Change in paradigm useful for Scotland? Victor Everhardt Head Prevention Unit [email protected].

Change in paradigmuseful for Scotland?

• Victor Everhardt• Head Prevention Unit • [email protected]

2025 Half the problem

• 50% prevalence rate: – young people that drink alcohol?– The general population that use drugs?– Last month, life time?

• Only 200 drug related death?• Prevalence rate of HIV/Aids among idu?• Half of the current idu’s are changing the

dragon?

2025 War or Peace?

• Roll back option, drug free society

• Containment, Mr Costa (UNODC)

• Layers of defence strategy: prevent-treat-reduce health & social damage

Modesty

• On the outcome of a Drug policy

• On the contribution of Prevention

• On treatment opportunities for a chronic disease like drug use

WHO recommendations (alcohol)

• Integrated approach

• Price

• Availability

What about effectiveness of a drug policy

• Integrated approach?

• Price? (XTC - precursors)

• Availability? (The Taliban)

Integrated approachModels of coordination structure

some examples• France: MILDT

• Hungary: State secretary

• Sweden: National board

• The Netherlands: Ministry of Health

Integrated approach Strategy and Action plans

• All over in the EU• Mid term reviews• Realistic goals reached?• Evaluation process: only two examples

Hungary (on the process) & Portugal (midterm)

Drug Policy Portugal

• The strategy has had a positive impact in many ways:– There has been an increase in the numbers of drug

users attending prescribing services.– The number of drug users with AIDS decreased

absolutely and relatively to the total number of people with AIDS.

– Drug related deaths more than halved from 369 in 1999 to 152 in 2003.

Drug Policy Portugal

• “The evaluation of the strategy,which remains ongoing, has proved coherent and useful; in the past evaluative work was more dependent on the scientific interests of local university departments rather than on trying to construct a robust and global evidence base”.

Drug Policy Portugal

• Challenges for the future

1.Ensuring that quality treatment is also available for those with different drug use profiles than the traditional problematic heroin user.

2 Re-affirming the importance of drug prevention work, which has been somewhat overlooked in some areas since the increased focus on treatment and harm reduction.

A National Drug Monitoring system

• Every year an update of facts & figures• Basis for a realistic political debate• Basis for adjusting it’s strategy• Basis for new topics for research

From Policy Paper to Practice

• Quality and Professional attitude• Salary and other rewards• Long term or short term commitment of

the money suppliers • Cooperation and Equality between

partners• Management of expectations

Cyclic quality model

Practice in Europe

• No steady influx of money (financing of projects in stead of long term commitment)

• Ideology and no real Pragmatism • Too strong belief in the benefits of

prevention

Scotland, opportunities for a paradigm shift

• High Prevalence rate

• Absence of a (new) national strategy and action plan on drugs

Scotland, opportunities for a paradigm shift 2

• Drug related deaths in Scotland: 420.– 10 x rate of The Netherlands

• Prevalence rate of heroin users in Scotland: 50.000– 5 x rate of The Netherlands

Recent (last year) use of cocaine among young adults (15–34

years)

Trends in recent (last year) amphetamine + ecstasy use in

young adults (15–34 years)

Trends in recent use (last year) of cannabis among young adults

(aged 15–34)

What is needed

• Formulating of realistic goals with clear ambitions

• Investment in: – a: monitoring and evaluation – b: the workforce & quality of the work process– c: long term commitment of the investors– d: a clear coordination structure

Belief in prevention

• Too strong belief in the benefits of prevention

• Lessons from Portugal: Re-affirming the importance of drug prevention work, which has been somewhat overlooked in some areas since the increased focus on treatment and harm reduction.

Assumptions

• Knowing is doing• Fear facilitates behaviour change• Not using drugs is a question of strong

will / character• Drug use is per se negative

Findings from evaluation of school-based (primary)

prevention (1)• Substantial effect on knowledge• Some programs have small effect on substance use

– At best 8 – 10% reduction– These effects decrease over time and have disappeared

after 2 / 3 years– Thus, best effect delay in onset

• Most (about 75%) prevention programs do not have an effect on substance use

→ DARE programme (Drug Abuse Resistance Education), • Best programs focus not only on information about the

substances, but also on the reasons for using, peer pressure, and generic life skills

Findings from evaluation of school-based (primary)

prevention (2)Some evidence on effectiveness of following components:• Interactive methods (with a focus on discussion among students

themselves, use of peer leaders, role playing, in stead of non-interactive presentation of knowledge by teachers);

• The social influence model as a theoretical basis of the prevention program (this model says that prevention may be inoculation to peer pressure to use substances);

• Adding generic life skills (such as social skills, cognitive skills, problem solving skills) to a curriculum);

• Programs led by 'peer leaders' have a larger effect than programs led by adults, but only on the short term;

• Cognitive behavioural programs have larger effects; • Programs aimed at the school environment have larger effects than

curriculum only programs.

Findings from evaluation of other forms of (primary) prevention (2)

• Mass media campaigns seem to have little or no effect on substance use, knowledge about substances and attitudes towards substance use

• Mass media campaigns effective in agenda setting but not in behaviour change

• Fear-based campaigns in-effective or even counterproductive

What do we know?

• Knowledge is essential but does not result in behaviour change

• Prevention can delay onset• Fear does not help• Lifetime prevalence is high – prevalence of

regular use is relatively low• Experimenting and – to a lesser degree - regular

substance use of legal and illegal substances widespread among young people

What can we conclude?

• People love / believe in primary prevention even it is not really effective

• People reject / don’t believe in evidence that primary prevention is not effective

• The traditional concept of primary prevention is belief-based

What can we do?

• More realistic approach: Drug prevention as stepped approach aiming at:

• Media advocacy • Supporting abstinence• Delaying onset• Mindful / sensible coping with drugs• Reduction of frequency / dosage• Limiting possible health damage

→ Risk management / harm reduction