Chapter 16

Prevention

Prevention is a key component of public health strategies and is increasingly part of the array of measures used to fight crime, especially crime related to the abuse of psychoactive substances. Viewed–in theory, at least–as a public health issue, an illegal drugs policy should therefore call for a strong  prevention strategy.

Nothing, however, is more fluid, vague, even controversial, than prevention. The measures used to enforce the law are clear: they give power to the police and set down guidelines for the courts in dealing with people found to be in breach of the law. Correctional measures are equally clear: they implement the sentences imposed by the courts. Already, the measures used to treat people with drug problems are  vague; there is no consensus on what constitutes treatment, when treatment begins and, most importantly, when treatment ends. The literature makes a distinction between primary, secondary and tertiary prevention; prevention through social development and situational development; universal, specific and indicated prevention; and prevention of use, at-risk behaviour and abuse, yet does not agree on the specific content of each field or the approach that should be taken in public policy.

When it comes to illegal drugs, the legal and political context makes the issue of prevention even harder to clarify and actions even harder to define. There are policies and initiatives in place that aim to prevent at-risk behaviour related to alcohol, such as heavy drinking, driving under the influence and domestic violence. In some circumstances and used in some forms, alcohol can be a “dangerous” substance; what we want to do is preclude those circumstances and identify the indicators of abuse so that we can prevent at-risk behaviour from leading to excessive, even pathological behaviour. It is possible to make these distinction and not deal with use per se because alcohol is a legal substance. But the national legal context surrounding illegal drugs and the interpretation of international drug policies (see Chapter 19 on the latter subject) are such that because they are defined a priori as harmful substances, illegal drugs must not be used. Another way of putting it is that any use is abuse. The glossary published by the United Nations Office for Drug Control and Crime Prevention states: 

In the context of international drug control, drug abuse constitutes the use of any substance under international control for purposes other than medical and scientific. [1][1] (Our emphasis) 

If use is abuse, if individuals or organizations involved in prevention are unable to make distinctions that are essential in setting objectives and devising preventive measures, what hope is there of establishing successful prevention programs?

The international context on drugs is decidedly full of surprises. Each year, the International Narcotics Control Board, whose mandate is to monitor the implementation by Member States of the various international conventions, publishes an annual report which includes, in its first section, a commentary on a specific theme. The 1997 report commented on prevention. Regretting that the social environment was promoting drug use, the report noted:

 

Preventing the abuse of drugs is becoming an increasingly difficult endeavour, at least partly because of the rapid and growing spread of messages in the environment that promote drug abuse. Many of them can be regarded as public incitement and inducement to use and abuse drugs. Therefore, present efforts at prevention need to be strengthened and innovative prevention initiatives need to be developed and implemented.

(…)

While the elimination of all forms of drug experimentation, use and abuse will never be achieved, it should not be a reason to give up the ultimate aim of all prevention efforts, namely a drug-free society. [2][2]

 

Among the various factors favourable to drug use and abuse, the Board cited popular culture (songs, films, etc.), the media, the Internet, the promotion of hemp products and political campaigns. The report equates advocating for liberal policy options to the promotion of drug use and suggests a rather disquieting notion of prevention:

 

Sensationalism, the desire to be provocative and the need for higher ratings, may also be behind the fact that several television companies in some countries in western Europe appear to be broadcasting many more programmes in support of a change in the drug law, if not the outright legalization of drugs, particularly cannabis, than programmes examining the consequences of following such a policy and the harm arising from it. Preventive education campaigns aimed at accurately informing the public in general of the effects of drugs and drug abuse will help to promote a more rational approach to drug problems and to avoid sensationalism.

(…)

It is possible to curb the showing by public broadcasting media, such as the press, radio, film and television, of favourable images of drug abuse. In some countries, it is possible to do this through legislation; in others it can be done through voluntary codes of practice; in still others, however, no restrictions on promoting drug abuse are in place because freedom of information and freedom of speech are considered to be more important than limiting the promotion of illicit drugs. The Governments of those countries may need to reconsider whether unrestricted access to and the propagation of such information are detrimental to the social and health conditions of their populations.

(…)

Election campaigns have been conducted with candidates standing for parliament on a drug legalization platform. Some campaigns, such as the successful campaigns for the "medical" use of cannabis in Arizona and California in the United States of America, have sought to change the law (…). Such political campaigns need to be met with rational arguments and unambiguous language pointing out the manifold problems that might arise from the decriminalization of drugs and that certainly would arise from the legalization of drugs, in particular the health and economic consequences of such action. (…) The Board notes with regret that despite the fact that (…) Governments of States that are parties to the 1988 Convention are required to make the incitement or inducement to take drugs a criminal offence, either this has not been done or the law has not been enforced.  [3][3]

 

If criticisms of the current public policies and demands for alternative approaches are equated with condoning drug use, if prevention means curbing freedom of speech – whether or not one agrees with these critiques – then one has to wonder what prevention is about.

