intervention. Run by the Trust for the Study of Adolescence, the project’s main aim is to test whether involving young people in a family programme is more effective than parenting programmes focused on parents or carers. Participants will be drawn from families referred by the courts because of the behaviour of their children. One of the five services in the study is using Strengthening Families as an example of a whole-family approach. The project ends in August 2004.

Source: DRUG AND ALCOHOL FINDINGS ISSUE 10 2004

Filed under: Prevention (Papers) :

By Daniel Bent

Lasers are beams of ordinary light that are made powerful by the fact that the individual waves of ordinary light are in sync, aligned and concentrated in a manner consistent with the laws of physical science. Our efforts at drug prevention policy can be made extraordinarily more powerful if we understand the science of what makes members of a community intolerant towards drug use and concentrate our individual messages consistent with that science to motivate the majority to actively stand up against permissive drug policies. This paper explains how.

What is necessary is educating the vast majority who don’t use drugs about how other people’s drug use negatively affects them. This can create a social climate hostile to drug use. Such a change can bring back an America where drug use is negligible. Achieving that change in public attitude should be a major element of the future strategy against drugs.

Educating Drug Users is a Waste of Resources: Here’s Why –

Attempting to educate current drug users is a waste of drug education resources. For drug users, drug education is up against the basic reward or survival mechanism of the brain. Reason and cognitive thought are simply no match for a chemically stimulated reward center of the brain.

A drug user who has had the pleasure or reward mechanism of their brain intensely stimulated by cocaine or crack, as obvious examples, or those who use depressants and thus avoid anxiety and pain are unlikely to modify their drug using behaviour in response to drug education. An explanation of the brain and its operation demonstrates why.

First, pleasure is the brain telling the body that what it did to achieve the pleasure was what it should do and that it should do it again. Two familiar primary natural stimulators of the pleasure or reward mechanism are food and sex. This principally takes place deep in primitive areas of the brain. It is our basic survival mechanism. Areas of the human cortex were added to assist humans to achieve such pleasure and avoid pain to improve the chance of survival. For example, some of the cells added to the cortex enabled humans to see in colour and thus enabled the more successful gathering of edible fruit. Thus the additional cortex was not a substitute for the existing reward mechanism but served it.

Second, the forebrain which is a large part of the cortex which allows us to learn in the sense of drug education or indeed any “thinking” process was also designed to increase our ability to obtain those things that stimulate the reward mechanism with pleasure or increase our ability to avoid pain. It allowed us to engage in cooperative hunting, planning, and other behavior to improve our survival.

When the reward mechanism is “hot-wired” by drugs, an attempt through education to change drug-using behavior is likely to be rejected. When the reward mechanism already has its pleasure, the operation of the forebrain is superfluous and the natural process of reward from the use of the forebrain is unused. This was demonstrated during an experiment at Concordia University in Montreal where rats were given unlimited access to cocaine. They rejected opportunities for food and sex in favour of the drug.

Cigarette addiction is a clear example of this phenomenon. There is hardly a smoker now that does not cognitively understand that chronic cigarette smoking is harmful to their future health. They understand it but are not likely to act on that understanding in the face of the message that the reward mechanism receives when a smoker lights up a cigarette. The cigarette “hot wires” the reward center of the brain by stimulating it and provides an immediate message of reward, i.e., pleasure. After frequent reinforcement from repeated smoking a competing cognitive message via the forebrain that smoking is harmful is superfluous. In other words, once the reward center of the brain has a direct means of stimulation, the rest of the brain processes are simply not any competition.

Drug use in America has been seemingly intractable because the power of drugs over the reward center of the brains of drug users is so powerful. There is, however, a way to use the power of the brain s marvellous survival mechanism to increase the effectiveness of drug education.

Engaging the Survival Mechanisms of Non-Drug Users:

What can be done for impact is education of a different sort. That is educating non-drug users how other people’s drug use affects them. With this form of education, the survival mechanisms of the brains of non-drug users will be stimulated to protect their interests and survival by asserting their strong opposition to drug use by others in their communities.

Americans by nature tend to respect each other’s freedom to do what they want. We will tolerate the behaviour of others that we personally reject for ourselves. This tolerance has its limit. The limit is when we perceive that the behaviour is directly affecting us–our quality of life or in more fundamental terms, the quality of our survival. What takes place at this point is that our survival mechanism, the reward centers of our brains, react to the threat to our interests from other people’s behaviour and we take action to address and oppose it.

Again the smoking issue provides an extraordinary example. For decades we knew that a cigarette smoker was affecting his or her own health. Only a small handful of American cities and towns enacted smoking bans in public places. Then the Surgeon General of the United States and the National Academy of Sciences issued simultaneous reports finding that non-smokers’ health is affected by incidental second hand smoke. Overnight, cities across the country enacted ordinances limiting smoking to public places. Many enacted ordinances against smoking that would have been impossible even immediately before these highly publicized reports. More important, in a sudden shift of behaviour, non-smokers began to express their intolerance of smoking directly in both social interaction and in the workplace. The difference -non-smokers finally understood that other people’s cigarette smoking affected them. They did what Americans will do when they perceive their personal interests are negatively affected. They took action.

In order to use such self-interest to turn public opinion against drug use, drug education should be focused in large part on educating non-drug users how other people’s drug use affects them. Self-interest works to make people more productive. It’s the basis of our economic system. It can work here too. Indeed the “parent drug prevention movement” has been one of the most effective quarters in bringing positive action to bear on the drug issue because parents are driven to protect their children. They are simply an extension of their own self-interest.

We already do this brand of drug education to some extent, albeit serendipitously. News reports of the Baltimore Conrail crash in which sixteen passengers died when the pot smoking train engineer failed to notice a warning signal taught non-drug users of the harm from other people’s drug use. Reports of drug use among air traffic controllers, school bus drivers and pilots are examples of the same. It has been effective. We simply need to focus our energy into such targeted drug education to effectively pursue the ultimate strategy of turning public opinion into outrage against drug use.

If one group’s survival mechanisms are engaged on an issue and the majority’s is not, the first group will continue to push their issue and do whatever it takes to prevail. It has been called the “iron law of political economy”: “The many with a small interest, is no match for the few with a big one.” This is the circumstance we face on drug use in America. To prevail we must engage, as occurred with the tobacco use issue, survival mechanism vs. survival mechanism. This has the potential for achieving a society that is intolerant of drug use and those who promote it. With that we will be within reach of returning again to a drug-free America.

Enough for the Theory – Here are Examples of How To ….

The following are examples of proposed public service advertisements that are written pursuant to the strategy discussed above:

FLYING HIGH:

Two people sit facing the camera in what appears to be a poorly lit room. The field of view is their faces and upper torsos. They are passing a marihuana joint back and forth and each drag brightens the area around their faces a bit. After a few passes, the person on the right says, “Let’s go to work.” As he puts the joint away, the person on the left almost immediately slips on a cap and the camera starts slowly backing away so that the field of view increases. As the camera backs, the viewer comes to the realization that he/she has been looking through the windshield of a commercial aircraft. The camera continues to slowly back away until the full windshield and full nose are in view. The plane starts rolling out while the camera continues back. The plane is filmed in a jump frame sequence so that the viewer follows its roll out onto the runway and take off. As the plane is approximately 40 feet in the air, just at the point the landing gear starts up–the frame freezes. The following words appear in white on the bottom of the screen: “So you think other people s drug use doesn’t affect you? Not On Your Life!”

TOO BUSY TO CARE:

This begins with a nighttime scene of an average 40-year old male leaving an office building on a rainy wet night in a downtown area. He stops suddenly, obviously an internal pain clutching his chest as he leans against a light pole. The sound of heavy heartbeat rises. The sidewalks are vacant but as he looks up he sees a lighted taxicab approximately half a block away and raises his arm to hail it. He struggles into the back of the taxi. Leaning onto the seat and with difficulty he tells the taxi driver, “I think I’m having a heart attack!” The driver understands immediately and rushes away with his passenger. He makes a u-turn, drives briefly down a one-way street, then on a main street speeds from corner to corner slowing only for red lights going through them in order to quickly reach a hospital. The viewer gets a sense from this part of the episode that the passenger in distress is fortunate to have run into a taxi driver willing to do what’s necessary to get him to an emergency room as fast as possible. The taxi pulls up to the door of an emergency room. The man staggers out as the taxi driver says, “Forget the fare. Good luck, Buddy.” The man staggers through the sliding hospital doors, walks up to the nurse’s station clutching his heart. No one is there. The viewer realizes that several people are being worked on in the adjacent treatment areas and the man staggers from one to the other trying to get someone’s attention. As he goes to each treatment area, there are teams of medical people working desperately to save the life of the patient on the table. At the first treatment area as the team works, one is heard speaking. The only clearly discernable word heard is “overdose.” The man staggers to the next treatment area to a similar scene where it becomes clear from the conversation of the medical team that they are dealing with a crack crises–crack induced psychosis. At each treatment area the work is frantic.

At the last treatment area, a similar scene where one of the members of the team states, “we’re going to have to pump this junkie’s stomach.” Another states, “Hey, wasn’t this guy in here the night before last.” At this point, to get assistance the man tries to hail a nurse rushing into one of the treatment rooms. He is ignored. His back is against the tile wall of the hospital emergency room. He obviously recognizes, by his facial expression as he looks into the camera (close up), that he’s not going to get any help soon. The scene is held for a few seconds so that the viewer comes to the same realization. As the realization sets in, he slides down the wall out of view. At the bottom of the screen appear the words, “So you think other people’s drug use doesn’t affect you? Think again!”

BUSINESS ON THE LINE:

A man and woman are in an office decorated to convey that it is a law office. They are apparently discussing documents in a file. Both are dressed as professionals. The woman is firmly telling the lawyer “You must oppose their motion so the judge will see the evidence at a hearing.” The lawyer, apparently distracted, nods in agreement telling her “Don’t worry, I’ll object.” He then tells her “Hold on a minute before we leave for court.” He quickly goes into an adjacent empty room without her and closes the door. Inside and alone he pulls out a vial and snorts a white powder (cocaine). He rejoins her and they leave.

The next scene is a courtroom. The lawyer is seated next to his client and is rising and addressing the court, “No objection, Your Honour” as the woman, surprised, is looking up at him in complete disbelief. The scene fades. The words, “Some lawyers call drug use a victimless crime!” appear.

SLICK SMOKE:

The camera starts with a close-up of an individual standing up in what appears to be a room. The wall is slightly out of focus and therefore, in the beginning, unrecognizable. The person facing the camera is smoking marihuana. During the few drags he is obviously lost in the pleasure of the joint and not paying attention to his surroundings. A bell, which only is vaguely recognizable as a ship’s bell, rings four times. The bell startles the marihuana smoker back to his task. At this point the camera starts moving back. As the field of view increases you realize that the person has been standing at the wheel on the bridge of a ship. The camera continues to pull back as the viewers recognize that they have been looking through the windshield of the bridge. The camera moves back toward the bow and up and away at a right angle so that the ship’s profile, that of a huge oil tanker, is finally in view. The background is then recognized. The background is modified for each audience. For example, for audiences on the East Coast, the background can be New York harbour, Boston harbour; Miami’s harbour, etc. For West Coast audiences–the Golden Gate Bridge, Long Beach harbour, the Channel Islands and Puget Sound; and, for Hawaii audiences–Waikiki Beach. The following words appear on the screen: “So you think other people’s drug use doesn’t affect you? Think again!”

TRAFFIC HAZARD:

The ad begins with a view of a car travelling along a highway. It is passing oncoming traffic all travelling at a high speed. Between cuts of the traffic shots where the car is passing through intersections there are close ups of the driver. The first cut of the driver shows him rolling a joint in his fingers while the palms of his hands rest on the steering wheel. Alternating scenes of the car going through intersections, school zones, communities, and facing oncoming traffic as the driver finishes rolling his joint and lights it. In the last scene with the driver dreamily smoking his joint a school zone sign flashes on the screen, then image of a child crossing the street, and then back to the driver dreamily puffing his joint when the frame freezes. The following words appear on the screen: “So you think other people’s drug use doesn’t affect you? Think again!”

You get the idea. The strategy of educating non-drug users how other people’s drug use harms their interests them can be applied not just in advertisements, but also by everyone in their own sphere of activity and influence. That is not as difficult as it may seam. We merely focus our efforts on engaging the survival mechanisms of the majority of Americans who are non-drug users. Indeed, there is no more laser like focused way we can get the result we need . . . a return to a drug-free America.

* * * The author, Daniel Bent, is a mediator, arbitrator and attorney. He is a former United States Attorney in the Reagan and Bush administrations. He was the chairman of the U.S. Attorney’s Committee on Drug Prevention and Education. His email address is: DanBent@FairMediation.com.

Filed under: Prevention (Papers) :

Paper by Peter Stoker C. Eng., M.I.C.E. (Retd). Director, National Drug Prevention Alliance (UK).

“We need to get beyond the notion that prevention is merely stopping something happening, to a more positive approach which creates conditions which promote the well-being of people”.

The essence of prevention is not centred on blocking negative behaviours which are unlawful, unhealthy or anti-social; it is centred on promoting positive, healthy, behaviours which are life-affirming and which bring lasting benefits to self and society. Paraphrasing Lofquist, I would add that we also need to ‘get beyond the notion’ that engaging in a few mechanistic processes, or pumping out a few aspirational messages, will solve the problem. To quote American humourist H L Mencken,

“For every complex problem there is a simple solution – and it doesn’t work”.

The implications of this for prevention are major. It means that if we are to have a significant preventive effect we must not only look at the mechanisms of drug abuse but at the mechanisms of society – in which drug abuse is but one of several problematic behaviours.

I like the story of the drug worker who fought his way across deserts and through blizzards to reach the cave where the greatest guru in the world lived. ” Oh, Great Guru” he said ” Can you tell us how to solve the massive problem which is drug abuse?”. ” Why do people abuse drugs?” asked the guru. ” To escape reality” said the drug worker. “That’s easy, then” said the guru “You just need to improve reality”.

Culture is another word that can be interpreted in many ways. My dictionary tells me that it can relate to the arts; to the producing of what is known as ‘cultured people’. Or it can relate to the growing of things like bacteria – or of a pearl in an oyster – perhaps this latter concept is a nice one for us to hold on to; that out of gritty situations we can help to produce a thing of beauty and value. But leaving those definitions aside, the dictionary definition of culture which we are ordinarily engaged with is

“The Attitudes and Behaviour of Particular Social Groups”.

2. WHERE DOES CULTURE COME INTO PREVENTION?

Culture is both reactive and pro-active. It reflects what is already there – but also influences what is to come. If prevention is “… the sum of our actions to ensure healthy, safe and productive lives for all our children and families” (CSAP 1993)(Ref.2) then culture is the sum of all our expressions and influences – be they healthy or unhealthy.

This leads me to the definition of ‘Health’. Far too often this is narrowly described in terms of physical capacity or mental illness. But we should surely know from classical and modern writings that ‘Health’ is much wider than this, and in its other manifestations it is much more prone to cultural influences. A typical definition of ‘Total Health’ – such as is used by (int. al.) the World Health Organisation – is:

Physical           How well do I use the body I have?
Mental           How well, or ill is the structure of my brain?
Intellectual       How well do I use the brain I have?
Social          How well do I interact with my community?
Emotional         Am I in touch with my feelings, or do they control me?
Spiritual           Is there purpose, or just a void, within me?
Environmental   Am I a giver or a taker, in this planet I inhabit?

There are many factors influencing decisions about behaviour – factors which contribute to the culture in which the decision is taken. You can address these individually or corporately, but if you only address them individually, you are unlikely to significantly affect the culture. Why do you need to be conscious of this? Because of that essential truth – ‘Think globally – act locally’ – if, that is, you want to act sensibly and effectively at the local level. Another very good reason for taking the wider view is that the culture around behaviour can be likened to a kind of ‘social ecology’. In a paper (Ref.3) written jointly with Professor Roy Evans of Brunel University, this concept of social ecology is explored. The essence of it is that width of vision and caution is required, because actions in one element produce reactions in others, sometimes unexpectedly, and sometimes undesirably. The corollorary is also true: that is, you may be able to beneficially generate an effect in an element you have not explicitly impacted, by addressing other elements which in turn influence it.

3. HOW DOES CULTURE INFLUENCE BEHAVIOUR?

To explore this, let’s look at a concept developed by American prevention expert Bill Oliver (Ref.4), to explain the development of addiction, and which I have augmented; to illustrate the culture of behaviour – Bill uses the analogy of a tree… the Tree of Behaviour.

When the Tree of Behaviour is fully developed and regularised, it will display itself in two crowning branches – one healthy; the other unhealthy. Unhealthy regularised behaviour is what we in the drugs field call dependency (or addiction). This is reached progressively by behaviour which started as just trying something, then repeating it occasionally, then regularly, and then habitually repeating it. Despite the increasing evidence of the damage that this behaviour is causing, there is a compulsion to continue.

Some of this will also be true of healthy behaviours, but with these there will be no need of a compulsion to over-ride the negative experiences; positive experiences will play a part in encouraging the behaviour to continue (though the value of ‘positive reinforcement’ is also well proven). This is what we hope for and seek to develop through our prevention efforts.

