Chapter 16 - Prevention 

Preventing what and how?

 

Agreeing on the need for prevention is a bit like agreeing on the importance of virtue. Yet, as we saw in the introduction to this chapter, whether we all agree on the very concept of prevention is not all that clear. The United Nations Office for Drug Control and Crime Prevention glossary defines prevention as follows:

 

Prevention activities may be broad-based efforts directed at the mainstream population(s), such as mass general public information and education campaigns, community-focused initiatives and school-based programs directed at youth or students at large. Prevention interventions may also target vulnerable and at-risk populations, including street children, out-of-school youth, children of drug abusers, offenders within the community or in prison, and so on. Essentially, prevention addresses the following main components:

--         Creating awareness and informing/educating about drugs and the adverse health and social effects of drug use and abuse, and promoting anti-drug norms and pro-social behaviour against drug use;

--         Enabling individuals and groups to acquire personal and social life skills to develop anti-drug attitudes and avoid engaging in drug-using behaviour;

--         Promoting supportive environments and alternative healthier, more productive and fulfilling behaviours and lifestyles, free of drug use. [1][22]

 

What this means, then, is taking initiatives that alter the factors leading to drug abuse, where all use is abuse in the case of an illegal substance or a substance controlled by international conventions. The definition identifies as a factor in abuse first-time use of drugs, on the premise that introduction – at least in people considered to be “at risk” – leads to more frequent use or use of other substances. The proposed areas of action indirectly identify other factors: the absence of information on the adverse effects of drug use and social norms that are insufficiently anti-drug, inadequate personal and social skills to resist drug use, and unsatisfactory lifestyles that are not health oriented are other factors in drug abuse.

But what do we know about the reasons why people use drugs, marijuana in particular? We know that men use more alcohol and drugs and that women use more prescription drugs. Do we really know why? We think that there may be more than 150 million marijuana users in the world, and we have said that there are approximately 3 million a year in Canada; are we to conclude that those people lacked the personal and social skills needed to resist drugs? When, at what point, does use become a problem? Depending on the answers to those questions, the entire prevention strategy will be different.

Genetic baggage aside, public health factors are a function of:

 

[Translation] […] environmental factors related to the setting in which the person lives, from conception to death: the social as well as the physical environment. Education, employment, income, family and social relationships, and distribution of wealth are all factors that come into play. There is a close link between socio-economic status and health and well-being: that link is confirmed by data on hospitalization, disability, health problems and mortality in a given population. Other factors of course include lifestyle and behaviour, such as tobacco use and diet. Even though these are factors that can be changed and are often targeted by prevention, they are also largely conditioned by socio-economic factors. The last factor is health services, the level and organization of which vary from community to community and country to country. [2][23]

 

It is true that epidemiological data tend to show that young marijuana users are more likely to be from disadvantaged socio-economic backgrounds, are more likely to smoke tobacco, and probably have parents who smoke or even use marijuana. These are referred to as environmental risk factors. According to some authors, regular or heavy users, those who are at risk, also suffer low self-esteem, are more likely to drop out of school or not finish high school, and do not perform as well academically. These are personal risk factors.

Another term in the vocabulary of prevention besides “risk factor” is “protective factor”. The United Nations Office for Drug Control and Crime Prevention defines “protective factor” as follows:

 

A factor that will reduce the probability of an event occurring which is perceived as being undesirable. This term is often used to indicate the characteristics of individuals or their environments, which reduce the likelihood of experimentation with illegal drugs. For example there is some evidence from research in developed countries that each of the following are, statistically at least, protective in relation to illicit drug use: being female; of high socio-economic status; being employed, having high academic attainment; practising a religion; and being a non smoker. [3][24] 

 

Epidemiological data show that use is lower among women, non-smokers and people who practise a religion. However, the data are not as clear in terms of the impact of socio-economic status or level of schooling.

One of the key works in the literature on prevention is without question the 1995 research by Hawkins et al.[4][25] The authors give a comprehensive list of risk factors related directly or indirectly to drug abuse, divided into five categories: individual, family, school, peer and community environment. These factors were identified based on a series of longitudinal studies that tracked children and adolescents over long periods.