Of course there are, as this chapter will show, many prevention programs that are not aimed solely or even particularly at the prevention of use, but rather the prevention of at-risk behaviour. Harm reduction, for example, is not only a general strategy for dealing with psychoactive substances, but is also a preventive approach that seeks to lower the risks associated with drugs and drug control without requiring abstinence. However, harm reduction is the subject of much controversy and criticism because it is based on the premise that use of drugs is a social reality.

Is law enforcement a preventive measure? Many practitioners, not just police officers, would surely say it is, and they would be right insofar as visible police presence or community policing does have some preventive effect. But in the current context, this is designed to prevent use, not at-risk behaviour, and does so through deterrence, not education or empowerment. And Chapter 14 showed that its effectiveness is very limited. Are sentences, including deprivation of liberty, preventive measures? Of course they are, at least for the time the offender is under supervision or in custody (although drugs are available in prison). But we saw in Chapter 15 that criminalization and penalisation do not deter use. And it is generally admitted that intervention by the justice system is in fact a sign that preventive measures have failed (or were not taken). Are citizenship education, health awareness and self-esteem programs preventive measures? They are indeed, but so, too, are social justice and fairness initiatives, efforts to reduce inequities and measures aimed at improving relations with Aboriginal peoples. If everything is prevention, what, then, constitutes the field of prevention?

Addressing the issue of prevention means considering at the same time government policies on illegal drugs. This is particularly true in the case of cannabis.  Preventive messages, as will be seen later, must be credible. The message that smoking tobacco causes lung cancer and cardiovascular disease is credible, at least in part because it is based on a large body of epidemiological studies that have established a strong, statistical cause-and-effect link. The same is true for impaired driving and the wearing of seatbelts. However, as Chapters 6, 7 and 8 have demonstrated, the findings for cannabis are by no means as cut and dried and the weight of the evidence would tend to indicate that it a much less harmful substance than most other psychoactive substances. Contrary to what many told us, marijuana is not illegal because it is dangerous and this is well established in the history of national drug law and international conventions.

The UNDCP glossary also states:

 

Prevention is defined broadly as an intervention designed to change the social and environmental determinants of drug and alcohol abuse, including discouraging the initiation of drug use and preventing the progression to more frequent or regular use among at-risk populations. [4][4]

 

A careful reading of this definition is in order. It says that preventive intervention aims to prevent the abuse of drugs and alcohol. In the case of drugs only, however, one must aim to prevent people from becoming users in the first place, since drug use will progressively increase. Yet, the research on marijuana does not support this distinction. Alcohol – and before that tobacco – are far more likely than marijuana to lead to more frequent use, even at-risk use, and to be a gateway to other illegal drugs. But alcohol, like tobacco, is legal. Marijuana is not.

Any discussion of prevention entails discussion of the limits of government intervention and of how one conceives of human action. How far should government interventions go in identifying groups at risk without further stigmatizing groups already at risk? To what extent are humans rational beings who act in their best interest provided they are given the right information?

Finally, any discussion of prevention in the Canadian context necessarily has a constitutional dimension: to the extent that preventive measures are matters of health provinces have the primary jurisdiction, and to the extent that prevention is education provinces have exclusive jurisdiction. As we saw in Chapter 12 on the history of federal legislation on illegal drugs, it was no accident that the Narcotic Control Act was criminal in nature: since Parliament is authorized to adopt criminal legislation pursuant to the criminal law power conferred by the constitution. The federal government’s role in the field of prevention of drug use is limited at best and non-existent at worst proprio motu.

This chapter on prevention begins with a statement that will come as no surprise to health or justice experts: when it comes to prevention, there is lots of talk, but the resources allocated are small and the initiatives weak. The second section asks the question: what prevention? We look at current knowledge of the factors underlying prevention initiatives and the effectiveness of some preventive measures, with special emphasis on one of the most important weapons in the war on drugs, the DARE program. The third section looks at the harm reduction approach to prevention. As in the other chapters, our conclusions are in the form of observations that may serve to guide future actions.

 Preventive and social messages in contradiction

For some observers, the fact that society has become more tolerant of cannabis in recent years has contributed to increasing levels of use among young people and undermined the prevention efforts.