But the Tree of Behaviour doesn’t grow out of nowhere – it isn’t spontaneously created; it is the outcome of a process that is largely invisible. Invisible because it is below ground; it has roots. Within each of us – in our personal mission control centre and as the root of our behaviour, is an assemblage of intellect, will and emotion. As impulses reach our centre of consciousness, our intellect, will and emotion respond to the impulse and the outcome is that we develop a thought. We give consideration to that thought – including whether or not we want to put it into action – and in the process we develop an attitude towards it. Our attitude towards any action we are contemplating is probably the first visible sign which others can see – like the first green shoots of a tree coming up through the ground. This is why, as parents, we need to be vigilant about the attitudes our children display.

What I want you to concentrate on, though, is that internal, ‘underground’ phase – before the attitude develops. Psychologists have identified a stage before a thought formulates; it is what they call ‘pre-contemplation’ – meaning that you are thinking about thinking about something. In this seminal stage, a great many influences apply… Memories – good and bad. Using those memory banks to project images of what might happen if this behaviour is followed. Values and boundaries for the individual Weighing advantages and disadvantages to oneself and to others. Applying learning received so far. Peer pressure and role models. The drive for personal pleasure. Curiosity and risk taking. Pain and how to avoid it. Feelings of spirituality and faith – or the lack of them. All these and more will influence the nurturing of that first thought, and will decide whether we reject it – or decide to act on it. I would term this ‘the culture in which decisions are made’.

If someone alters the culture within which decisions are made, it is virtually certain that there will be different outcomes. In my paper “Moralising, Demoralising … the Fight over Personal and Social Education” (Ref.5) I describe how the Values Clarification philosophy founded by Carl Rogers and Professor Sidney Simon (and which also drew in part on the thinking of their contemporary, Abraham Maslow) can be seen to have found fertile ground in which to breed – firstly in California – where else?! – but later touching down in various spots around the world. The confluence of Rogerian thought with other liberally-inclined arguments produced a juggernaut that crushed all but a few vestiges of the morally-based opposition. The confluence was further swollen by the expansion of illegal drugs – out from marginal use by the mid-twenties and older age groups – into mass use by the young, and is also accentuated by the new ‘cult of youth’ – the conferring upon them of greater freedoms at the same time as the removal of much of the authority traditionally held by parents and teachers. Greater disposable income level by the young, and the consequent emergence of a youth market, were other key factors.

I would argue, from all this, that it is not too much to say that Culture drives Behaviour – be it at individual or societal level. It follows that if you want to change behaviour, you have to change the culture. No small task!

4. NESTS OF CULTURE

Consider first this simplified hierarchy – or ‘nest’ of cultures:

Culture within ourselves effects our attitude, our values and boundaries, as we think, review the action we are contemplating.

Our group culture opens us up to peer pressure, as well as to spirituality and religion.

Our community culture opens us up to norms of behaviour as well as economic, social and political constraints.

Our society culture does the same, but on a bigger stage.

Each of these cultures is nested within another, and also inter-related with other cultural influences in a complex mix.

Each of us moves between these nests in a way that it is influenced by our environment, acting in tension with our personal culture – and the beliefs that flow from it. Structural factors may be positive or negative – things like employment (or lack of it); bereavement, frustration, love, recognition, fulfilment, friendships, housing, money (or the lack of it), – all these and more will all act to steer us into different cultures.

One of the most dramatic examples of how culture can influence behaviour came in 1974, when a study of Vietnam War veterans found that only 12% of those who were addicted to heroin in Vietnam took up the habit again once they had returned to the USA, despite heroin being easy to find in the US, to the extent that half of them admitted trying it again before abandoning the practice.

Societal factors overlay and add to the culture. Whilst there are positive societal factors – such as the growth of ‘volunteerism’ and the increase in government subsidy for the arts; there is no shortage of societal factors which tend to encourage drug abuse. Here are some examples:

Conspicuous consumption – displaying my ability to spend

Rapid gratification – pleasure NOW, not this afternoon

Rights but no responsibilities – my wants, free of ‘cost’ (to me, that is)

The ‘Right to be Happy’ – others have no right to stop it

Self before society – others are all there to serve me

Youth on top – defer to them; they are ‘kings of’cool’’

Political Correctness – follow these rules, right or wrong.

Politics is a culture all of its own, operating in its own idiosyncratic way. Avoidance of loss of face, and the search for re-election are two of the cultural criteria. In an information-laden age there is increasing reliance placed on the ‘Civil Servant’ – the hired hand who analyses, recommends and speech-writes for his hurried master, the politician. The civil servants have their own cultural standards, partly rooted in the need to be seen by their politician (amongst others) as ‘expert’ – this means they too have to find other ‘experts’ from which to obtain the expertise, and this lays them open to lobby groups.

Norman Dennis, in his short paper: “The Culture of Intoxication” (Ref.6) expresses horror, but gives us a timely warning, in observing arch-legaliser Arnold Trebach and others actively presenting their libertarian arguments within the European Parliament. We will all have our own view of the European Parliament – and to what extent it relates to reality – but the core concern has to be that Trebach and others like him have far greater resources than we do, and there is therefore the very real risk that the European Parliament will recycle the pro-drug cultures statements, presenting them to the unwary – especially in the new Enlargement Nations – as ‘wisdom from the centre’

Melanie Phillips, in her paper “Hatchet-Faced Idealists” (Ref.7) described how there has been Left Wing support for terror since the French Revolution, running on through the eras of Stalin, Mao and Pol Pot. In the 1940s George Orwell savagely attacked the so-called ‘intellectual left’ for its innate defeatism, its disaffection with the West and its fascination with the brutal governance of the Eastern bloc. From these stark beginnings can be seen the emergence of ‘intellectuals’ giving succour to drug abuse – rationalising it as a ‘legitimate’ expression of disaffection for conservative/’right wing’ ideology and authority.

And of course one massive player in the culture game is The MEDIA. The ‘messengers’. The rulers of this magnificent city which is Rome used to have a tradition of killing any messenger who brought bad news – if we continued this practice these days we wouldn’t have any journalists left! But instead we seem to expect bad news – and disbelieve anything good we hear. Meanwhile the messengers have transformed themselves from reporters of the news into makers of the news – and filtering everything through their own belief system. It used to be said that journalists gave us ‘All the news that’s fit to print’ – nowadays, the more cynical attitude is summed by the strapline on the front of Rolling Stone magazine … ‘All the news that fits’.

TV is the big one, of course. A major survey in America a few years ago found that an encouragingly high percentage of children got their information about life issues from their parents. But the same survey asked the parents where they got their information from … the great majority answered: ‘the TV’. Radio is more pervasive than you might think, especially with the young, who tune in for the music but get a lot more besides. Newspapers, populist and ‘quality’ also indulge in what is known as ‘Advocacy Journalism’ – which means lobbying to you and me. There is of course always a place for ‘Opinion’ pieces in journalism, but what we have now is way beyond that. Generous space is afforded to advocates of drug law relaxation, whilst prevention advocates stand outside with their noses pressed to the window; largely ignored or else used in a tokenist way to give a suggestion of ‘balance’.

What you and I may define as ‘balance’ is often very different to the definition the media uses. In his book ‘Bias’ the former senior journalist with CBS News, Bernard Goldberg (Ref.8), describes how most journalists seriously believe that in their liberal – or even libertarian – views, they represent the middle ground, so it follows that anyone seeking to preserve moral order is of the Extreme Right, and thus to be shunned or ridiculed. The ruthless way in which they dispatch those who challenge their orthodoxy is well described by Melanie Phillips, in her paper “The Trouble with the Liberal Elite is that it just isn’t Liberal” (Ref.9). She laments the fact that today is an era in which truth has become relative. The American philosopher William James (1842 – 1910) went so far as to suggest that

‘Truth may be defined as that which it is ultimately satisfying to believe’.

Melanie goes on to paint a stark picture of modern life, in which drug legalisation is contemplated for no other reason than profit; alternatives to the traditional family structure are destroying marriage; tolerance of alternative lifestyles is overtaken by pressure to endorse and promote them; and so-called liberals castigate anyone who seeks to protect morals as ‘authoritarian’, ‘nanny’, or ‘fascist’. Liberalism, she says, was born out of reaction to the tyranny of monarchies and other hardline authorities, but when democracy replaced these despots, liberalism – instead of stepping back – went on a quest for justification of its continued existence, and in the process became a perversion of its earlier noble purpose. Liberals will now tell you that only they can achieve the nirvana of perfect lifestyle for us all – and that this has to be an existence in which no one is judged. As she wryly concludes:

‘all moral judgements are wrong, except the judgment that judgment itself is wrong’.

It is a matter of record that a significant number of media outlets have decided to actively campaign for liberalization of drug laws. And to persuade other publications, if not actually to join them, at any rate to show some degree of sympathy. Amongst the British national newspapers there is currently only one which takes a consistently outspoken line against drugs (and another which takes a lower-key approach). The outspoken paper is the Mail, traditionally held to be the paper Mr Blair most worried about, because of its strong center ground position and high circulation. It is quite clear that over the past three or more years a steady campaign to assassinate and marginalize the Mail has been sustained in the media and amongst the ‘chattering classes’.

The newspapers’ colleagues in print, the magazines, are amongst the strongest promoters of hedonism. ‘Style’ magazines like Face, FHM, ID, Ministry, have long pursued a love affair with ‘lad/ladette’ behaviour – heavy drinking, ‘caning’ (drugs), promiscuity are all seen as milestones which all must pass to gain entry to the World of Cool. Even the youth magazines – like Bella, 19, and Just17 – all of which are regularly read by those much younger than their ostensible readership age – have an unhealthy pre-occupation with sex. In addition to these ‘generic’ magazines, there are of course the ‘specialist’ magazines like ‘High Times’, ‘Cannabis Culture’’Heads’ to cater for the dedicated doper – and to intrigue the casual reader.

Films rely on something called ‘Product Placement’ to boost their revenue – this is the inclusion of commodities on the screen to make people want to buy them. It works for commercial products – but it also works for things like drugs, which are many times included in the action with no justification in the storyline, and with inappropriate audience ages … ET and Crocodile Dundee are just two examples of this malpractice. Posters. Tee shirts. The fashion industry with its exploitation of ‘heroin chic’. The advertising industry with its cynical deployment of drug culture icons. They all add to the picture … a picture which – you might say – is being developed in the negative!

5. PREVENTION AND ITS ENGAGEMENT WITH CULTURE

It is in the nature of our overloaded, under-resourced profession that we behave like Chinese jugglers, rushing from one stick to another to keep the plates spinning. One plate is marked ‘Education’, another ‘Awareness’, while another concerns ‘Messages’ (or slogans). Others concern Speeches, Posters, Advertisements, Songs, Drama, Poems and so on. In this situation it is all too easy to become obsessed with twiddling the sticks and – fearful of stepping back – we can neither see the whole of the structure, nor the gaps in it. What we therefore tend to do is to keep on spinning plates and hope that what we are doing is somehow improving the situation.

Some experts have already addressed the inter-action of prevention and culture. Responding to the assertion of legalisers, that John Stuart Mill (regarded by many as one of the forefathers of ‘Liberty’ as we understand it – or misunderstand it – today) would have benn sanguine about drug abuse, Professor Norman Dennis in his paper “Drug Legalisation and ‘On Liberty’ – the Misuse of Mill’ (Ref.10) defines a continuum of cultures stretching from ‘Anomie’ (anything goes) to ‘Authoritarianism’. He paraphrases Max Weber in saying that there are four main types of culture; of which two have little to do with rational thought; one is driven by tradition and the other by emotion. The other two, more rationally based are the ‘fully rational but self-interested, calculating’ approach and – lastly – what Weber calls the ‘value-rational’ approach. This last one is driven by principles, rather than self interest. Advocates of drug legalisation have attempted to tendentiously pigeonhole John Stuart Mill in the ‘self-interested’ culture, quoting his statement that

“Over himself, and over his own mind and body, the individual is sovereign”.

This ploy by the legalisers is a gross misrepresentation, as should be immediately obvious to anyone who reads not just this sentence from Mill, but the sentences which precede and follow it; for example:

“Whenever, in short, there is definite damage, or definite risk of damage, either to an individual or to the public, the case is taken out of the province of Liberty and placed in that of Morality or Law”.

The problem in these times is that ‘Morality’ and ‘Law’ have become (a) objects of derision and (b) enormously and cynically obfuscated. Offenders have been cast adrift in a sea which has few if any moral landmarks. Chuck Colson, in his paper “The Cultivation of Conscience”(Ref.11) draws out the reality today, that many young felons simply do not know the difference between right and wrong. (As one of my own colleagues, who deals with tough kids put it to me “How can we ask them to be good, when they don’t know what good looks like?”). They are unlikely to find out under the new regime … what our young people are increasingly being encouraged to use as a basis of their behaviour is “Do what you think is right”. This ‘Value Clarification’ approach harms formation of young consciences – and Columbine and Jonesboro are the prices we pray. Colson concludes that Nietzsche’s deconstruction of morality brought not Superman, but people clinging to the wreckage of their values and beliefs, with their only touchstone being ‘It works for me’ .

Norman Dennis echoes this sentiment; in his paper ‘The Uncertain Trumpet’ (Ref.12) he describes how Nietzsche and those who came after him have induced a massive shift from what Nietzsche characterized as an Apollonian culture (reasoned, restrained,seemly and decent) to a Dionysian culture (intoxicated, orgiastic, and orgasmic) – and as an example of this brave new world they have fostered, Norman cites the reports of a British a video shop owner was recently fined £5,000 for selling videos which were not as pornographic as their titles suggested.

Returning to Colson, he further observes that ‘Rationalism’ and ‘Empiricism’ have been blown away, as has the idea of inculcating morality – simply because morality, being based on ‘pre-existing values’ is automatically rejected by the Values Clarification disciples. The result is feral children, ethically and morally abandoned. In what must surely be an ominous precursor of this, Cardinal Newman, as long ago as the 18th century, said:

“Conscience has rights because it has duties… it is a stern monitor, but in this century it has been superceded by a counterfeit … it is the right of self-will”

You might say this means that conscience erects a ‘Stop’ sign when one’s ‘self-will’ is speeding. Without this control system, self-will proceeds onto the assumption that one has a ‘personal right’ to this behaviour, thence to the notion that there is a ‘constitutional right’ to the behaviour, and thus to a pressure to legalise it. This can be seen in several aspects of our culture today; it is certainly not confined to drugs. It would be nice, says Colson, to think that churches would be the ones to hoist the ‘Stop’ signs; sadly too many of them are selling out, panicked by the spectre of dwindling congregations.

On the day that this paper was consigned to the conference organizers, BBC national radio ran an interview with a churchman, exploring why there has been such a growth of attendance in some churches (but not others). The churchman referred to people being unsettled by “… seismic changes to our culture …” which he saw as a primary drive behind them seeking renewed strength and stability in the church. A challenge which demands a response, surely?

And what about ‘the Pursuit of Happiness’? First you have to identify what you mean by happiness; Colson distinguishes between mere shallow gratification and what Aristotle called ‘eudaimonia’; it may sound like an infectious illness, but it actually means ‘ the (consciously) good life’ – fulfilling, balanced and responsible. Clearly, conscience plays a major role in this, and equally clearly the death of conscience leads to tyranny as a means of regulating what will become chaos. It follows that if we do not want to be ruled by tyrants in future, it is in all our interests to promote conscience now. According to Colson, this means going back to what he sees as the three core institutions – family, church and university, and instilling a health-promoting model in all of them.

6. WHAT ABOUT COUNTER-CULTURES?

Counter cultures can be a significant obstacle to prevention. Before you can negate them, you need to understand them. Here are a few examples:

Brazil – $6 is the price of a life. Brazilian senior journalist Olavo de Carvalho delivered a chilling description of life in his country, in his paper “Drug Traffic and Public Policy in Brazil” (Ref.13). Olavo traces the origins of self-serving behaviour back even further than Carl Rogers, – the ‘fountainhead’ mentioned earlier in this paper – pinpointing Hungarian Giorgy Lukacs, a post-Marxist philosopher as a primary source of this thinking. Lukacs in effect argued that in conditions of social ‘Alienation’ and ‘Reification’ – a term coined to describe man viewing himself as an ‘object’ … a ‘cog in the machine’ rather than a sentient being, the individual is justified in putting himself first). So, by this concept, a man is less guilty for personal acts than for those against the class to which he belongs, and there is no evil in the world except ‘conservative morals’ – an object of contempt. Olavo’s paper goes on to give a stark description of life on the streets and in the ‘corridors of power’ in Brazil. $6 is the price you pay in the Rocinha Hills, to have someone killed. Drug barons exercise ‘droit de seigneur’ – but over any woman in the village, at any time. Petty criminals depend on the barons for the loan of weapons and vehicles – and even for the ‘freedom’ of living in a slum. Compared to the power of the barons, the police are a largely marginalised force. The intellectuals have played their part, teaching the young that drugs had a ‘liberating role’ in the struggle against ‘capitalist aggression’. Many criminals recognized that the pickings were richer if they left the world of crime in favour of careers as ‘revolutionary militants’ – it was out of this trend that the Sao Paulo Forum was born, combining legitimate organizations with criminal ones, including the Brazilian President seated at the same table as FARC, the revolutionary army which dominates large swathes of Colombia, and is now said to control most of the cocaine production and export from that troubled country.

Libertarianism – the abuse of John Stuart Mill. This has already been described in Section 5 of this paper.