 

Recent longitudinal research has identified risk and protective factors in the individual and the environment that consistently predict drug involvement. Moreover, the evidence indicates that the likelihood of drug abuse is higher among those exposed to multiple risk factors and that the risk of drug abuse increases exponentially with exposure to more risk factors. The higher rates of drug abuse among criminal and homeless populations are consistent with studies of personal, social and environmental risk factors that are predictive of substance abuse. This line of research suggests that intervention to prevent drug abuse should focus on reducing multiple risk factors in family, school, peer, and community environments. [5][26]

 

1.     Individual factors

The authors include among the individual factors identified by the research family history, genetic history, biochemical characteristics, early and persistent behavioural problems, alienation and rebelliousness, attitudes favourable to drug use, and early introduction to drugs.

 

2.2.      Family factors

These factors include parents who use or permit the use of substances, poor parenting, poor parent-child relationships and family conflict.

 

3.3.      School factors

These factors include academic failure and a weak commitment to school; intelligence is not a factor, but the school environment and learning difficulties have a determining effect.

 

4.4.      Peer factors

Peer rejection in primary school and peers who use drugs are also factors related to substance abuse.

 

5.5.      Environmental factors

The availability of drugs, legal and cultural norms, poverty and an unstable living environment.

The authors identify as protective factors individual characteristics (resilience, social and personal skills, intelligence), the quality of childhood relations in the family and especially at school, and individual and social objection to drug use.

These factors must not be confused with causes. They are statistical links that are themselves limited by methodological problems related to measurement of behaviour, evaluation of the impact of intervention, and other considerations.[6][27]

 

A clear advantage of the protective/risk factor approach is the understanding that many social and health problems are linked by the same root factors – an understanding that can lead to better integration of strategies and economizing of resources. However, because a factor is linked to substance use problems does not necessarily mean that it causes such problems. Consequently, the actual preventive effect of addressing one or another of the protective or risk factors is not very clear and no doubt varies between the factors. Nevertheless, it appears that addressing protective or risk factors in several domains of a young person’s life (i.e., individual, school, family and community) can lead to positive outcomes. [7][28]

 

Hawkins et al. reviewed a series of initiatives–prenatal and neonatal, and preschool, primary school and secondary school–that were evaluated. They found that the most promising strategies are multidisciplinary approaches involving the community.

 

The evidence suggests that multistrategy approaches that address multiple risks while enhancing protective factors hold the most promise for preventing substance abuse. The current challenge for substance abuse prevention research is to test prevention strategies that empower communities to design and take control of their own efforts to explicitly assess, prioritize, and address risk and protective factors for substance abuse. [8][29]

 

Prevention is not, however, a formula that can be used over and over in the exact same way. The characteristics of local communities, existing social relationships, and the strength of community organizations are among the factors that play a key role in the success of preventive measures. There is growing consensus among authors on a series of steps that are most likely to bring about success. The compendium of best practices published by Health Canada proposes the following:

 

··                Build a strong framework

âØ     Address protective factors, risk factors and resiliency

âØ     Seek comprehensiveness

âØ     Ensure sufficient program duration and intensity

··                Strive for accountability

âØ     Base program on accurate information

âØ     Set clear and realistic goals

âØ     Monitor and evaluate the program

âØ     Address program sustainability from the beginning

··                Understand and involve young people

âØ     Account for the implications of adolescent psychosocial development

âØ     Recognize youth perceptions of substance use

âØ     Involve youth in program design and implementation

··                Create an effective process

âØ     Develop credible messages

âØ     Combine knowledge and skill development

âØ     Use an interactive group process

âØ     Give attention to teacher or leader qualities and training

 

What actions are proven and promising? The compendium lists a number of Canadian intervention programs, but none has really undergone comprehensive evaluation.

A number of people who spoke at our hearings, police officers in particular, mentioned the DARE (Drug Abuse Resistance Education) program.