 

The other important part to remember is acceptability in terms of how drug use is perceived. Even more than availability, acceptability is affected by legal sanctions. When we have sanctions against drugs, it reduces social acceptability and helps hold consumption down. Two aspects of acceptability are perceived risk in using the drug and perceived social acceptance of the drug. Those are two tools we have to keep consumption down. [5][17]

 

According to the 1996 Monitoring the Future study by the University of Michigan, today's teens are less likely to consider drug use harmful and risky, are more likely to believe that drug use is widespread and tolerated, and feel more pressure to try illegal drugs than at any other time in the last decade. […]

 

The implication of these perceptions is that these factors influence an increase or decrease in the levels of drug use. Legalization of illicit drugs would only weaken these perceptions further. It tells our children that adults believe drugs can be used responsibly. It suggests that there is less risk and that drugs are more acceptable to society. […] Another influence is the media and the power of communication. Media coverage of individuals smoking marijuana in cannabis clubs tells kids that drug taking can be fun. Within this atmosphere, it is very difficult, if not impossible, to reach children and convince them that doing drugs is harmful. Increased drug availability and drug use will worsen our crime problems. Increased drug use has terrible consequences for our citizens. [6][18]

 

As one American commentator said, telling children that marijuana is a dangerous drug is one thing, but what happens when they find out in high school that their friends are using it without frying their brains? The message probably has to be adapted to the audience, the context and the objectives. However, it is surely just as necessary to tell children and adolescents the truth in prevention programs about drugs, their real effects and about what we still do not know. If our society engages in contradictory debate over cannabis, it is not because some pot activists are manipulating the media; otherwise we would have to question the ability of our media to remain neutral and keep a critical distance. In light of the epidemiological findings presented in Chapter 6 and the scientific research on the effects of cannabis presented in Chapter 7, we believe that alarmist rhetoric on the effects of cannabis is probably counterproductive for the very people who legitimately hope to prevent its abuse.

That was among the points raised in the recent Health Canada report on best prevention practices.

 

The most important principle for every program, regardless of program goal, is that drug information be scientifically accurate, objective, non-biased and presented without value judgment. […] Even if younger participants initially accept messages that focus solely on the negative aspects of drug use, once they receive more accurate information, there is a danger that all the messages received earlier will lose credibility. […] Fear-arousing messages accompanied by incorrect or exaggerated information are not effective, and can generate scepticism, disrespect and resistance toward any advice on substance use or other risk behaviour. […] Similarly, simplistic messages that young people believe to be unrealistic (e.g., just say ‘no’) or not feasible (e.g., play sports when there are not facilities readily available) will not be seen as credible. [7][19]

 

There is a body of knowledge on which we have to draw

Without question, there is a widespread preventive practice in Canada that has developed on a trial-and-error basis and is frequently nursed along with limited resources by people who truly believe in it. As we will show in the next section, there is also a body of knowledge on the initiatives that are most likely to have a real effect on risk factors and the processes most likely to support strong preventive measures.

One of the problems is that this “knowledge” all too often remains in the heads of a few people, primarily because few or no evaluative studies are conducted. What studies are done appear in scientific journals and are seen by experts but do not reach practitioners. And there are still few systematic means of disseminating information. This raises the question of how practices proven elsewhere can be adapted to other contexts.

 

We suggest to the Committee that rather than focusing on reforming our drug laws, efforts would be much better spent on examining strategies focused on prevention. Canada’s Drug Strategy points out that first and foremost, prevention is the most cost-effective intervention. If we know that to be true, should we not focus our attention on tactics that will ensure greatest possible return on our investment? […] In a compendium of best practices by the Canadian Centre on Substance Abuse, the authors draw attention to the importance of parental influence in high-risk behaviour among youth. […] Numerous studies completed at the Center on Addictions and Substance Abuse at Columbia University which include extensive research into prevention programs, have reached the same conclusion. [8][20]

 

Finally, in our years of work and prevention we have come to understand that the real problem is not so much a drug problem as a people problem. That is, all people - especially kids who have suffered abuse, neglect, trauma, and addiction in the home - seek ways to deal with their feelings of anger, despair, hopelessness or powerlessness. Some may have feelings of boredom, curiosity or a desire to belong. Marijuana and other drugs can seem to solve or at least soothe these emotions. […] Alternatively, there is great potential through prevention to foster informed, confident, capable young people, who from the earliest ages learn sound mental health practices that are drug-free ways to manage these pressing and understandable human feelings. [9][21]