Harm Reduction and the Abuse of Liberty. My paper ‘The History of Harm Reduction’ (Ref.14), presented in Sweden in 2001, gives a detailed appraisal of how the traditional process of intervention with known users – as part of the treatment process (the stated goal of which remains as abstinence in the British strategy at least, notwithstanding that country’s lurch towards liberalism in other aspects of drug policy) to mitigate the harm that they do to themselves and others, whilst working to bring them to cessation – was deliberately subverted to produce a mechanism for liberalizing drug abuse. In echoes of Olavo de Carvalho’s remarks, it is known that at least one of the ‘inner cabal’ who engineered this stratagem was a Stalinist.

Stalin himself is attributed with the following passage, which very revealingly argues for the use of drugs as a lubricant in social revolution:

“By making readily available drugs of various kinds; by giving a teenager alcohol; by praising his wildness; by strangling him with sex literature and advertising to him or her … the psycho-political preparation can create the necessary attitude of chaos, idleness and worthlessness into which can then be cast the solution that will give the teenager complete freedom everywhere. If we can effectively kill the national pride of just one generation, we will have won that country. Therefore, there must be continued propaganda to undermine the loyalty of citizens in general and teenagers in particular”

Nihilism and the culture of despair. There are probably few western societies that do not have ‘sink estates’ – pockets of poverty in which crime is rife, and often perpetrated by neighbour against neighbour. Boys as young as 12 sell their bodies to pay for drugs; pensioners live in fear of reprisals if they should complain of errant behaviour; police define ‘no-go’ areas for their patrols, ceding control of the streets to the criminals. In these conditions it is hardly surprising that drugs are a way of ‘escaping reality’ – and there is no sign of anyone heeding that guru I mentioned at the start of this paper, and seeking to ‘improve reality’. Journalist Nick Davies graphically describes this brutalized environment in his book ‘Dark Heart’ (Ref.15) – and his criticisms of the failures of successive governments to address the problem are justifiably trenchant. Sadly, Davies has gone on to absorb the distorted arguments of the liberalisers, and suggest that legalizing and prescribing all drugs – including heroin – would improve the condition of the poor. It is hard to comprehend how such illogic gains hold … but it is there, in the ‘journalist classes’ of Britain – as much as the journalist classes of Sao Paulo.

Sexual cultures – whilst there are few statistics to reinforce the anecdotal evidence, it is widely held that drug abuse is prevalent amongst gay lifestyles. Some drugs, such as amyl or butyl nitrite, are said to be favoured by the gay community; it is also possible that drug abuse might be a response to feelings of being a ‘persecuted minority’. At the same time the gay activists are strident campaigners who will pick up any issue that may look to be a useful platform. Thus it was that when Police Commander Brian Paddick was relieved of his post in Lambeth, South London, after unilaterally decriminalising cannabis in his area and then having his (gay) partner claim that he had smoked cannabis in their flat, the issue was not only taken up by the pro-cannabis lobby, but even more forcibly by the gay lobby, who accused the police authorities of homophobia, and characterized the disciplining of Paddick as being not about cannabis policing – but about attacking gay culture. The pro-cannabis groups were quite happy to march behind this unexpected vanguard, illustrating how apparently disparate pressure groups ally under a ‘flag of convenience’.

7. WHO IS WINNING NOW?

They have been, but not by as much as they think they are. Despite all the media reports that highlight Britain’s position at the top of the European drug abuse league, and the incessant stream of stories suggesting that every young person is knee-deep in pills, potions and powders, the well-proven fact is that 83% of British youth either never use at all or else give up after one or two tentative tries. Of the 17% who use more than this, many give up in the early stages of their drug use ‘career’. We are a long way from having to run up the White Flag of surrender.

However, a warning note needs to be sounded. Statistics also show that the great majority of young people who do not themselves use drugs, do not care if people in their circle are using, and do not see it as their business to intervene. This substantial absence of ‘positive peer pressure’ is almost certainly holding back progress in reducing drug abuse.

The way to win is perhaps best indicated by Sweden, where an experiment with decriminalization spanning several decades was eventually dumped in favour of a preventive policy coupled with assertive treatment services. The comparison between Sweden today and places like South Australia, where decriminalization is in full swing, are salutary. Researcher Lucy Sullivan (Ref.16) found that in Sweden, lifetime prevalence was one-fifth of that in Australia, use in previous year was one fifteenth, and dependent heroin users were – at worst – no more than one tenth of those in Australia. Other parameters, such as youth dependency, methadone prevalence, drug-related deaths in general and for under-25s were all significantly lower in Sweden.

8. HOW CAN WE STRENGTHEN PREVENTION CULTURE?

How can we ‘cultivate the cultivators’ of healthy lifestyles? The longest journey begins with a single step, so Buddha tells us; therefore, let us resolve to take the first few steps, gaining in confidence as we leave each footprint behind. Here are a few ideas:

Communications:

Study this paper’s recommendations, plan any new actions from it

Disseminate your own recommendations to others

Build ‘more bridges, fewer towers’ – open yourself to other organizations, and actively co-operate with them, rather than competing with them, or starving them of information

Generic activities:

Plan structurally – with the ‘Social Ecology’ in mind

Audit your strengths and build on them (SWOT Analysis – strengths, weaknesses, opportunities, threats)

Work to the model of ‘Total Health’

Advance the concept of ‘Other, not just Self’

Expose and dispose of ‘Values Clarification’

‘Cultivate the Conscience’

Improve Reality:

Establish primary prevention as main criterion in drug education All education should have prevention in mind

Establish improved, rapid access treatment centers Treatment, including mandated attendance, should be available sooner

Define and confine ‘harm reduction’ as within treatment, for known users only Pseudo-harm-reduction should be exposed for the sham it is

Pro-active Media Strategy Cultivate your media, learn to love them, programme your initiatives

Fix ‘Broken Windows’ Restore order and reduce crime by not tolerating even the little things

‘Prevention Cities’ Follow the San Salvador example

‘Police Get a Pizza the Action’

This title refers to a scheme (Ref.17) in which police co-operated with shopkeepers in a district where fights often broke out amongst crowds of people waiting to be served with pizzas after pubs had closed. The scheme installed ‘ hotlines’ from every pub to the pizza parlours, allowing advance ordering and no-wait distribution of pizzas; result – no crowds, no more fights. An excellent example of ‘problem-oriented policing’.

‘Cool to be clean’ tee shirts, and similar promotions Give your creative people a chance to shine!

Music business re-energised with prevention in mind

Art and Drama re-energised with prevention in mind

Promote products like ‘Life on Sunday’ (the first ever UK national newspaper driven by family values)

Support the Prevention Institute Seek out the worldwide family of relevant Institutions

And, of course, we might take strength from the belief that God is on our side – whatever that means for each of you. I once asked a friend of mine, who is a priest, whether I could assume that God was on our side. He replied

“I’m not really authorised to say – I’m only in Sales, not Management!”

But at the very least we can be sure that our efforts in prevention have a high purpose, are altruistic, and tend to enhance the quality of life in a way that is sorely needed in the social and spiritual desolation which typifies too much of society today.

To create something requires spirit and energy – to destroy something requires only a big mouth. We can look at others and criticise – or we can look within ourselves and create value – create something worthy of the life which it is our blessing to enjoy. That is the challenge of prevention.

_____________________

REFERENCES:

1. Lofquist WA (1983) ‘Discovering the Meaning of Prevention’ pubd AYD Publications, Arizona. ISBN 0-913951-00-5.

2. Various publications from US Center for Substance Abuse Prevention, DSDSC, 5600 Fisher’s Lane, RW 11, Rockville, MD 20852, USA. (Link via NDPA website)

3. Evans R & Stoker P (2002) ‘Facing the Elephant in the Living Room: Promoting the Healthy Development of Youth whose Parents have Drug Problems’ – available on NDPA website ‘Papers’.

4. Oliver W ‘Parent to Parent training system’. Apply to Passage Group Inc.,1240 Johnson Ferry Place, Suite F-10. Marietta, GA 30068, USA.

5. Stoker P (2001) ‘Moralising … demoralizing; the Fight over Personal and Social Education’. Available on NDPA website ‘Papers’.

6. Dennis N (2003) ‘The Culture of Intoxication’. Available on NDPA website ‘Papers’.

7. Phillips M (2003) ‘The Hatchet-faced Idealists’. See www.melaniephillips.com 8. Goldberg B (2002) ‘Bias’ pubd. Regnery, Washington DC. ISBN 0-89525-190-1.

9. Phillips M (2000) ‘The Trouble with the Liberal Elite is that it just isn’t Liberal’ See www.melaniephillips.com

10. Dennis N (2001) ‘Drug Legalisation and ‘On Liberty’ – the Misuse of Mill’. For The Salisbury Review. Available on NDPA website ‘Papers’

11. Colson C (2002) ‘The Cultivation of Conscience’. Available on NDPA website ‘Papers’.

12. Dennis N (2003) ‘The Uncertain Trumpet’.pubd Civitas, London.

13. Carvalho O de (2003) ‘Drug Traffic and Public Policy in Brazil’. Available on NDPA website ‘Papers’.

14. Stoker P (2001) ‘The History of Harm Reduction’. Available on NDPA website.

15. Davies N (1998) ‘Dark Heart – the Shocking Truth about Hidden Britain’ pubd. Vintage, London.

16. Sullivan Dr L (1999) ‘Drug Policy – a Tale of Two Countries’ pubd ‘News Weekly (Australia). Available on NDPA website.

17. Davies N (2003) ‘Using New Tools to Attack the Roots of Crime’. pubd. The Guardian newspaper, London, 12 July 2003. Note: this is a useful summary of and commentary upon the Government’s current crime reduction proposals, but it should be borne in mind that Nick Davies is a campaigner for legalizing all drugs, and his writings should be viewed through this optic.

NDPA informally engaged with relevant staff with in the Departments of Health, Education, Home Affairs, Foreign and Commonwealth, Cabinet Office, and MPs and Lords in all parties. NDPA works with other relevant agencies, and with several Police forces. It has a Youth Division. It also works abroad. As an ‘umbrella’ body for Prevention, NDPA is not predominantly engaged in delivering programmes, however it does manage the delivery of specific prevention programmes for primary school teachers, for adolescents in a ‘Peer Prevention’ process, and for parenting skills training. The main focus of NDPA’s work remains the advancement – both in quality and realization of potential – of Prevention.

Contact: PO Box 594, Slough, SL1 1AA, UK. Tel./Fax: 00+44-1753-677917. e-mail: ndpa@drugprevent.org.uk website: www.drugprevent.org.uk

‘DRUG STRATEGIES AND THE CULTIVATORS OF CULTURE’

For some time now a feeling has been slowly growing in me that there must be a way to empower ourselves by combining the many disparate elements of our prevention work into a unified whole. We are each of us toiling away at our respective tasks, but low resourcing and constant attacks by our detractors mean that we have little time to take the broad view, to view the structure of the environment in which we work.

I am not alone in currently exploring this area, and in preparing this paper I gratefully acknowledge the work of many others. I make special mention of Emeritus Professor Norman Dennis of Newcastle University, Professor Juan Alberto Yaria of the University of San Salvador, and amongst many eminent journalists, Melanie Phillips and Peter Hitchens of Britain, Olavo de Carvalho of Brazil, and Larry Collins – of many places!

I have no illusions that this paper represents wisdom, but if it provokes you into looking afresh at your working environment; at the influence of culture, and how you might in turn beneficially influence it, then it will have achieved its objective.

1. DEFINITIONS:

Prevention is a much abused word; I would hope you would all agree with one of my most respected mentors, Bill Lofquist (Ref.1) who said:

Filed under: Prevention (Papers) :

Presentation by Peter Stoker, National Drug Prevention Alliance

Title: Many Roads Lead From Rome

Prevention is a much abused word; I would hope you would all agree with one of my most respected mentors, Bill Lofquist , who said:

“We need to get beyond the notion that prevention is merely stopping something happening, to a more positive approach which creates conditions which promote the well-being of people”.

Culture is another word that can be interpreted in many ways.. But the definition of culture which we are ordinarily engaged with is

“The Attitudes and Behaviour of Particular Social Groups”.

3. HOW DOES CULTURE INFLUENCE BEHAVIOUR?

With acknowledgements to American prevention expert Bill Oliver, here’s a model … the Tree of Behaviour. And here are the stages of its growth. (powerpoint slides shown here)

The Tree of Behaviour doesn’t grow out of nowhere – it isn’t spontaneously created; it is the outcome of a process that is largely invisible. Invisible because it is below ground; it has roots. Within each of us – As external impulses reach our centre of consciousness, our intellect, will and emotion respond to the impulses, and the outcome is that we develop a thought. We review that thought – ‘yes/no/maybe’ – and in the process we develop an attitude towards it. Our attitude towards any action we are contemplating is probably the first visible sign which others can see – like the first green shoots of a tree coming up through the ground. This is why, as parents, we need to be vigilant about the attitudes our children display.

What I want you to concentrate on, though, is that internal, ‘underground’ phase – before the attitude develops. In this seminal stage, a great many influences apply. Memories – good and bad. Using those memory banks to project images of what might happen if this behaviour is followed. Values and boundaries for the individual. Weighing advantages and disadvantages to oneself and to others. Applying learning received so far. Peer pressure and role models. The drive for personal pleasure. Curiosity and risk taking. Pain and how to avoid it. Feelings of spirituality and faith – or the lack of them. All these and more will influence the nurturing of that first thought, and will decide whether we reject it – or decide to act on it. This is ‘the culture in which decisions are made’.

If someone alters the culture within which decisions are made, it is virtually certain that there will be different outcomes. The Values Clarification philosophy founded by Carl Rogers and Professor Sidney Simon (and which also drew in part on the thinking of their contemporary, Abraham Maslow) when combined with other liberally-inclined arguments produced a juggernaut that crushed large sections of the morally-based opposition. Not including us!

4. NESTS OF CULTURE

Consider first this simplified hierarchy – or ‘nest’ of cultures:

Societal factors overlay and add to the culture. There is no shortage of societal factors which tend to encourage drug abuse. Here are some examples:

Conspicuous consumption
Search for Rapid gratification
Rights but no responsibilities
The ‘Right to be Happy’
Self before society
Youth are the Supreme Beings
Political Correctness

Politics is a culture all of its own, operating in its own idiosyncratic way. History shows the emergence of ‘intellectuals’ giving succour to drug abuse – rationalising it as a ‘legitimate’ expression of disaffection for conservative/’right wing’ ideology and authority. Liberalism was born out of reaction to the tyranny of monarchies and other hard-line authorities, but when democracy replaced these despots, liberalism – instead of stepping back – went on a quest for justification of its continued existence, and in the process became a perversion of its earlier noble purpose – and a tyrant as ruthless as any it once fought to depose. Liberal forces tend to have lots of money and resources; there is therefore the very real risk that the European Parliament will recycle the pro-drug culture’s statements, presenting them to the unwary – especially in the new Enlargement Nations – as ‘wisdom from the centre’

And of course one massive player in the culture game is The MEDIA. The ‘messengers’. The rulers of the magnificent city which is Rome used to have a tradition of killing any messenger who brought bad news – if we continued this practice these days we wouldn’t have any journalists left! But instead we seem to expect bad news – and disbelieve anything good we hear. Meanwhile the messengers have transformed themselves from reporters of the news into makers of the news – filtering everything through their own belief system.

The newspapers’ colleagues in print, the magazines, are amongst the strongest promoters of hedonism. ‘Style’ magazines like Face, FHM, ID, Ministry, have long pursued a love affair with ‘lad/ladette’ behaviour – heavy drinking, ‘caning’ (drugs), promiscuity are all seen as milestones which all must pass to gain entry to the World of Cool. Even the youth magazines – like Bella, 19, and Just 17 – all of which are regularly read by those much younger than their ostensible readership age – have an unhealthy pre-occupation with sex. In addition to these ‘generic’ magazines, there are of course the ‘specialist’ magazines like ‘High Times’, ‘Cannabis Culture’ ‘Heads’ to cater for the dedicated doper – and to intrigue the casual reader.

5. PREVENTION AND ITS ENGAGEMENT WITH CULTURE

‘Anomie’ (anything goes) to ‘Authoritarianism’. Advocates of drug legalisation have attempted to tendentiously pigeonhole John Stuart Mill in the ‘self-interested’ culture, quoting his statement that

“Over himself, and over his own mind and body, the individual is sovereign”.

but they ignore his saying that

“Whenever, there is definite damage, or risk of damage, to an individual or the public, Liberty (must give way to) Morality or Law”.

You might say this means that conscience erects a ‘Stop’ sign when one’s ‘self-will’ is speeding. Without this control system, self-will proceeds onto the assumption that one has a ‘personal right’ to this behaviour, thence to the notion that there is a ‘constitutional right’ to the behaviour, and thus to a pressure to legalise it. If we do not want to be ruled by tyrants in future, it is in all our interests to promote conscience now. According to Coulson, this means going back to what he sees as the three core institutions – family, church and university, and instilling a health-promoting model in all of them.