 

We use a revised, Canadian version of DARE, which is not the program most people have been hearing about for years. We are achieving success and acceptance with it. [9][30]

 

We were unable to continue to fund Canadian programs, and to the credit of the RCMP and its members across the divisions, they turned to DARE, the Drug Abuse Resistance Education, from the United States. It was a pre-made, off-the-shelf program. Our budget still does not permit us to develop Canadian programs or to do evaluations. Unfortunately and embarrassing is that of the money that has gone to teaching Canadian police officers to instruct, a total of $750,000 has been paid for by the United States. The Canadian government has not funded any DARE training. [10][31]

 

DARE was introduced in the United States in the early 1980s by the Los Angeles Police Department. In 1996, the program was being used by 70% of school districts and was serving 25 million students. Some 25,000 American police officers were trained to deliver the DARE program in schools. DARE is also used in 44 other countries around the world. It includes a number of modules delivered in different ways depending on the community. Basically, it entails a series of visits from kindergarten to grade four in which the children are given short lessons on personal safety, respect for the law, and drugs. The main 17-week program is designed for students in grades five and six. A 10-week program for middle-school students focuses on resistance to peer pressure, the ability to make personal choices, conflict resolution and anger management. Another 10-week program for high-school students focuses on personal choices and anger management. Finally, DARE+ is an after-school program for high-school students built around recreational activities. The main 17-week program for grades five and six is the one most frequently used (81% of American school districts). It is delivered by a uniformed police officer and focuses on the ability to resist drugs. It provides information on drugs and their effects, self-esteem, and alternatives to drugs. The program includes lectures, group discussions, audio-visual presentations, exercises and role playing.

A document we received from the RCMP shows that the DARE Program is being taught in 1,811 schools in 584 different communities in Canada outside Quebec. Alberta leads the way with 150 school districts, 583 schools and more than 21,400 students in 2001, followed by Ontario (40 districts, 346 schools, 10,940 students) and British Columbia (60 districts, 289 schools, 10,800 students). All these schools offer the main 17-week program. In 2001, the program served more than 53,000 students. In all, the various components of the DARE program reached more than 65,000 Canadian students in 2001.

We do not know how much the program has been “Canadianized”. To our knowledge, there have been no studies to evaluate the program’s impact. The document we received is the first phase of an evaluation study that should, in the second phase, provide data on impact. The first phase of the study deals with students’, teachers’ and parents’ opinions, preferences and perceptions.[11][32] The study looked at all of the grade 5 and grade 7 students in the West Vancouver school district who took the program (500 and 570 students, respectively), as well as their parents and teachers. The findings showed a very high level of satisfaction with the program:

 

âØ         97% of the students, 95% of the teachers and between 78% and 94% of the parents, depending on the grade, were in agreement with the program and the program objectives;

âØ         78% of the teachers agreed with the content of the DARE program for their grade level;

âØ         72% of the students felt that the information they received was valid and up to date;

âØ         97% of the teachers were very satisfied with the relationship between the police officer delivering the program and the students;

âØ         96% of the students said they understood the message;

âØ         88% of the students said that DARE had helped them resist drugs in middle school; the result was 58% in high school;

âØ         between 82% and 89% said that they had a better understanding of the dangers of drugs.

 

These are only some of the findings. The data are in line with what can be found on the DARE’s U.S. Internet site and in a number of evaluations. However, those evaluations measured opinions, perceptions and attitudes, not behaviour. To some extent, these results, positive though they may be, are not really surprising.

In contrast, almost all of the evaluations that have endeavoured to measure the impact of the DARE program on behaviour, specifically the prevention or reduction of drug use, have shown that the program had no impact or, at best, very little and very short-term impact.

The compendium of best practices produced for Health Canada contains a separate section on the DARE program which states in part:

 

There have been many D.A.R.E. reviews and evaluations, but few rigorous scientific evaluations. While some evaluations show positive results, studies published in peer reviewed journals, including a 5-year prospective study and a meta-analysis of D.A.R.E outcome evaluations, have been consistent in showing that the program does not prevent or delay drug use, nor does it affect future intentions to use. On the positive side, it does seem to boost anti-drug attitudes, at least in the short-term, increase knowledge about drugs and foster positive police-community relations. Also, acceptance of the program is generally quite high among police presenters, students and their parents. [12][33]

 

Of course, the absence of program impact can be attributed to the requirements of the evaluation. However, these requirements are the same as those used for other program evaluations.