8. HOW CAN WE STRENGTHEN PREVENTION CULTURE?

Generic activities:

• Understand and work to the model of ‘Total Health’

• Advance the concept of ‘Everyone, not just Number One’

• Expose and dispose of ‘Values Clarification’

• ‘Cultivate the Conscience’

Improve Reality:

• Establish primary prevention as main criterion in drug education All education should have prevention in mind

• Put harm Reduction where it belongs Part of treatment, not a policy in itself

• Establish improved, rapid access treatment centres. Treatment, including mandated attendance, should be available sooner

• Define and confine ‘harm reduction’ as within treatment, for known users only. Pseudo-harm-reduction should be exposed for the sham it is

• Pro-active Media Strategy Cultivate your media, learn to love them, programme your initiatives

• Fix ‘Broken Windows’ Restore order and reduce crime by not tolerating even the little things

• ‘Prevention Cities’ Follow the San Salvador example – you need to contact Prof. Yaria

• Police get a ‘Pizza the Action’ Prevention by police/community initiatives.

• ‘Cool to be clean’ tee shirts, and similar promotions Give your creative people a chance to shine!

• Music Art and Drama re-energised with prevention in mind

• Support the ‘Prevention Institute’ Seek out the worldwide family of relevant Institutions

What are the indications for Latvia?

As an advocate of prevention you would expect me , I’m sure, to advocate that Latvia commits to prevention. But I hope I can give you put a little more balance than that. You should know that in the first half of my 20 years in this field, I worked in treatment, as a counsellor for people with a problem, as an advocate in the justice and police system and has a specialist adviser in schools. so in these suggestions I’ll try to reflect that width of vision.

This would be a fortunate country indeed if every drugs service that was needed were to be in place – and to be present in sufficient quantity and of adequate quality. In reality, I know of nowhere where these Utopian conditions have been achieved. The best we can do is to optimise placement of resources, and to keep them under continuous observation, so that as conditions change, the services change.

(At this point a power point presentation was made – including describing in detail the Jellinek curve. the argument for much stronger universal prevention. Explanations of indicated and selective prevention. true and so-called ‘Harm Reduction’. )

The Rome conference was commendable in looking as widely as possible at the many factors influencing human behaviour. In today’s brief conference I would recommend you to keep this principle in mind. Don’t imagine that if you apply a push to one point that you will move the whole structure – as a former civil engineer, I can assure you that is very unlikely to happen, and what you’re more likely to do is to over stress that part of the structure you’re pushing and cause the whole thing to fall down on top of you. The lesson of this is that you need to have a good appreciation of the whole picture of each section interacting with another. Another analogy would be to call this whole environment around drug use a social ecology – I would hope we have learnt enough about ecology to understand the risks of tampering with just one part of whilst ignoring the rest. The best advice is – move slowly, move cautiously.

If I had to sum up where most of the conflict arises in drugs services, apart from haggling about which service gets how much money, I would say that it comes from the struggle between the rights of the individual and the rights of society. (John Stuart Mill) This always has been, and probably always will be, a never ending tug of war. the best we can do is to recognise that the individual and society both have rights and it is the duty of government to act as the referee – even if all the players and the onlookers shout for your death! In that thankless task I wish you best of luck.

Thank you.

SECOND PAPER – CANNABIS AND SYNTHETICS – SCHOOL SYSTEMS.

Antonio Maria Costa, the Head of INCB, gave a worrying warning to us all last when he said that synthetics will be the major drug problem in future. Why might this be? And how far away is this future? Should we drop everything we are doing now and concentrate only on synthetics? And what are synthetics anyway? We can’t even agree on the definition of a ‘drug’ – let alone what a synthetic one is.

And what’s really happening in schools. When we say we want schools to prevent use, what are we also saying? That the rest of us can switch off? I don’t think so! And when we issue statements as to what teachers must do, how much do we measure the possibility of them doing this within their present workload? What about their own attitude and learning about drugs? And how many of them are drug users? How many have swallowed the gospel according to Saint Maslow? And to what extent is any kind of ‘freedom’ almost welcomed in this post-Soviet era – and because of this, is any attempt at prevention automatically decried as repression/repressive? This is where culture comes in – and I tried to open that subject for you this morning.

So what we are facing here is an enormous journey – a journey of learning as well as teaching. But the Buddhists will tell you that the longest journey begins with a single step, therefore let us see if we can take that first step today.

The first thing is to define what are we trying to achieve. If you are just trying to achieve a peaceful life in your school, you can expel any one you suspect of drug use so that they have to go to somebody else’s school. Of course there is the risk and you will have to take people who are expelled from another school, and so the merry-go-round continues. But I suggest to you that you are trying to achieve more than this. Firstly you are trying to achieve healthy young people in a Healthy school which is part of a healthy society. Secondly, you are trying to achieve succes here, and people in a successful school which contributes to a successful society.

Now I need to define what health means. Why? Because in a society which is heavily influenced by medicine, we tend to think of ‘health’ as just the absence of sickness. and when somebody is defined as ‘well’ , we define this in terms of how fast they can run 100 metres. Say someone has just stolen your wallet with all your money and then runs away – covering 100 metres in 10 seconds, would you look at them and say they are truly healthy? I don’t think these will be the words on your lips.

Health is a great deal more than the absence of sickness, and you can find much more complete definitions of it even in ancient writings. more recently there are definitions which match these earlier ones, such as that by the World Health Organisation, which match these earlier ones. The definitions generally agree that health is a combination of physical, mental, intellectual, social, emotional, spiritual and environmental aspects. In order to be fully healthy, one has to be scoring well on all these aspects and this is why the school curriculum needs to address the whole person, not just the academic person – but it needs to do so within a clearly defined and accepted moral framework, which balances individual liberty against responsibility to others – a theme I touched on in my previous paper.

How can you achieve this full health? I suggest that you need to involve and gain commitment from everybody in the school, and I mean everybody – from the Head and the teachers, to the caterers and the janitor – not just the pupils. The starting point for this is a school drug policy which promotes health – not just imposes discipline. I can tell you that in my own country a great many of these policies developed by schools start with what I would call Chapter Three of the complete book. Chapter Three says what we will do with a pupil when we discover them using drugs. But the policy is silent on Chapters 1 and 2; Chapter 1 says ‘what are the goals of this school’ and Chapter Two says ‘how are we going to achieve those goals’. These are the chapters in which you set out your PREVENTION plan – if you only start at Chapter Three then I’m sorry to tell you that you have a sick policy, not a healthy one.

I can tell you much more about what ought to go into a school policy, but I cannot cover it fully in the time I have today. So let me give you some examples of what you could do

Draft a policy for your school along the lines I have suggested above. Then discuss it with your school’s teachers, with your school’s governing body or committee, with the parents of your pupils and with the pupils themselves. You can do this even in primary-schools, although it will be at a lower level. You could interact with parents by a combination of survey forms and focus groups. You need to involve all of these because you want them all to ‘take ownership’ of the policy – and in doing this they will be more likely to adhere to it.

Structure your curriculum with the goal of a health-promoting school, and then Staff it with that in mind. I have seen a number of schools where a particular teacher is nominated as ‘the drug teacher’ – not because they are perfect for the job, but because nobody else wants it. You might as well hand out drugs at the school entrance if you’re not going to be serious about this subject. Bear in mind that school teachers may be required to share any information pupils give them, share it with the head teacher, or parents, or even the police. If you have discovered a pupil who is dealing drugs to others then it is right that you should tell all these other people, but if what faces you is a pupil who has just started using drugs in response to some form of emotional distress or disturbance, then you need a different response, one that probably involves individual, confidential counselling. If your school does not have pastoral counsellors who have the power to keep information confidential, then you may have to make an arrangement with an external counselling agency where pupils can be referred to cover this need.

What about the actual process of ‘educating for prevention’ – can you educate to prevent? I would say “only sometimes”. Consensus of research into behaviour is that if you wish to modify it you must address three subjects – known simply as KAB. Knowledge, attitudes and behaviour.

Knowledge is what you can deliver in the classroom, but just transmitting knowledge does not necessarily change behaviour – only sometimes, as I have said. Attitude can also be addressed in the classroom but needs to be addressed more widely throughout the school; you can challenge and mould attitude during class lessons, in debates, through the school newspaper, by the informing and sustaining of discipline, and by good examples. What the research also shows is that even though you may change attitudes this does not automatically change behaviour. You need to specifically address behaviour to a improve your chances of achieving a health promoting school.

Behaviour is the toughest one to tackle, because it is the most volatile. It is a combination of encouragement and discouragement, of positive reinforcement for behaviour which you welcome – not just a process of punishment for behaviour of which you disapprove. When it comes to disciplinary responses, these need to be in accordance with the consequences which everybody has been told about and acknowledged when they first join your school. They need to be consistently applied but this need not mean rigidly applied – the way you have written your drug policy should give you scope for sensible and sensitive discretion on how you deal with each person.

The shortage of time precludes me from going into more detail about random student drug testing, restorative justice schemes and the use of Peer Education projects for prevention. Please feel free to contact me at the National Drug Prevention Alliance if you wish to further this discussion. I thank you for the invitation to share our views on Drug Prevention in the schools setting. My colleague (and wife) Ann will now give you a presentation about a successful drug prevention programme called Teenex which was written in 1988.

I have been asked by Sandra Rubene to give you a re run of the paper which I presented at Rome – and to give you best value in the time we have, what I propose to do is not only that, but also to give you a quick overview of the rest of the happenings in the Rome conference; what the conclusions were, and then to wrap up this first session by suggesting how you might take this information – and apply it in Latvia.

In September 2003 for Fifth Global Conference on Drug Prevention was held in Rome. 500 delegate 8th from 84 nations attended – including your own Aelita Vagale .

The atmosphere of this conference was something special. There was not just the usual concentration on the pharmacology of drugs, their physiological effects and how to educate against the use, valuable though that is. All of those subjects were covered, but in addition there was a vigorous examination off for the effects of culture on drug use, the value of religion in countering drug use, and an old subject under a new title – bio-ethics, meaning the interaction of ethics and human nature. It was this a holistic approach that made this conference so exciting and so memorable.

Another memorable aspect was the enormous commitment shown by the Italian government; no less than 11 senior figures from the government of Italy attended. This included the Vice Prime Minister, Gianfranco Fini, the Co-ordinator of National Anti-drug Policies Pietro Soggiu, and ministers within departments as Health, Social Affairs, Regional Affairs, Prisons, and the Interior. The unified message coming from this extraordinary assembly of officials is one that I would commend to Latvia. I will come back to this in more detail at the end of this paper, but for now, will tell you that their conclusion was that they had tried for long enough to make peace with the drug culture; they had now decided that this had only made things worse, not better, and a new direction was essential.

Of the other delegates at the conference the there were many who were notable. The first Lady of Bolivia spoke on the first day. She was joined by US Congressman Mark Souder. The Swedish Minister for Public Health and Social Services was there, as were an impressive array of academics from many countries. This was Rome, so we were fortunate in hearing from the Papal Nuncio and several of his senior colleagues from the Vatican. But we also had representatives of Islam, Hinduism, Judaism and Buddhism, who all gave papers – and all these faiths showed a remarkable degree of unity in their definitions of what constituted Responsible Behaviour in their communities.

So let’s move now to my paper. I’m going to give you a shortened version of it here, but the full version has been given to Sandra. It was entitled ‘Prevention strategies and the Cultivators of Culture’.

Filed under: Prevention (Papers) :

Address by Peter Stoker, Director, National Drug Prevention Alliance to the ECAD 10th Anniversary Mayors’ Conference Stockholm May 15, 2003

I have worked in this field for over 15 years; in Counselling, Treatment, Justice, Education and – not least – in Prevention. I have visited or dialogued with drug programmes and agencies in more than 20 countries and NDPA continues to exchange information and good practice with many more, through our membership of organisations like Drug Watch International, the Drug Prevention Network of the Americas, and the Institute for Global Drug Policy. All this has woken me up to the ‘World of Alternatives’, and this morning I hope to bring you some insight into practical, workable Alternatives you could apply in your own city.

Alternatives. Creating the Alternatives. It is said that we live in a sometimes crazy world, and one sign of this occasional craziness is when we give unjustified hearing to people who offer ‘alternatives’ to our present social and legal policies which may suit them very well, but which would be deeply dangerous to our children and to our society. Maybe we should blame ourselves for this; perhaps the Crazy Alternative might not sound so attractive if we became more effective in making people hear the Sane Alternative.

As we are in Scandinavia, let’s consider Hans-Christian Andersen’s story of the Emperor’s New Clothes – in which it took the innocence of a child to open the eyes of adults, an internationally-known metaphor describing blindness to the truth. An affliction taken to new heights when it comes to drug abuse.

Society obviously differs between different countries, but in western society we can see some broadly similar patterns. Let me describe what we see in the UK. Our society is one in which behaviour is conditioned by the conspicuous pursuit of consumption, by the demand for rapid gratification (‘Give me pleasure NOW); by an environment in which people march for of their rights but never for their responsibilities, by the idea that we have ‘ a right to be happy’, by the elevation of the Self above the Society (Me first) – and certainly by the elevation of youth, above all. [Ref 1] When you take all this into account, it is easy to see how drugs can have assumed a new prominence.

We also live in a society where ‘Political Correctness’ shackles our thinking, so that, for example, I can no longer call myself ‘able-bodied’ but must instead call myself ‘a person who is non-disabled’. This is just one more example of how clever use of words can confuse the mind, in the same way that the Tailor confused the Emperor – and the way in which the Emperor’s subjects went along with the deception.

This is the fertile ground in which drug-abuse grows, and one of the cleverest tactics of the pro-drug lobby is to convince you that there is no alternative – we must surrender to the inevitable; accept drug use, legalise it, and keep the harm to a minimum – for the users, that is!

We have allowed ourselves to be seduced by clever words and convoluted arguments – and a major part of this process is that the sane counter-argument to this insane dialogue gets only a tiny proportion of the media’s attention. If we were to apply the ‘Emperor’s Clothes’ logic that is advanced for drug abuse to other social behaviours there would be a national, if not international outcry.

Let’s take a fictitious example. Suppose you were designing a new social policy concerning rape. Would you think it enough to just provide services for the victim after the attack? Surely not. How about some Harm Reduction advice for the rapist? They have rights too, you know. After all, maybe it was just ‘recreational rape’ – and the rapist’s lawyer says he is ‘an otherwise law-abiding person’. Maybe if we relaxed the law this would improve things – and look at all the police time we would save! ……It is at times like this that I envy that child who showed us that the Emperor had no clothes. I envy him because his story ended with the community recognising the truth and common sense of what he said.

I have enough faith in human behaviour to believe that we will achieve this condition of sanity with drugs policy in the end – but I am also sure that it will not be achieved through apathy. Ultimately, we get the society we deserve. That is why the commitment all of you are showing through your support of ECAD – and through your actions which flow from that – is so very important. The question then is, how can we create saner alternatives?

My eminent fellow-speakers this morning will be telling you about their successes in treatment and rehabilitation. I have visited several of them in my travels, including Delancy Street – whose speaking slot I have filled today – and I can testify to what marvellous projects they are. They do an enormously valuable job, and deserve more support. But we don’t beat problems only by treating the casualties – and the sheer numbers of those with problems mean we have to do something else as well. Just consider the numbers. If we take the four major projects presenting here, and add in other large projects such as Betel in Spain, Delancy street in America, and Synanon in Germany, their combined throughput is probably something under 10,000 people a year, and yet it is said that in Britain alone we have more than 250,000 addicts. One thing is sure; treatment centres are unlikely to become redundant in our lifetime or our children’s lifetime.

Another concern is that whilst the projects presenting here today are models of good practice, not everybody matches these standards. A survey of British treatment projects on behalf of the Big Issue magazine found that most drugs other than heroin were rarely addressed by treatment centres, and that for heroin there was often only the ‘new solution’ of prescribing methadone. Big Issue found that far from weaning people off drugs, methadone prescriptions were supporting 33% of addicts for 5 years or more and 16% for 10 years or more, with both percentages rising. Moreover, 80% of methadone ‘clients’ were also using street drugs, with 44% of those on prescribed methadone using heroin on a daily basis. – and up to 50% of them still commit crimes.

If treatment and rehabilitation alone cannot turn the tide, what else is there? Let’s go back for a minute to that imaginary social policy we were looking at; the policy for rape. If we agree that rape is a bad thing; bad not just for the victim, but bad for the rapist and bad for society as a whole, our policy would not confine itself to just reacting to it, and treating the casualties. Our core policy would be to prevent it.

Rapes still happen, but we do not take this as evidence that the prevention of rape should be abandoned, anymore than we seek to dissolve driving schools because we still suffer car crashes. We take a rational view that if we were to be fatalistic about rape, there would be a lot more of it around. So, instead of surrendering, we work harder at improving our rape prevention technology.

I want however to qualify one point in my remarks: there is actually a limited scope for Harm Reduction – provided you deliver it to the right people in the right setting. It was properly defined and limited as to its scope in Britain’s first National Drug Strategy in 1995 [Ref2], a definition also enshrined in the 1998 strategy [Ref 3] which Keith Hellawell – whom you heard speaking so eloquently yesterday – designed and introduced. The ‘limit of scope’ is to use it only with people you know are users, on a one-to-one basis, as part of the treatment process; that is, whilst the user is moving towards cessation. Drug workers like myself have always practised this limited scope – indeed one could argue that there is a moral obligation to do so. But this practice only relates to a fraction of our population – it has nothing to do with the hijacked version of Harm Reduction [Ref 4] which is applied to the whole population, and which asserts that:

You cannot prevent drug use

You are inhibiting personal rights if you try

Everyone may use at some time, so

Guidance for everyone on how to use is the key, and

Policy should be confined to reducing harm

This is a very cunning alternative – for if you introduce it, and then find that use increases, its proposers will say this proves that Prevention is useless and therefore Harm Reduction is clearly the right path to follow. A self-fulfilling prophecy. (The story of how this came about is too long to repeat here).

The truth is that in the past we have rarely tried to prevent, in the true sense of the word, that is, working ‘pre the event’. This is the Alternative on which I want to focus for the remainder of this paper, and in the process to give you some useful Alternatives to consider, from the examples I’ve seen around the world.

Let’s start with a piece of Prevention history. A common claim by the pro drug lobby is that “the Just Say No approach doesn’t work”. This has been repeated so many times that it has become a mantra – a classic example of the Orwellian principle; that if you repeat a lie often enough it becomes perceived as the truth. Saying that Just Say No “doesn’t work” is simply another way for the pro-drug lobby to claim that “the War on Drugs is failing”. Another cliche. Another lie.

Very few members of the general public know that in the so-called ‘War on Drugs’ a victory was recorded every year for 12 years, and that over those 12 years drug abuse was reduced by over 60 per cent – an astonishing public health success by any standards. [Ref 5] Even if they do know that, they are unlikely to know that one particular prevention programme was pre-eminent throughout the period. The name of the country? America. And the name of the programme? Just say No.

The Just Say No programme was much more than the chanting of slogans. It was a comprehensive personal, social and health education programme, backed up by trained volunteers and professionals. I have copies of their manuals and I can assure you of that. [Ref 6] But we can now see that a major factor in its success at that time – between 1980 and 1992 – indeed perhaps the main factor, was the culture of the society in which it was operating.

Culture is vital as the deciding factor in behaviour. And the key cultural force that swung into action to generate those successful years was not the Ministry of Education, or the Ministry of Health, or the Police and Courts – it was the community. Ordinary communities like yours, in cities across America. Parents were the main activists, acting just as that little boy did when he saw the Emperor – they exposed the truth, which the professionals had been too blinded by dogma to see. The parents shamed the professionals into producing truly preventive programmes – with the splendid results I have just stated. And those proven techniques are still available to you today – if your city only has the political will to use them.

America may have been one of the first to properly tackle prevention, but it was by no means the only one. Let’s take a quick trip around the world and see some of the other things that have happened in this context: Most countries have good and bad aspects, so in the time available this will have to be a simplified review.

Poland: The Warsaw Institute has seeded many good prevention programmes.

Germany: More than 30 of our Teenex camps, plus parent skills trainings.

Portugal: Projecto Vida and others have executed many good projects, including over 35 Teenex camps..

Belarus:

Is keen to co-operate with UK on prevention.

Kazan: Has sent young people to UK Teenex prevention camps. Keen to do more.

Bulgaria: Excellent community structures are now addressing drug prevention and other services. Burgas, on the Black Sea coast, is an ECAD member and is one of the cities in which we have just started work.

Italy: Has changed to more preventive policies. Hosts the World Prevention conference 2003 – in Rome.

Belgium: Exemplary work has been initiated in the Eastern cantons, over many years.

Sweden: Has drug use levels far below the rest of Europe, largely from inducing a culture which discourages drug abuse.

Latin America: Countries like Brazil and Peru have vigorous prevention programmes. The next world conference of the International Task Force on Strategic Drug Policy will be in Argentina, next month.

Spain: Have just invited UK to co-operate on a primary school prevention programme.

Australia: Birthplace of two wonderful prevention programmes – Life Education Centres (now operating in several countries) and the Kangaroo Creek Gang.

New Zealand: an oasis of prevention – make sure you get a copy of ‘The Great Brain Robbery’ – one of the best advisory books for non-expert parents and community officials I have ever seen.

America: so much has been and is being done to prevent drug abuse. Check out the websites at NIDA and CSAP, which you can reach via the links on our site. I would also like to say a word at this point about a great programme, which has so many daggers sticking out of its back it looks like a porcupine. That programme is DARE. It is precisely because it has been so successful, so widely adopted, that it has become a constant target for the pro-drug lobby and the professionally jealous. Like everything else, it has had its faults in the past, but it has addressed many of these and is now launching a strengthened curriculum. Its unique involvement of police officers in a sustained relationship with schools – not just a quick visit – has many benefits in and beyond prevention. Already seven police forces in UK are using it, with more coming.

United Nations: Despite all our worries about the money and heavy pressure applied to it, the UN came up with the right result in its recent 46th meeting of its Commission on Narcotic Drugs – ruling out any weakening of drug laws. I am sure that the 1.3 million signatures collected by many groups – including ourselves – under the leadership of Hassela Nordic Network had a big influence, and I would like to add my congratulations to HNN for this tactical masterpiece.

Plenty of good news, then. But before you assume everything’s solved, I must emphasise that the well-financed and highly-resourced machinery of the pro drug lobby is having a significant and growing effect…

Holland: Their story is well documented, liberalization continues, despite polls showing that 70% of Dutch citizens want the lax drug laws rescinded.

Switzerland: We hear glowing reports of their heroin experiments, but this is hardly surprising when we learn that the head of the experiments is also the head of the Swiss branch of the International Anti-prohibition League, a major player in legalisation.

United Kingdom: We have been subjected to enormous pressure, with international backing for the pro-drug lobby, and we are almost certainly about to have cannabis re-classified to a lower class of legal penalty – ridiculously demoted to rank alongside steroids instead of alongside amphetamines. This is despite a wide range of new research against cannabis – and no new science in favour of it. But the good news is that both the Select Committee [Ref 7] and the Advisory Council to the Government have turned their back on all the dishonest argument, and have said they will not recommend legalisation or decriminalization – (and, for good measure, they have said the same thing about ecstasy). They have also exposed the ‘medical cannabis’ argument by inviting scientific trials, but ruling out any use of ‘cannabis as grown’ (because if its extreme variability and pharmacological unreliability as well as undesireable side-effects) and they also rule out any use of smoking as a delivery method. Their stated intention is to test extracts of cannabis, not smoked but ingested by normal medical means, and not to be of psychoactive effect. So, you don’t smoke it and you don’t get high – not at all what the pot lobby had in mind!

East Europe: As I have said already, there are good outcrops of prevention, but this region is held to ransom by pro-drug influences, most notably George Soros, who has put tens of millions of dollars worldwide into weakening drug laws.

Australia: When South Australia first decriminalized cannabis possession there was a significant increase in use by young people, compared to neighbouring states. Sadly, this experience has not deterred the liberalisers, and worse is to come. Western Australia is now considering following suit.

Canada: Policy is deteriorating in the same way as Australia.

From time to time I encounter drug liberals who assert that there is no proof of prevention. I usually refer them to the research work of Nancy Tobler; [Ref 8] she analysed no less than 240 successful prevention programmes. 240. And still they come, with their cries that there is no evidence. And yet if you press them on the subject, the more honest of them will admit that there is little or no evidence of effectiveness of Harm Reduction. Such evidence as there is can often be damning, as is the case with Baltimore in the USA; this city has one of the biggest needle exchange and condom issue schemes in the USA and yet it has ended up with the highest levels of drug abuse, the highest level of HIV infection and is amongst the highest levels of addiction. Harm Reduction may be having an effect in Baltimore, but it is not the effect that the public were promised. Coming back to Nancy Tobler; she looked at the 240 programmes and found 140 that had enough common factors to allow her to conduct what is called a meta-analysis. From this she was able to indicate the components of the more successful programmes. Another advanced researcher, Bonnie Benard, who is now with NIDA – the National Institute on Drug Abuse – has repeated the same kind of comparative exercise over many years, and from this has produced a set of “Criteria for Effective Prevention” which are a classic, timeless in their value. [Ref 9] A summary of Bonnie’s criteria is included in the written paper supporting this talk.

If I had to choose just one key criterion from what I have seen in all these countries, it would be Culture. Localised programmes will be effective locally, and programmes concentrating on one topic – such as self-esteem or drug awareness – may be effective in those areas, but not much elsewhere. If you are intent on generating a healthier environment in your city then you need to look to generating a health-oriented, prevention-oriented culture right across your community – in the home, in the school, in the workplace, in the youth organization, in the leisure areas, in the shops, in the churches and temples – and certainly in the media.

Culture can be artificially distorted, at least in the short term – which is where the media can be particularly effective, or particularly damaging. But cultural changes generally are slower to happen, and require steady application of energy. If that effort is sustained then change will occur, like the dripping of water that wears away the stone. The drug liberals have learnt this truth – we must learn it too, along with another truth.- that we sometimes forget that today has not always been . We did not always have the drug culture and the society culture we have now. It was changed before, by others. It follows that we can change it again.

What can an ordinary city do to produce a more healthy culture? One of the most comprehensive examples I have seen of this is “Project Revitalisation” in Vallejo, California. [Ref 10] The project is designed to tackle drugs, alcohol and crime in the city’s worst areas. The heart of the project is a strong community partnership: – the Vallejo Fighting Back partnership, Vallejo Code Enforcement, Vallejo Chamber of Commerce, Vallejo Police Department, Vallejo Neighbourhood Housing, California Employment Department, the Private Industry Council, and many neighbourhood associations. It works to integrate neighbourhood revitalisation, alcohol and other drug policy, neighbourhood safety, job-training, and co-ordination of human services into a comprehensive effort. The project’s goals are to sort out and regularize the jumble of disorganized buildings and facilities, regenerating the neighbourhood; to reduce crime, and foster safety and quality of life for the residents of these deteriorating, crime-ridden neighbourhoods.

Project Revitalisation is based on four principles:

The physical make-up of a community has an important influence on its vulnerability to crime. This is equivalent to the very successful “Broken Windows” project run in New York [Ref 11]

Neighbourhoods where residents have commitment and interest in improving their area can influence the level of crime

Everybody, individuals and families, must personally gain from the project. You cannot expect people drowning in problems such as unemployment, addiction, lack of child care and other human service shortages to be interested in improving their neighbourhoods

problems with alcohol and other drugs contribute to neighbourhood deterioration and must be specifically addressed.

In a five phase process, Project Revitalisation moves from initial assessment to detailed assessment, then to initial ‘pilot’ interventions before full implementation. The final phase is to reinforce the new stability of the neighbourhood by establishing permanent neighbourhood groups.

First reports of results from the project show encouraging improvements; there has been a reduction in police call-outs and an improvement in the perception of safety by residents – this is a very important feature in my own country, where fear of crime is often as crippling as crime itself.

The efforts to reduce illegal drugs are probably well understood already; particular alcohol policies that Vallejo introduced included:

‘Conditional use’ (trial) permits for regulation of new alcohol outlets.

Improved ordinances to regulate existing outlets.

An ordinance for youth parties, to reduce non-commercial access of alcohol by young people

A social nuisance ordinance to hold property owners accountable for standards of building maintenance and for the conduct of their residents

A rental property inspection ordinance

Vallejo is a very comprehensive scheme but I’m sure you will agree that there is no ‘rocket science’ in what they are doing. Their deliberately steady progress, involving all the elements of the community at each stage, is reminiscent of the excellent work done by Dr Ernst Servais [Ref 12] in the Eastern cantons of Belgium. Both projects recognised that unless you carry the community with you at each stage, the effect of your labours is likely to be short-lived.

In summary, then, what Alternative do we have? What tools do we have in our toolbox? We could list these under three simple headings;

Before drug use

Early stages of drug use, and

Problematic stages of drug use

Before:

Culture. Prevention. Education. Parenting. Big Brothers and Sisters. Peer-group prevention. Policing for prevention. Media. Spiritual aspects. Workplaces. Sports (including FIT technology). Arts. Music.

Early stages:

Intervention. Counselling. Befriending. Harm reduction. Policing. Diversion (Alternatives). Containment.

Problematic stages:

Primary care. Treatment. Harm reduction. Justice. Drug courts. Restorative justice. Probation. Prison-based rehab treatment. Halfway houses. After-care. Relapse prevention.

Encompassing many of these initiatives, one brand new and usefully comprehensive addition to NDPA’s library has been the publication ‘Blueprint for a Drug-Free Future’ [Ref 13] by the Hudson Institute, USA.

Money – as always – comes into it. And because treatment is easier for accountants to count, it has traditionally tended to get much more of the available funding than other services. In economic terms, however, prevention gives a better return; even using conservative figures, prevention can be seen to give a payback of $6 for every dollar spent, [Ref 14] compared to only $3 for every dollar spent on treatment.

How might we inter-relate these services? Here is my model for doing that:

With the overall aim of a healthy society, the strategy relevant to the majority of the population has to be prevention. This does not mean that you have to accept anything in the name of prevention, or preventive education. You have every right to ask questions as to what a project is specifically aiming to achieve – and demand evaluations to make sure you get what you were promised.

For those who start to get involved – and they are still a minority – it is probably enough to expose them to prevention processes which they may well not have experienced before. Those who continue to stay involved will need more intervention effort, maybe even some form of treatment, but the outcome should still be that when they cease using this is affirmed by prevention processes. The problematic users are the ones we hear about most, but they are almost certainly only a few percent of your population. This whole structure needs to be buttressed by firm but fair legal and justice systems which firstly deter, then intervene, and – above all – correct aberrant behaviour. A justice system does not have to be confined to punishment, indeed I would argue that such a system is likely to be counter-productive; it should be a sensitive mix of punishment, retribution, restoration and rehabilitation.

CONCLUSIONS:

• There is no one programme around that does it all.

• What works for one person very well will not work at all for another .

• We need to see all of our services – prevention, education, intervention, treatment and so on as part of a continuous whole – and apply them holistically.

• We should not be afraid of having a variety of initiatives, but we should make sure that they are all inter-related.

• Don’t rush it, and don’t tamper with bits of the problem. This is like playing with the ecology – and will probably be equally disastrous. • Always monit

or and evaluate for process and outcome.

• Don’t be afraid to trust your gut feeling. If you have clear goals, then something which feels bad probably is bad.

• Don’t try to be an expert, but know where the ‘experts’ live – and in choosing them, be careful to check their background and agenda .

There is a great deal that you can do in managing a team of experts by asking some simple questions, such as: What are we trying to achieve? How are we trying to achieve it? What is it for? Is everything we are doing pointing in the same direction – if not, why not?

And remember – if one of these ‘experts’ offers you a wonderful new set of clothes, fit for an Emperor – get rid of him!

REFERENCES:

[up] 1. Stoker, P: Moralising, demoralizing .. the fight for Personal and Social Education. 2000. NDPA.

[up] 2. UK Government: Tackling Drugs Together. UK Drug Strategy 1995. HMSO.

[up] 3. UK Government: Tackling Drugs to Build a Better Britain. 1998. HMSO.

[up] 4. Stoker, P: The History of Harm Reduction. 2001 NDPA.

[up] 5. US Biennial National Household Surveys, correlated with Michigan Schools System. (Ongoing).

[up] 6. Just Say No International. Just Say No Club Book/Teen Leader Guide.1989. Walnut Creek, CA USA.

[up] 7. UK Home Affairs Select Committee. The Government’s Drug Policy – Is it working?. 2002. HMSO.

[up] 8. Tobler, N. Meta-analysis of 143 adolescent drug prevention programs. 1986. Journal of Drug Issues.

[up] 9. Benard, B. Characteristics of Effective Prevention Programs. 1987 acquisition. (Contact NIDA, USA).

[up] 10. Sparks, M. Project Revitalisation – Vallejo, California. 1998. Prevention Pipeline (NIDA).

[up] 11. Kelling, G. L., Coles C. M. Fixing Broken Windows. 1997. pub Touchstone, NY USA.

[up] 12. Servais, E. Before it’s too late. 1991. SPZ-ASL, Schnellewindgasse 2, B-4700, Eupen, Belgium.

[up] 13. McGarrell, E. F., Hutchens, J.D. Blueprint for a Drug-Free Future. 2003. Hudson Institute, Indianna.

[up] 14. Masi, D. A. Designing Employee Assistance Programs. 1984. Published by Amacom.

NDPA, P O Box 594, Slough, SL1 1AA, UK. Tel/Fax: +44 (1753) 677917.

Email: ndpa@drugprevent.org.uk

website: www.drugprevent.org.uk

Attachment to Peter Stoker paper to ECAD Conference, May 03,Stockholm

CHARACTERISTICS OF EFFECTIVE PREVENTION

By Bonnie Benard (With annotations by Peter Stoker to relate to the UK scene)

PROGRAMME COMPREHENSIVENESS/INTENSITY

A. Multiplicity: the causes of drug/alcohol abuse are multiple: personality, environmental, behavioural (Kandel, Logan, 1984; Hawkins et al, 1951). Programmes tackling only one area usually fail. You should target multiple systems (youth, families, schools, community, workplace, media, etc). Also use multiple strategies (information, lifestyles, positive alternatives, community policies) (Botvin, 1982).

B. Target whole community. School based programmes benefit less than community based approaches.

C. Target all youth. not just “high rise for prevention. Adolescence is seen to be a high risk time (for all youth in terms of health compromising behaviour. Labelling ‘high risk’ youth can provoke stigmatisation and lead to self fulfilling prophecies. There is however an argument for defining ‘high risk’ communities where an additional resource over and above the general prevention effort could be justified.

D. Build drug prevention into general health promotion. Drug abuse has been found by several (Lofquist, 1993) to be part of a complex pattern of interrelated factors e.g. delinquency, truancy, school failure, precocious sexuality, which share common antecedents.