In 1997, a major report on what works, what does not work and what is promising in the area of crime prevention was tabled in the United States Congress; Congress had commissioned the report from a team of prominent researchers at a number of American universities.[13][34] The report had the following to say about the DARE program:

 

Several evaluations of the original 17-lesson core have been conducted. Many of these are summarized in a meta-analysis of DARE’s short-term effects sponsored by NIJ [National Institute of Justice]. This study located 18 evaluations of DARE’s core curriculum, of which 8 met the methodological criterion standards for inclusion in the study. The study found:

1.1.      Short term effect on drug use are, except for tobacco use, non significant;

2.2.      The sizes of the effects on drug use are slight.  Effect sizes average .06 for drug use and never exceed .11 in any study. The effects on known risk factors for substance use targeted by the program are also small: .11 for attitudes about drug use and .19 for social skills.

3.3.      Certain other programs targeting the same age group as DARE […] are more effective than DARE. […]

Four more recent reports, three of them longitudinal, have also failed to find positive effects for DARE. Lindstrom (1996), in a reasonably rigorous study of approximately 1,800 students in Sweden, found no significant differences on measures of delinquency, substance use, or attitudes favoring substance use between students who did and did not receive the DARE program. Sigler and Talley (1995) found no difference in the substance use of seventh grade students in Los Alamos, New Mexico who had and had not received the DARE program 11 months before. Rosenbaum et coll. (1994) report on a study in which 12 pairs of schools (involving nearly 1,600 students) were randomly assigned to receive or not receive DARE. Although some positive effects of the program were observed immediately following the program, by the next school year no statistically significant differences between DARE and non-DARE students were evident on measures of the use of cigarettes or alcohol. […] These studies and recent media reports have criticized DARE for (a) focusing too little on social competency skill development and too much on effective outcomes and drug knowledge; (b) relying on lecture and discussion format rather than more interactive teaching methods; and (c) using uniformed police officers who are relatively inexperienced teachers and may have less rapport with students.

[…]

In summary, using the criteria adopted for this report, DARE does not work to reduce substance use. […] No scientific evidence suggests that the DARE core curriculum, as originally designed or revised in 1993, will reduce substance use in the absence of continued instruction more focused on social competency development. [14][35]

 

This information is in the public domain. It has been available for many years. Considering the limited resources available for the prevention of drug abuse in Canada, federal authorities and the RCMP ought to have looked at that information before deciding to implement even a Canadian version of the DARE program. Beyond the rhetoric that may please some, there are in this case–and this is so rare that we must take advantage–comprehensive studies which show that the program is not meeting its stated goals.

The same study identifies other programs that are much more likely to have a positive impact on drug use and abuse, in particular programs that develop social skills. The Canadian compendium also describes a number of programs that have undergone equally comprehensive evaluation and have shown positive results.

Like one of our witnesses, we seriously question the police-led practice used to deliver drug education in schools:

 

I have a quick aside about police-led drug education. We, personally, have some concerns with police officers teaching many hours of drug education in the classroom. We do not think it is sustainable financially to have paid police officers in at every grade level teaching hours and hours of drug education. Teachers - classroom teachers - are trained to be educators and that includes how to build self-esteem, how to make kids feel more capable. In addition, we know there are good, well-intentioned police officers, but our concern is that some of them do not, in our view, have sufficient training to do the type of education that is required. I am also concerned that the DARE program in the United States is now starting a whole new initiative.  […] they still are not addressing a very fundamental question, which is, ‘who is the best person to deliver these?’

We have heard concerns from students and teachers that police-led drug education can be more authoritarian and that it can come across not so much as helping kids to make their own carefully thought out choices, but more to lead them into one specific choice. [15][36]

 

We believe that there is a need for education about psychoactive substances, forms of use and the related risks. But we also believe that there is a need to rethink the approaches being used and that police officers, if they must be involved, should neither develop the programs nor deliver them to students.