E. Start early and keep going! Even in infancy there are influences in later behaviour. Developmental difficulties by age 3 are difficult to overcome (Burton White). Here it is of course relevant to mention Trevor Williams, Noreen Wetton and Alysoun Moon of the Southampton University team who have demonstrated so graphically in their “Jugs and Herrings” research paper that primary age children are not blissfully ignorant of drugs and alcohol. Prevention programmes starting from what children actually know are essential. Many secondary schools still seem to regard Years 11 and 12 as the age at which discussion of drugs or indeed sexuality) should be facilitated. Stable doors and horses come to mind!

F. Adequate quantity. ‘One shot prevention efforts do not work (Kumpfer, 1988) There must be a substantial number of interventions, each of a substantial duration Project DARE (Drug Abuse Resistance Education) initiated by Los Angeles Police and now in several other states delivers no less than seventeen onehour lessons to any given year and this is only part of the school programme.

G. Integrate family/classroom/school/community life. This is easier to say than do, but where it has happened results have been enhanced.

H Supportive environment, empowerment. Where young people are encouraged to participate and take responsibility their behavioural outcomes are improved. In Britain now peer education methods proven elsewhere are being piloted.

PROGRAMME STRATEGIES

J. Knowledge/Attitudes/Behaviour. Address these as a set, i.e. each must be directly tackled rather than assuming one will flow from another. The behavioural component is in part addressed by social skills development, but also supported by positive reinforcement activities drug free social/sporting events, commendations (preferably with something for everyone), media coverage, etc. Research suggests that Social Learning Theory (Bandura, 1977) produces some of the most profound improvements.

K. Drug specific curriculum. Affective education programmes that had not specifically covered drugs (including alcohol) were found unsuccessful, even though they addressed knowledge, attitudes and lifeskills.

L. Gateway drugs. So called because people now using heavy end drugs almost always started on these. Gateway drugs can be tobacco, alcohol and cannabis or, these days in Britain, even heroin! Concentration on prevention of these is therefore likely to prevent use of all substances. British research by MORI (Parents against Tobacco, 1990), showed that of youth who smoked tobacco 50% had also tried an illegal drug compared with only 2% of those who did not smoke tobacco. It should be particularly noted that cannabis is far from harmless: physical, mental and social damage is now being increasingly accepted as a reality.

M. Salient material. Whatever is used needs to identify with the audience, including:

• Ethnic/cultural sensitivity

• Appeal to youth interests

• Short term outcomes to be emphasised as important to youth as well as long term

• Appealing graphics and appropriate language, readability

• Appropriate to real age/reading age a key factor:

In a survey of 3,700,000 young American children, 25% of 9 year olds felt ‘some’ to ‘a lot’ of peer pressure to try drugs or alcohol (Weekly Reader, 1987).

N. Alternatives. Activities have to be plausible, be more highly valued than the health-compromising behaviour. Too often these alternatives are poorly thought through.

P. Lifeskills. Development of these will be of wider benefit than drug prevention. Included will be:- Communication, Problem Solving, Decision Making, Critical Thinking, Assertiveness, Peer Pressure Reversal, Peer Selection, Low Risk Choice Making, Self Improvement, Stress Reduction and Consumer Awareness (Botvin, 1985).

Choosing your friends has been found in some research to be more effective than resisting the peer pressure of said friends. Consumer awareness is a ‘companion’ to resisting peer structure, i.e. resisting media pressure.

Q. Training prevention workers. For the school setting the greater emphasis on experiential and interactive work requires teacher training to extend into youth work skills. Community development skills are valuable in taking school initiatives into the community. Imported ‘prestige’ role models are all very well, but good results have been achieved with parents, peers, teachers, or outside agency workers.

R. Community norms. Consistency of policies throughout schools, families and communities can greatly enhance impact.

S. Alcohol norms. Because of its dual status as a beverage and as an culturally accepted drug, alcohol is problematic for prevention. However, heart disease and tobacco prevention programmes have shown that societal norms can be changed.

T. Improve schooling! Listed here as a target because of its important correlation with healthy lifestyle. Within the current British economic and academic climate the most realistic hope may lie with co operative learning, see the TRIBES program for example.

U. Change Society. Don’t just stop with improving schools: add your voices to pressure for improvement in employment. housing, recreation and self development. (See ‘Project Revitalisation’ in Vallejo, California, for example). It is naive to suppose that prevention can take place in a political vacuum. Jessop recognises that failing to acknowledge the need for macro environmental improvement while at the same time placing the responsibility for health solely with the individual is tantamount to ‘blaming the victim’.

THE PLANNING PROCESS

V. Design, implementation, evaluation. Evaluations have generally concentrated on outcomes rather than the quality of design. However, implementation is as much dependent on engaging all sectors of the community (be it a school. a workplace, or a town) as it is on quality of design. Evaluation should therefore measure process as well as outcome.

W. Goal setting. Unrealistic or immeasurable goals help no one. It is important to set not only long4erm outcome goals (for prevention is long term) but also “process goals” such as increased involvement of parents and community, academic success, increased student teacher interaction. and so on.

X. Evaluation and amendment. Prevention workers have been criticized for giving too little attention to this area., the crushing shortage of funds has much to do with it (in America the ratio of funding between interdiction policy and prevention is about 200: 1). This lack of emphasis on evaluation has been the Achilles heel which pro drug campaigners have gleefully attacked. Effective evaluations have been those including longitudinal design, multiple measures of process as well as outcome (Tobler, 1986), and cost benefit analysis (CBA). CBA is perhaps the greatest marketing tool prevention has; where CBA has been applied substantial cost effectiveness has been demonstrated.

Bonnie Benard can be contacted at NIDA, the National Institute on Drug Abuse, 6001 Executive Boulevard, Bethesda,MD 20892-9561, or info@health.org

Filed under: Prevention (Papers) :

Declaration

In the Eternal City of Rome we, who are more than 500 delegates from 84 nations convening at this Global Conference, reaffirm our commitment to building and protecting the Common Good (‘Res Publica’), by creating and cherishing drug-free communities throughout the world.
In addressing this complex matter, which is of vital importance to every nation, Conference has participated in a wide variety of presentations reflecting (inter alia) cultural, ethical, scientific, medical, social, political and spiritual dimensions of the subject We come from Western and Eastern Europe, North/ Central and Latin America, the Caribbean, Africa, the Middle East Asia, Australia, Canada, Scandinavia – and maybe more.

We represent many diverse faiths and beliefs, but we are united in our support of Core Principles:

Core principles:

The pursuit of the ‘Common Good’ should define and guide the actions of Society.
A ‘Culture of Disapproval’ of drug abuse should be nurtured in all Society.
Society at large should honour ‘Moral Imperatives’ for responsible and constructive citizenship,striking a balance between the rights of the Individual and those of Society.
Proper validated science should under lay and inform all strategy, policy and – action.
Whilst we have pride in our past achievements, our focus is on the future – and our future lies with our children. For them, and for all society, we pledge to strive for an environment in which each and every person in our world has the best chance to fulfil their potential, in the best of all possible health and we pledge to create value in acknowledgement of the gift of life with which we have been blessed. We confirm the superiority of love, in relation to the education and building of our society: a superiority which has become a social, political, cultural and spiritual commitment.
*By ‘drug abuse’ we reaffirm we mean any use of illegal substances and any inappropriate use of legal substances.

ROME DECLARATION – SEPTEMBER 2003 Attachment

SCHEDULE OF INITIATIVES

The Conference resolves to progress initiatives in support of the Core Principles, including but not limited to the following:

Conference commends and supports our host nation, Italy, in its current renewal and strengthening of its policies against drug abuse.

Conference reaffirms the Declarations of all previous Global Conferences

PREVENTION

Prevention requires to be properly and fully recognised for its enormous potential; work to achieve this must be expanded. There must be a development of a positive, pro-active drug policy agenda which becomes the dominant policy initiative.

The whole community suffers from the problems of drug abuse, therefore the whole community must be consciously involved in the solution.

Youth are an important part of the solution, and yet they are too often marginalised, or exploited as ‘tokens’. Their significant potential as agents for positive change must be better recognised and utilised. Improved methods of reaching and empowering youth, in partnership with adults, must be created.

The total solution must be an optimized but flexible mix of all policies and practices, relevant to each nation’s culture. No one aspect of this should be allowed to dominate or otherwise jeopardise the orderly development and delivery of any other aspect.

Conference has recognised the significance of Culture in the drug abuse/drug prevention equation; action must therefore be taken to constructively influence culture in various ways.

The impact of drug abuse upon the individual – not only in the physical sense but ‘anthropologically’ – must be a key consideration; impacts on mental, intellectual, cultural, spiritual and bio-ethical components must all be addressed.

Impacts on the brain deserve special emphasis, and not just at the eventual stage of dependency. The early stages of use – especially by the young – must be more widely recognised for their serious damaging potential.

ORGANISATION

The Global Drug Prevention Network must be developed and widened: assistance should be given with the development of an African Demand Reduction Coalition.

there is a clear need to build and enhance alliances and dialogues with other bodies – such as faith-based groups, universities, and many others. Dialogues in the context of religion, culture and ethics are seen as enriching the whole process of our work.

the number of NGOs and other relevant bodies should be increased.

the technical quality of the work of the GDPN should be strengthened. In this regard, consideration should be given to the establishment, in due course, of some form of prevention institution – to define, monitor, enhance and safeguard scientific, ethical and cultural standards of performance. Additionally, the establishment of some form of international ‘training institution’ – perhaps web-based – should be studied.

LEGISLATION

Conference reaffirms its opposition to legalisation and other forms of drug law relaxation, and – in consequence – its opposition to any initiatives which, overtly or covertly, serve such negative expedience.

The fullest support should be given to the Vienna Declaration, which seeks to unequivocally support the UN Conventions on drugs, notably by the collection of 25 million supporting signatures by the year 2008.

FUNDING

Funding for prevention, and for demand reduction in general, needs to be moved to the top of the priority list, and significantly increased in amount.

International Aid programmes aimed at Producing Countries need to explicitly elevate the priority for Demand Reduction programmes and initiatives.

Source: http://www.ecad.net

Filed under: Prevention (Papers) :

Abstract:

Coalitions are a necessary and valuable tool, when faced with well-resourced legalisation lobbies. The processes for developing coalitions mirror and overlap those for developing policies. This paper addresses both, and suggests guidelines based on the author’s experience. The special potential which effective prevention has, in countering legalisation arguments, is discussed.

Key Words: Coalition, Policy, Practice, Legalisation, Prevention, NGOs

* * * * * * * * * * * *

My colleague Calvina has given you an expert overview of several of the key policy issues around legalisation which must be addressed by some means. I will try to show how you can do this most effectively, through the use of coalitions.

Policy development may alter in form, depending on the level at which you are working – from international summits all the way down to dialogues on the street corner. But though the form may change the essence will remain the same. My own organisation works at all these levels, so I hope that in hearing our experiences you will be able to extract what you need for your own purposes.

Individuals can sometimes generate a change in policy, but for most of us the more usual means of getting what we want – or stopping what we don’t want – is to work together; the Coalition. What we are all doing here in Palermo is one kind of coalition, and I hope it will grow into many permanent coalitions. This isn’t always easy; the word coalition ‘contains’ the word ‘coal’ – and coal is something that burns fiercely if ignited! What ignites a coalition? Policy discussion. A wise man once said

“Tasks unite. Issues divide.”

You cannot avoid confronting issues (meaning Policies) forever, especially in a subject like legalisation, but you can start with tasks that allow your coalition members to bond with each other, before you get into the inflammatory area which is Policy. You are also likely to find that coalition members arrive with their own agendas, or are competitive with one another. These and other spurs to disagreement can actually be very constructive, provided they are channelled properly – in fact, if you can’t hear any vigorous discussion in your coalition, you had better check for signs of life!

But even before you get to the stage of managing your coalition, the first two basic questions to ask yourself are “What use is a coalition to me?” and “Can I succeed without one?”.

Too many people embark on forming coalitions without a clear picture of their situation, their goals and their methods. Coalitions have many uses besides developing and delivering policies: they define and bond your interest group, and strengthen you, through knowing that you are not alone. And, by the way, having a coalition does not mean you cannot also have individual agents, role models, honest brokers, fixers, kamikaze pilots and so on. Your political process needs to be at least as sophisticated as that of both your target audience and your competitors.

Success without coalition? For the case of drug legalisation there is no doubt in my mind that you must have coalitions – plural. (I’ll tell you later why one coalition is not enough). So why exactly do you need coalitions for the drug legalisation issue? I can suggest some reasons:

– the nature of government and community today – interest groups are the norm.

– the size and complexity of government and community today – too much for one.

– their expectations of “interest groups” like you – amateur efforts will not do.

– the need to optimise skills/resources by sharing

– their existing knowledge/ignorance/bias – you have big barriers to overcome.

– the competition in trying to be heard, and

– your opposition’s strength and tactics

Let’s assume you have decided you do want a coalition for policy development on legalisation issues. Now, how do you build one? There are no architect’s plans to guide you, though the publication “The Future by Design” – published by the Centre for Substance Abuse Prevention (USA) is a valuable reference work which I would recommend you to obtain. (REF 1). On a more general level, there are some tried-and-tested guidelines from other fields of endeavour. It is also true that the processes you have to go through to develop a coalition are largely the same ones you have to go through to develop a policy, so in learning one you will learn the other. At the higher levels of central or local government, there will probably be accepted structures and procedures for coalitions and their policy development, but even here it is possible to waste time and energy by not having a clear definition of goals and methods to achieve them.

In simple terms, what you need is a Business Plan. Don’t be frightened by this term; there are basic but invaluable elements in a Business Plan which will enormously help the effectiveness of your anti-legalisation coalition. Even if you leave much of the rest of business planning to one side, you will greatly benefit from working on two key elements; these are “A to B” and “SWOT”.

A to B:

This comes from William Lofquist’s classic book for drug workers: “Discovering the Meaning of Prevention”. (REF 2) It is a model designed to help you think clearly.

A – exactly what is my situation now?

B – exactly where do I want to go?

Arrow – how will I get there? (methodology)

Ruler – how will I know I’m going in the right direction?

You should answer all these questions as fully as possible; for example:

A: what is the position of Government, significant opposition parties, other people/groups with influence on legalisation? Who is for you/against you/on the fence/apathetic? What are your resources? What have you achieved so far?

B: what are your goals in relation to legalisation (or other law changes)? What is your fall-back position i.e. where are you prepared to concede a little and where will you stand and fight without concession? What other policies do you want to see conserved/introduced/strengthened, so as to buttress the drug laws?

Arrow: what methods will you employ to achieve your goals? Which of these are familiar to you and which are new?

Ruler: what observations/measurements can you take; what mile posts can you establish to reassure yourself and others that you are going in the right direction?

What you should end up with is an ‘A to B’ for your overall strategy, with other ‘A to B’ structures nesting under this for each of your Policies and, under each of them, the same for your Actions.

SWOT:

This is a classic business management tool; the value of it is to highlight those assets which you can capitalise upon, and indicate those areas where you need to repair or strengthen your coalition. SWOT stands for

Strengths, Weaknesses, Opportunities, Threats.

Again, be as detailed as you can and as honest as you can, in answering each of these headings. It is quite usual to turn a Threat into an Opportunity, with a little positive thinking. It’s what the Buddhists call “turning poison into medicine”.

Policy Issues around Legalisation

Before you can properly measure your ‘A to B’ and ‘SWOT’, you need to define the policy issues which should concern you, in the context of legalisation. Some of these will be obvious and immediate; others less so. You won’t need to address them all at once, but you do need to be aware of them all now. These are just some of the issues which I think you will encounter in relation to legalisation:

– validity of the laws

– crime to pay for drugs

– crime because of drug use

– the justice system for youth and adults

– social disruption

– moral fabric of society

– health (personal and societal) including physical, mental-intellectual, spiritual, emotional, social, and environmental aspects.

– liberty – individuals and groups

– social inequality

– housing and employment

– children: healthy development

– choice – the limits

– religion: drugs as competition

– politics: drugs as soporific or revolution-maker

– the work place and commerce

– the media

– safety and security

– honesty in sports

– parental authority

– rights versus responsibilities

– teacher authority

– who teaches the teachers?

– Harm Reduction – when, where and what?

And the one that everybody forgets: Prevention.

In the extensive dialogues that you will undoubtedly hold in developing policies which address these and maybe other subjects, do not overlook that section of society which is the most involved, and is often characterised as “the problem”. By this I mean Youth. In another of his classic texts, (REF 3) Lofquist has very clearly described different adult attitudes towards youth; what you should be aspiring to achieve is engagement with youth as resources. This does not mean that they have supremacy, for your views are equally valid and your longer experience must also be taken into account. But what it does mean is that through partnership with youth you have a chance to produce a stronger set of policies, ones with which young people will feel “ownership” and thus be much more likely to assist in developing.

Building your Coalition: managing policy

“He who is my enemy’s enemy is my friend” (Arab proverb )

We can learn from this proverb; its use is in commending us to look very widely for allies. This is especially true of the non-governmental sector. Legalisers are very good at this, never more so than when it comes to public relations. In the back room they may be stabbing each other, but when the cameras roll they are unlimited in their praise of, and respect for each other. Is this unethical? Debatable. On the other hand, is public argument with your allies stupid and suicidal? Absolutely. In this, as in other aspects of the legalisation debate, look and learn from your opponents. They have probably been at it longer than you, and they certainly have more money behind them – George Soros estimated over two years ago (REF 4) that he had, by that time, put no less than $90 million into weakening drug laws, and he is not the only backer of the legalisers. So, observe the methods of policy development and practice which these people have spent so much time and money on, and pick their best ideas – they may not actually cost you very much to implement.

With the honourable exception of people like Drug Watch International and Drug Prevention Network of the Americas- the legalisers have also been better at international networking. If we look at some of the major legalisation initiatives, we can see that different “lead strategies” are applied in different countries (although all of the strategies will show up at some point in the priority order). What this means is that if a particular lead strategy succeeds in one country it can be fairly rapidly adopted as the new lead strategy in others. Of course the legalisers are helped in this ‘crusade’ by enjoying a much readier acceptance from the media than we do, and this is also on an international stage. This also means they get a lot more books published. But since those books are out there on the shelves, when you are looking for ideas on strategy, policy or tactics, why not take a tip from General George Patton? After defeating the master strategist General Rommel, Patton was asked by newsmen how he had managed to pull off this surprising victory. ” “Simple” said Patton. “I read all his damned books”.

A coalition which addresses legalisation issues will find it has a bewildering array of potential coalition partners. Choosing how much effort to give each one, and the priority of each target is a difficult judgement call, made more difficult by the fact that the priority rating of any target will change in relation to which issues are “hot” on the day.

Why are some of these apparently extraneous Groups/individuals mentioned? Firstly, because the effects of drug misuse are reaching them (whether they know it or not), and secondly because your coalition needs to be as widely-based as possible. It is a basic truth that people not directly involved in an issue are likely to be supportive of it, if there is some overlap with their own experience (REF 5), provided that they can see your coalition knows which way it is going, is under good leadership, and preferably will not put them into any “uncomfortable” situations.

Uncomfortable? Keeping all your allies allied is a full-time job. They will be quite happy to stand behind you while you do battle on their behalf, but sometimes they will get nervous if you seem to be too outspoken. Others will be worried about compromising their funding if they are seen to be too close to you (you may be viewed as ‘Mad, Bad and Dangerous to know!’) – this is especially true if your country has libertarians liberally insinuated into its government or other fund-giving structures, as we have in Britain. Your allies may therefore want to pressure you into watering down your policy statements. This is a tough decision for you; a dilemma not easily or quickly solved. You will have to take this on an issue-by-issue basis and, over time, help them to achieve an understanding that on some subjects it is necessary to be courageous and take a stand – even if this upsets a few people at the time, they will respect you for it later. In doing so always stay cool, attack the plan but never the planner. Don’t rush into this, sustain your effort and keep repeating it: one of Britain’s oldest think tanks, the Fabian Society, works to a guiding principle which they call “The Inevitability of Gradualism”. Now that’s clever.

I said earlier that you should have coalitions – plural. Why would you need this? Firstly, to make your “Army” look bigger, and frighten the opposition. Secondly, to impress the decision-makers. And thirdly, to have other coalitions still in action if one of yours becomes damaged in some way or becomes unacceptable to the decision-makers. The legalisers are also good at this; when the earlier coalitions they formed became discredited as “hippy potheads in tie-die shirts” with antagonistic names like Legalise Cannabis Campaign, they replaced them with suit-and-tie organisations, giving them soothing, intelligent-sounding names like the Drug Policy Foundation or – even more obscurely – the Lindesmith Foundation, names which conveniently hide their purpose.

The Beau Geste stratagem

There is nothing to stop you having groups which belong to many coalitions; there is also nothing to stop a few individuals forming many groups – or forming groups which sound enormous and impressive to the public, but are far from it. I have heard the Director of NORML Canada, an organisation you might think was huge, admitting that his total membership coast to coast was nine people. In Britain, in a subject area very much related to drug misuse, we have a group of people who have been extremely active in ‘fabricating’ “Children’s Rights” groups. (Funny how we never hear of groups pressing for “Children’s Responsibilities”) Less than 20 of these people have established around 15 groups, all of them enjoying national standing. (REF 6). As I said earlier, look and learn.

Getting it right, getting it heard: Policy Development

So now you have a coalition (or family of coalitions). You clearly understand your present situation, and your goals – your ‘A’ and ‘B’. Now how do you get to B? Here is a suggested sequence of tasks:

– Develop Mission Statement (to match ‘B’)

– Develop Resolutions (to support ‘B’)

– Develop Policies (to achieve ‘B’)

– Develop Action Plan (‘A’ to ‘B’)

– Agree Action Plan within your Coalition – Define Milestones (Ruler)

– Get funding

– Divide tasks between appropriate activists in your Coalition

– Deliver, achieve your goals (arrive at ‘B’)

– Review, evaluate, improve (redefine ‘A’)

Let’s focus on Policy Development for a minute. We burn up a lot of time and energy reacting when we should be “pro-acting”- opposing when we should be proposing. As a means to better policy, why not invest time in your own unofficial Policy Think Tank, and make your first focus the development of policies to get what you want, before moving on to consider how to stop the other side getting what they want? I have given some suggestions in the handouts, but as a starting agenda for discussion, how about the following?:

Strategy: A Healthy Society for All

Some Policy Nuggets:

– Prevention that engages the whole community

– Parents re-empowered to develop a healthy children through a proper mixture of love, guidance and discipline.

– Education that imparts sound values and goals

– Teachers who are trained to achieve this, in partnership with parents

– Police who intercept and divert young offenders early on

– Justice systems that give rehabilitation more than they take revenge

– Health systems that do more than just react to sickness

– Workplaces that get involved in healthy working

– Laws that underpin health goals and are worthy of respect

– Faith bodies that show courage and speak unequivocally

– Media that puts truth above ratings, society’s health above self-indulgence

– Sports systems that bring out the best in behaviour

– Drug services that focus on abstinence, and

– Citizens who know the meaning of the word “Citizenship”.

In a phrase – “Don’t solve the drug problem – PREVENT it!”

You also need to define a Communications Policy. In your nation, where does the power lie? In Britain, much of it lies with the Civil Service (the Administration), which – unlike America – is not changed every time a new President is elected. They are enormously powerful and therefore they have to be one primary target. Again, for your nation, who are the people with influence on the decision -makers, and how can you get to them? And how should you vary your message to suit different organisations or people? Media Liaison, of which we do a great deal, is a whole subject in itself, for which I have no time – I’m glad, therefore, that Calvina has addressed this vital aspect. These are not just matters of Procedure; which message you give to whom, and when, are all matters of Internal Policy; matters which are intricately mixed with your External policies.

Your Coalition will soon find that it cannot limit itself to a narrow message (such as “Legalisation? Just Say No”). You will have to demonstrate that your message is built on a good foundation of knowledge, understanding, analysis, popular support etc, also that it has breadth of vision – it takes account of the effects on other policies, on other areas of life as a whole, and it addresses (and, hopefully, pre-empts) any arguments by others. Your coalition’s growth will be stifled if members do not freely share information and contacts; this is not as easy as it sounds – old habits of competition die reluctantly. Encourage all to take courage and be generous. After all, a coalition is like a marriage – you are united in order to achieve a common goal. You are partners, so act like partners!

* * * * * * * * * * * *

Calvina has eloquently described much of the significant negative rhetoric which is forcibly pushed into the legalisation debate, and which therefore must be a major focus in your policy development. I would like to finish my contribution to this prevention conference with one of the key positives.

A significant number of people, including many ordinary members of the public – not just the legaliser lobbyists – would prefer the young, and others, not to do drugs, but they have somehow come to believe that prevention is largely ineffective, and that “everybody’s doing it”. Even some who have a gut feeling that it is the right thing to do are still induced to see it as an honourable but futile action – a Mission Impossible.

Because the public believe this to be a fact, they reluctantly conclude that legalisation is the next best thing – a way to “Reduce Harm”. One of our greatest challenges is to overcome this “credibility gap”. If the majority of the public can come to truly believe that drug prevention works, then they will turn their back on the legalisation lobbies – no matter how many millions of dollars, or highly paid journalists they have behind them. And one of the best weapons we have – which too often is under-utilised – is the coalition.

The evidence and the argument for prevention already exists. The “Prevention Works” handout for our coalition, and of which we are already circulating 100,000 copies across the UK, is one example of this. Please feel free to use this leaflet as it stands, or to borrow sections from it. (We would be grateful if you would attribute us when doing so).So, we have the evidence and we have the argument; and our job is to get it out there where it can do some good.

Coalitions can share the load, share resources, and encourage one another to greater achievement. Just one example is the World Wide Web – and again this is an example where we can “look and learn” from the legalisers. There are literally hundreds of websites in praise of legalisation, many linking with each other. How many sites do we have? Not enough!

You do not have to pay large sums of money to establish your website. Ours, which you can find on
www.drugprevent.org.uk was designed by a university undergraduate in his spare time, and yet it was judged good enough to beat more than 600 other worldwide entries to reach the finals of the Stockholm Challenge this spring. Why don’t you look around and find a local student web enthusiast – or even a number of them, and run a competition for them, with prizes? But above all, and in all, do something, and do it now.

In closing, here is some final guidance from people wiser than I can ever hope to be. The final quote is from an unknown Chinese poet, but first we hear from Edmund Burke on why we must get together when we face threats like drug legalisation:

“When bad men combine, the good must associate; else they will fall, one by one, an unpitied sacrifice in a contemptible struggle”.

And lastly, bear in mind that the best of coalition are run by ‘Invisible Men’ (and Women!):

Go to the people, live among them, learn from them, love them, start with what they know, build on what they have; but of the best of leaders, when their task is accomplished, their work is done, the people all remark “We have done it ourselves”.
____________________________________________________________

REFERENCES:

1. Center for Substance Abuse Prevention (1991) “The Future by Design”. CSAP, 5600 Fishers Lane, .Rockwall 11, Rockville, MD 20857. DHHS Pubn. No. (ADM)91-1760).

2. Lofquist W.A. (1983) “Discovering the Meaning of Prevention”. AYD Publications, Arizona. ISBN 0-913951-00-5

3. Lofquist W.A. (1991) “The Technology of Prevention Workbook”. AYD (as above). ISBN 0-913951-02-1.

4. Time magazine (1997) “.. Soros spent over $90 million..” AP wire 8/25/97.

5. Kelly G.A. (1955) “The Kelly Repertory Grid” (from ‘ Psychology of Personal Constructs’) Norton, NY).

6. Burrows L.(1998) “The Fight for the Family” Family Education Trust, Oxford. ISBN:0-906229-14-6.

Filed under: Prevention (Papers) :

What price drug education? Recent reviews of the literature have suggested that drug education does not work. Peter Stoker argues that there is a way forward

It will come as no revelation to reader of this journal (Mersey Drugs Journal, 1987) that prevention (meaning primary prevention) has for some time been taking a hammering. Mere mention of it raises hackles in some and dismissive epithets in others. The hackle-raising comes from those who choose to interpret the word literally: How dare one ‘Prevent’ others from using? This is a reprehensible, even immoral, infringement of personal freedom. Empowerment, meaning free choice in the use of drugs, should he the right of every individual of whatever age. As part of this educators should stay silent on the use/non-use issue; teaching should be about drugs, not against them (O’Hare et al., 1988). The dismissive epithets emanate from those who have read a good deal of the literature available and conclude that drug use cannot he prevented.

Over the years that NIDA (USA) biennial household survey results have been readily accepted a,; proof of the need for harm reduction, suing for peace as the ‘War on Drugs’ crumbles. However, when the same survey started showing reductions in drug use, it was scorned as no more (or less) than a conspiracy by the American public to make prevention workers feel good. Prevention workers in the area covered by these results have every right to feel good. Whilst the ‘War’ as prosecuted by people in uniforms may well be a depressing sight, it is the ‘civilians’ in prevention work who are showing real progress. Other than this, there is the occasional reported success, for example the Germans have shown that they are good at rnore than just foot hall, but such reports are rare indeed (Nilson-Giebet, 1980,pp.20-24).

So why bother, the argument continues. If it is impractical and immoral to prevent use then switch to plan B – school the user (or potential user) so as to minimise harm, and switch the drug agencies who are ‘stuck in the outmoded abstinence model’ over to a harm reduction role, retraining them to service the user’s needs during his or her drug-using ‘career’ (Parry, 1988).

For drug agencies or drug educators world wide having primary prevention as part of their role all the above cuts at the very roots of their philosophy. But far from reacting, the response of many has been to disdain or ignore the criticism and carry on anyway. Too busy or too shy for long, sophisticated debate they have left the rostrum and the printed page to their critics. Small wonder then that the residual impression is that prevention has no case to offer.

Other factors have had their influence on current attitudes. Perhaps the most graphic example of harm reduction is in response to HIV/AIDS; few in Britain would argue against the issue of clean syringes/needles and condoms, plus advice, as part of the effort to prevent the spread of HIV infection. Merseyside has been particularly effective. Many prevention workers, including the author have thought through and accepted this logic, seeing no dichotomy between harm reduction for existing users coupled with prevention for the non-user. The argument starts (or should start) when the above, extremely justifiable, introduction of harm reduction ‘in extremis’ is opportunistically exploited as a springboard, promoting harm reduction as the educational model across the board, i.e. de-fund primary prevention and even treatment, redeploying the funds into harm reduction (Parry, 1988).

Undoubtedly one spur to this dialogue is an argument about funding priorities in a time of limited resources. Partisan argument will always emerge in this situation, but again prevention workers are leaving the field to their competitors for funds, when a more rational approach would he concerted action pressing for a general increase of funding. Meanwhile the argument against prevention proceeds by endeavouring to classify us all as drug users; your coffee beverage makes you just as much a drug user as someone else’s heroin. By this definition ‘non-drug-users are a deviant minority’. Ergo, use of all drugs should be considered normal. This is but a short step from saying drug use should be the norm.

Norm, normal, normalisation – soft, low-key words lessening the chance of hard reactions from conservative authorities. Credit must be given to liberalist campaigners such as NORML and the Drug Policy Foundation for this sophisticated approach; likewise the ‘softly, softly’ strategy adopted by EMNDR All of them eschew provocative wording and all of them speak up volubly ,and articulately.

The cause of prevention has hardly been helped by cosmetic campaigns mounted by governments who are more concerned to show that they ‘care’ than about any lasting effect on drug use. This has happened in several countries and of course Britain has received its share. Advertising screws you up.

Further, where prevention initiatives have taken place evaluation has been the last item on the budget list, or more often has not even appeared at all. Projects short of people and/or cash make a professional judgement at the planning stage as to whether an initiative is worth while, then go for it, leaving any classic proof of worth to the academics. In the case of prevention this is perhaps more understandable, if not excusable, because it is notoriously difficult to evaluate definitively anything to do with attitudes ‘and behaviour. We can rarely be sure if a behaviour changes, that it is the result of the educational initiative that is being tested, or whether other factors held sway, or whether the person concerned just changed his or her ruined (Edwards, 1984).

LACK OF PROOF

The blunt summation of all this is that there is very little solid evidence to show that prevention works.

The skills for Adolescence programme developed from the American QUEST programme was subjected to evaluation in seven schools in 1988 by workers from Christchurch College, Canterbury (Parsons et al., 1988). It won praise for reducing truancy, improving class discipline and performance, and strengthening pupil-teacher and school-parent relationships. But when it came to appraising drug, use prevalence, before and after, the researchers ducked the question, making superficial remarks such as ‘How can you measure it ?’ and thus another opportunity for proper evaluation was lost.

The PRIDE organisation in America (Parent’s Resource Institute for Drug Education) has plenty to be proud about. Its 1991 conference, the fourteenth, attracted almost 7000 attendees, youth and adult, and nearly 300 workshops were held during the week, involving delegates from over 80 countries. But for an organisation boasting over 60 full-time staff, the resources applied to evaluation are regrettably slight; Al the more surprising when considering that the PRIDE President is a University of Georgia professor (of physiology). Perhaps the single most tangible evaluation tool PRIDE has is a confidential questionnaire (though its original raison d’etre was to awaken and galvanise communities previously unaware or in denial). This questionnaire has been run now for over 8 years and respondents run into millions; in one month alone (October 1987) 450 000 students in PRIDE’s home state of Georgia completed the survey.

Co-author and coordinator of the computer analysis of these questionnaires is Ronald D. Adams, another professor (of education), this time at Western Kentucky University. His location may explain why one of PRIDE’s most detailed evaluations – a 5-year longitudinal study – is based in Bowling Green, Western Kentucky (1989). Graphs of usage of various substances and various school grades almost all show sustained reduction in the 5-year period. A specimen graph is given as Figure 1. As is usual with most statistics there is more than one way of viewing the results. For example, use of cannabis by twelfth graders may have dropped from 45 per cent to 30 per cent (= success?) but it is also true that even after 5 years of this programme 30 per cent are still using (= failure?) – depends where you stand! Similar results are described in a more recent PRIDE newsletter (Summer, 1990) concerning 30 schools in California and Oregon. A 5 year study of 4000 students showed reduction in cannabis and tobacco use, but no reduction in drinking (Ellickson and Bell, 1990).