Lists of risk and protective factors and of successful programs aside, it is key to have a holistic vision of prevention, because drugs are part of a complex social, cultural and historical environment. Analysis of the debate over prevention and prevention practices shows that one of the risks lies in putting forward a reductionist and mechanistic view of personal and community health. We observed in Chapter 6 that the available data showed an increase in marijuana use among high-school students. We also saw in Chapter 10 that public opinion is perhaps more tolerant than it used to be. And we have seen in this chapter that little has been done in the area of prevention. Does this mean, as the Canadian Centre on Substance Abuse has said, that the increase in use is merely the result of all these factors combined?

 

The resurgence of drug use we are now witnessing is led largely by mainstream youth, indicating that we may have paid a heavy price for changing our focus and neglecting this group in Phase II (of Canada’s drug Strategy). Ultimately we must aim our prevention messages at all youth. The Centre believes that all young people-drop-outs and A students alike-are vulnerable to drug use and should be viewed as an at-risk population. [16][37]

  

Is it really the effect of the prevention initiatives taken in the first phase of the strategy (1987-1992) that accounts for the relative decline in use during that period? Is it really the absence of debate and prevention practices in the 1990s that accounts for the increase in use? Strictly speaking, no one knows. Not only was there no evaluation of the first phase of the national strategy, but even the most comprehensive evaluation might not have been conclusive. The increase in use in the 1990s could just as easily have been the result of a series of entirely different factors, such as cutbacks in government services, the decline in the youth labour market or even globalization of world markets, which makes people feel powerless to change their living conditions. There might even be other factors of which we are not yet aware.

In the United States, the use of illegal substances decreased between 1982 and 1991, then started to rise again in 1993. Did policies and approaches change? Incarceration rates for drug-related crimes certainly did not drop. At least as much money was spent on prevention and education programs. The rate of alcohol use among youth under 17 also decreased; can that be attributed to the same factors? Inversely, the proportion of smokers in the population hardly changed at all despite equally or more aggressive awareness and prevention campaigns. What do we make of this? The decrease in illegal drug use may be attributable in part to “war on drugs” policies, but that is by no means a completely satisfactory explanation. And we also have to consider the social and economic cost.

 

The U.S. government’s ‘War on Drugs’ resulted in a tremendous expansion of resources applied to supply reduction and interdiction efforts focused on illegal drugs and in increasingly harsh criminal sanctions against users, including those caught in possession of relatively small amounts of illegal drugs. These policies have apparently had little effect on the availability of addictive drugs or on reducing abuse. They have fueled higher costs associated with prison construction and a tremendous increase in the prison population, leading some to call for legalization of currently proscribed drugs such as marijuana and cocaine. [17][38]

 

Through all of this, there is little room for a less mechanistic view of individuals. We were reminded of this by J.F. Malherbe in the paper he wrote at our request:

 

The human experience is always complex and multifactorial, and no statement of risk referring to a single factor has any meaning for an individual subject (even though certain correlations appear to be well established). The future cannot be predicted for a singular individual on the basis of statistical information. We can therefore wonder at times about the level of scientific training (or honesty) of doctors who confuse "statistical correlation" with "risk factors" and "causes". It is true, however, that it is more convenient to "preach" to people about the causes of cancer than to support and inform them in the often chaotic advance of their freedom toward fuller responsibility for themselves, for others and for the fragile biosphere to which we belong. [18][39]

 

Professor Malherbe went on to say:

 

The true harm, the worst of all, the most intolerable, the only one that must absolutely be repressed is wanting to make people happy by deepening their fear of disease and death, without asking each individual to make personal choices and realize his or her preferences. The true, the only harm stems from health ideology, from the furor sanandi, which sketches out our happiness without us being able to enjoy it.

Does this mean that everything should be permitted without distinction? Of course not. But the test is still to discover step by step through our trials and errors, and it cannot be imposed on us by experts – doctors or economists – in the name of a prior and death-causing order. The joy of fertile disorder is better for life than the boredom of a type of planning, the arbitrary nature of which equals nothing but sterility. [19][40]

 

Moreover, prevention, especially in schools, must provide a forum for open discussion that makes young people accountable and permits the acculturation of substances. Demonization and indoctrination can never take the place of education.