A BRITISH INTERVENTION/PREVENTION STRATEGY

The author’s practical experience with a west London drug agency is similar to that with many agencies in the work done with users, their families and friends: non-judgemental and not insisting on abstinence as a condition of attending, greater emphasis placed on the user appraising his or her own life and making informed choices, having considered actions and consequences. Other similarities exist in much of the education, training and HIV/AIDS work in schools and community. Harm reduction guidance/assistance for known users and also those perceived to he at risk is and always has been included, in work over more than 8 years.

Meanwhile self-funded study tours by the author to the USA (several) and Hong Kong (once) augmented desk study of prevention programmes operating in many countries. Among several good contenders the Illinois Teen Institute’s I 5-year experience of weeklong experiential training camps looked particularly promising, together with the PRIDE youth programme and Youth to Youth (Columbus, Ohio). The author’s wife and professional colleague created this international research and developed a prevention programme appropriate to the British culture, with the aim of empowering youth to stay drug, abuse free and maybe help others to achieve the same. In 1988 the first home-grown version was launched. In 1989 we saw a repeat with guest delegates from Sweden, Switzerland, Portugal and America; camps of 1990 and 1991 have been held with a sprinkling of international youth. The programme was named TEENEX, meaning ‘teen experiential’ learning.

Attendees at the camp are predominantly non-users but with a small proportion of casual users and other youngsters at risk in some way or other, the intention being to facilitate a positive peer environment to the benefit of all. In addition to the annual camp there are evening meetings and, when funds permit, residential weekends.

Besides TEENEX, another innovative project introduced has been TRIBES, a cooperative learning process 5. applicable to primary and secondary schools and used for many years in several American states, with multiple benefits. Other initiatives have included Kangaroo Creek Gang, a video-based training programme currently in use in every primary school in Australia, and utilisation of the Life Education Bus (also Australian based) for which funding comes from TVAM and the Dire Straits rock band.

The striking aspect in comparing contributions by hundreds of international delegates at American conferences with those of the 400 or so delegates in Hong Kong (very few of whom were American) was the unity of commitment to prevention and the broad similarity of initiatives. Another commonality was the universal absence of British delegates! Prevention workers would say that this shows that Britain is behind most countries; doubtless hardened xenophobes would say it 7. shows Britain is ahead, and it’s everyone else who is out of step.

Xenophobia, and in particular Americophobia, is a frequent facet of criticism of prevention, sometimes matching the hysteria it seeks to condemn (011are, 1988). The American political and media rhetoric does of course set itself up for pillory but it is no more representative of the main body of serious drugs work than is the case in this country. Likewise some American drugs workers come across with almost missionary zeal, but to discount the message because of some of the messengers is either a mistake or a deliberate misconstruction.

DOING THE HOMEWORK BETTER

If prevention is to sway the sceptics and justify a firm future then several specific actions are indicated:

1. More money now into longitudinal studies. The British Government’s new Central Drugs Prevention Unit could usefully involve itself in this.

2. Better collation of existing research world wide, published as The Case for Prevention, in plain words.

3. Critical assessment of which schemes work, which don’t.

4. Collation of ancillary research justifying prevention: work by those such as Dr Robert Gilkeson on the harm caused by even moderate use of cannabis; Dr Harith Swadi’s (1988) work on peer influence and family factors; Stoker and Swadi’s (1990) on the same topic; Botvin’s (1983) research on smoking prevention work and the use of lifeskills training.

5. Recognition that harm reduction has a place, but put it in its place, and in proportion to prevention. Educators, youth workers etc. need to retain the ‘I personally don’t recommend you using because’ message alongside harm reduction; staying silent on prevention would be taken by even more youth as a tacit message that it’s okay to do drugs so long as you use the least risky method.

6. Drop the rhetoric about ‘War on Drugs’ which backfires all too often. Apart from the inflammatory effect, if one talks of war people expect a victory in a finite period, and that isn’t going to happen. What, we have with drugs is more like the contest between the Dutch and the sea. The sea continually seeks to ~ erode the land, whilst the Dutch continually prevent erosion and sometimes even achieve substantial reclamation, but they will never be able to let up.

Much more concentrated prevention work: it must he recognised that a little here and there is at best useless. To succeed, prevention has to be substantial and sustained Prevention is riot alone in needing evaluation evidence to support its case. Any measurement of changing, behaviours around harm reduction is fraught with all the same difficulties. The struggle to change behaviour is just as tough. Review of British syringe exchange schemes by Goldsmiths showed that despite all the efforts over a third of clients using the exchanges were still sharing (Stimson et at., 1988). Behaviour among those not patronising the exchanges is unlikely to he more careful. Such statistics are of course of no comfort to anyone, but they strengthen the resolve of prevention workers to continue to strive to reduce the number of people reaching such straits.

A note of caution here: the majority of critiques of drug education programmes have themselves been criticised as being inadequately rigorous (Goodstadt 1980). Scrutinise everything, including the scrutineers! Prevention workers may not realise it but they owe harm reductionists and other sceptics a debt of gratitude. In forcing a more rigorous assessment of prevention programmes (what works and what doesn’t) a much more potent bran(] of prevention should be developed.

Above all there is a need to be clear that prevention is being chosen not merely to salve some moral conscience but because it is a rational, proven and effective process.

This article is based on a paper presented to the PRIDE International Conference at Atlanta 1988, Georgia. Peter Stokes at the time of writing was a project worker with a west London drug/alcohol agency. He is now the director of the National Drug Prevention Alliance; PO Box 594, Slough, SL1 1AA.

REFERENCES

Adams, R. D. (1989). From the computer: Bowling Green yields marijuana findings in five-year case study of PRIDE community plan. PRIDE Quarterly, Summer.

Botvin, G. J. (1983). Prevention of adolescent substance abuse through the development of personal and social competence. In: Glynn, T, J., Leukefeld, C. G. and Ludford, J. P. (Eds). Preventing Adolescent Drug Abuse: Intervention Strategies, pp. 115-140. Department of Health and Human Services, Maryland, USA.

Dorn, N. (1987). Minimisation of harm: a U-curve theory. Druglink, March/April.

Edwards, G. (1984). Addiction: a challenge to society. New Society, 25th October.

Ellickson and Bell (1990). Prevention programmes effective in school setting. PRIDE Quarterly, Summer.

Goodstadt, M. S. (1980). Drug education – a turn-on or a turn-off? Journal of Drug Education, 10.

Nilson-Giebel, M. (1980). Peer groups help prevent dependence among youth in Federal Republic of Germany. International Journal of Health Education, 23,20-24.

O’Hare, P. A. (1988). Drug Education: the American way. Mersey Drugs Journal, May/June.

O’Hare, P.A, Clements, 1. and Cohen, J. (1988). Drug Education: A Basis for Reform. International Conference on Drug Policy Reform, Maryland, USA.

Parry, A. (1988). Unpublished presentation to NW Thames Regional Health Authority Drug Workers Seminar, 15th September.

Parsons, C. et al. ( 1988). Food for thought. (Evaluation Unit, Christchurch College, Canterbury). Monitor (TACADE) No. 78, Autumn.

Stimson, G. Donoghoe, M., Alldrit, L. and Dolan, K. (1988). Syringe exchange 2 – the clients. Druglink, July/August, 8-9.

Stoker, A. and Swadi, H. (1990). Perceived family relationships in drug-using adolescents. Drug and Alcohol Dependence, 25, 293-297.

Swadi, H. and Zeitlin, H. (1988). Peer influence and adolescent substance abuse: a promising side? Journal of Addiction, 15 3-15 7.

Source: Mersey Drug Journal 1987

Filed under: Prevention (Papers) :

The follow-up results of a six-year study by the Institute for Prevention Research at Cornell University Medical College provide important new evidence that drug abuse prevention programs conducted in school classrooms work. In a large-scale study involving nearly 6,000 students from 58 schools in New York state, students who received a skills-based prevention program in junior high school were found to have significantly lower odds of smoking, drinking, and using marijuana at the end of high school. This is the first scientifically rigorous study to show conclusively that a school-based drug abuse prevention program can produce meaningful reductions in drug use lasting over the critical junior and senior high school years.

The study was conducted by researchers at Cornell University Medical College’s Institute for Prevention Research with funding from the National Institute on Drug Abuse. The research team was led by Dr. Gilbert J. Botvin, professor public health and psychiatry. Schools were first grouped according to their rates of drug use and then randomly assigned to either receive the prevention program or to serve as controls. The prevention program, called Life Skills Training, taught students self-management skills and general social skills as well as information and skills for resisting pro-drug use influences. Students received the prevention program during the 7th, 8th, and 9th grades. Final follow-up data were collected at the end of the 12th grade.

Students receiving the prevention program had less tobacco, alcohol, and drug use at the end of the study than control students who did not receive the prevention program. The odds of smoking, drinking immoderately, or using marijuana were significantly lower for the students who received the prevention program during grades seven, eight, and nine. For these students, the odds of smoking, drinking, or using marijuana were up to 40 percent lower than for controls. Not surprisingly, the prevention program was less effective for students whose teachers taught only part of the program. On the other hand the strongest prevention effects were found for students who received at least 60 per cent of the drug abuse prevention program.

In addition to assessing the long-term impact of the prevention program on the use of individual substances, the effectiveness of the program was also assessed in terms of polydrug use (defined as the use of two or more drugs by the same individual.) A criticism of previous prevention studies is that they have only demonstrated an impact on relatively low levels of drug involvement – for example, the occasional use of cigarettes. This study directly deals with this issue by looking at the impact of the prevention program on the regular (weekly or more) use of cigarettes, alcohol, and marijuana. The odds of using all three substances on a regular basis were up to 60 percent lower for the students who received the prevention program than for controls.

Two forms of the prevention program were tested. One involved providing teachers conducting the program with special training and feedback by project staff. The other gave teachers a videotaped version of the training and no feedback. All teachers assigned to teach the prevention program were given a teacher’s manual and student guides for each year of the program. The teacher’s manual contained 12 units designed to be taught in 15 class periods. Each unit included an overall goal and specific student objectives as well as detailed lesson plans spelling out the material that should be covered with step-by-step instructions. The student guide contained information related to each of the program units and classroom activities along with workbook assignments intended to supplement classroom material.

Teachers in the schools assigned to receive training and feedback attended a one-day workshop that taught them about the causes of drug abuse and the reasons for using this particular prevention method. They were also taught how each of the classroom sessions should be conducted. During the time they were teaching the prevention program, members of the project staff periodically watched the teachers conducting the program in the classroom and whenever necessary gave them feedback and advice on how to teach the prevention program more effectively. The teachers in the other group received the same prevention materials and videotapes for each year of the program offering the same material as the training workshops. Although teachers in this group were also periodically observed while teaching the prevention program, they did not receive any feedback or advice.

Both prevention groups had significantly lower odds of using drugs by the end of the study. However, when results were examined with respect to the most serious patterns of drug use – using two or three drugs once a week or more – as expected, the prevention program was more effective for the students whose teachers received the training workshop and ongoing support from the Cornell researchers.

The results of this study have several practical implications for developing more effective drug abuse prevention programs:

Prevention programs should contain components that make students aware of the actual rates of drug use and the fact that only a small percentage of adolescents use drugs in order to correct the misperception that “everybody’s doing it.”

Prevention programs should teach skills for resisting pro-drug use social influences.
They should also teach a variety of general life skills for helping adolescents deal with the challenges of adolescent life. These include self-improvement skills such as goal-setting and self-reinforcement, skills for making decisions and solving problems, skills for thinking critically and analyzing media messages, skills for coping with anxiety, skills for communicating effectively, skills for meeting people and making friends, and general assertiveness skills.

Even if a prevention program previously found to be effective is being taught, it will only be effective if it is properly implemented. Because there are many competing demands on the school schedule, it is sometimes difficult to teach drug abuse prevention programs in their entirety. However, this and other studies show that there is a direct relationship between how much of the prevention program is implemented and its effectiveness. If prevention programs are only partially implemented, they are not likely to reduce drug use or drug use risk. Similarly, changing a prevention program known to be effective by modifying program components or adding new ones that have not yet been tested can render the prevention program ineffective.

Drug abuse prevention programs must be taught over a prolonged period of time. Prevention programs that are only one year long or do not contain two or more years of booster sessions are not likely to produce lasting reductions in a drug use. In fact, evaluations of prevention programs not including booster sessions have shown that initial reductions in drug use decrease after about a year and disappear totally after about two or three years.

In order to have maximum effectiveness, training and support from prevention experts should be obtained whenever possible.

The prevention program tested in the Cornell study was effective whether teachers received a formal training workshop and ongoing consultation and support or only received a training videotape. However, with respect to more serious drug use, it was most effective when teachers received formal training and periodic consultation and support.

Researchers have been searching for effective prevention programs for more than two decades now. The goal of a prevention program that could actually produce measurable reductions in drug use behavior has been elusive. Prevention approaches that relied on teaching factual information about the dangers of drug use have consistently been shown to be ineffective, as have a variety of other prevention approaches. Prevention programs that teach students how to resist social influences to use drugs have produced short-term reductions in cigarette smoking and, to a lesser extent, alcohol and marijuana use. Several long-term follow-up studies have raised questions about the ability of these approaches to pro duce lasting reductions in drug use.

The results of the Cornell study provide important new information that prevention works. The right kind of program, when properly implemented with junior high school students and with four years of booster sessions, can produce prevention effects that last at least until the end of high school. A prevention program that teaches general skills for dealing with life as well as skills and information for resisting social influences to use drugs can significantly reduce the chances that junior high school students will experiment with drugs. It can also reduce the likelihood that these same students will develop more serious patterns of drug use by the end of high school . With this study, it is clear that drug abuse prevention has come of age.

Source: Western Center News – June 1994 – Western Regional Center for Drug-Free Schools and Communities – published in ‘The Challenge’ vol. 6 No.1.

Filed under: Education,Prevention (Papers),Prevention and Intervention,Youth :

Introduction
Several reviews of the substance abuse prevention literature have concluded that social-influence-based prevention programmes can significantly delay the onset of tobacco, alcohol, and other drug use and slow the rate of increase in substance use prevalence among entire populations of early adolescents. Less is known about the capacity of these and other primary prevention programmes to effect decreases in substance use. This is an important question, since some youth have already begun to experiment with drugs by the time that usual primary prevention programmes have reached them. Youth exhibiting early drug use relative to their peers are considered at higher risk for later drug use and abuse. The few studies that have investigated the effect of primary prevention programmes on those who have already begun using tobacco or other drugs have yielded equivocal results and have not systematically evaluated maintenance of decreases in use. The purpose of this study was to evaluate the secondary prevention effects of a primary prevention programme in reducing cigarette, alcohol, and marijuana use among baseline users.

Abstract
Objectives. This study investigated the secondary prevention effects of a substance abuse primary prevention programme.
Methods. Logistic regression analyses were conducted on 4 waves of follow-up data from sixth- and seventh-grade baseline users of cigarettes, alcohol, and marijuana taking part in a school-based programme in Indianapolis.
Results. The programme demonstrated significant reductions in cigarette use at the initial follow-up (6 months) and alcohol use at the first 2 follow-ups (up to 1.5 years). Models considering repeated measures also showed effects on all 3 substances.
Conclusions
Primary prevention programmes are able to reach and influence high-risk adolescents in a non-stigmatizing manner.
Discussion
Primary prevention programmes have been criticized for affecting future occasional users but not youth at the highest risk for drug abuse (e.g., current users). In this study, we reported 3.5-year follow-up effects of a primary prevention programme in decreasing drug use among adolescents who were users at either sixth or seventh grade. With a very conservative criterion to define decreased use, the results indicate that the programme did effect reductions in use, especially cigarette and alcohol use. These secondary prevention effects were significant for cigarette users at the 6-month follow-up and marginally significant at the 2.5-year follow-up. Effects were also found among baseline alcohol users through the 1.5-year follow-up. Consistent with other prevention studies, the effect sizes were small for cigarettes (range: .05-.31) and alcohol (range: .08-.24) and medium for marijuana (range: .38-.58). Although no significant effects were detected among baseline marijuana users, it is important to note that the programme group consistently demonstrated greater reductions in all 3 substances across all follow-ups, except marijuana at the 3.5-year follow-up. When the secular trend was also considered, the Midwestern Prevention Project consistently showed significant secondary prevention effects on cigarette, alcohol, and marijuana use.

There are several methodological limitations to this study. For example, a possible threat to the validity of the findings was the reliance on self-reported drug use. However, extensive research conducted on the validity of self-reported smoking dispels this concern, especially if a bogus pipeline activity is built into the procedures for data collection, as was done in the present study. Another possible limitation is that measurements were limited to a fixed point in time (previous month) from year to year, thus leaving open the possibility that the last reported use level may have been an under-estimate of actual normal use patterns. However, given that this study was fully randomized, the programme and control groups should have been equal in regard to their validity estimates of the point prevalence of drug use measured.

This research suggests that social-influence-based primary prevention programmes can have an impact on not only students who are nonusers at baseline but also those who have begun to use drugs. The advantage of such a primary prevention programme is that it may reach and affect a ‘silent’, not-yet-identified, high-risk population of early drug users in a nonstigmatizing , nonlabeling fashion at an age when youth are more easily persuaded (treating the young users, in effect, like nonusers contemplating use).

Source: Chih-Ping Chou, PhD, et al. American Journal of Public Health, June 1998, Vol.88, No6

Filed under: Education,Education Sector,Education Sector (Papers),Nicotine,Prevention (Papers),Prevention and Intervention,Youth :