BMA – Delaying initiation and minimising the use of illicit drugs

The British Medical Association have produced a large report looking to:

open and refocus the debate on drug treatment and drug policy through the eyes of the medical profession.

Chapter 7 of the report sets out their reading of the evidence for drug prevention and their take on the policy landscape.

What I notice is that the authors take a pretty pessimistic view of the state of evidence, pointing to the limited amount of research that has been carried out, how most of that has been carried out in the US, and the difficulty of showing long-term outcomes.

In many ways this is very similar to much of what we at Mentor point out when we talk about prevention, but our tone is much more positive about the potential for achieving better outcomes.  The slide I use in my presentations [below] describes the same research landscape as the BMA paint.

olive of prevention

What I try to emphasis is that the challenge is to grow the red ‘pepper’ and white ‘garlic’ parts of the olive while reducing the brown ‘bruise’.

I also note that when the American National Academy of Sciences looked at these issues in 2009 they seem to have come to a very different view of the evidence, arguing that:

Several decades of research have shown that the promise and potential lifetime benefits of preventing mental, emotional, and behavioral (MEB) disorders are greatest by focusing on young people and that early interventions can be effective in delaying or preventing the onset of such disorders.

The BMA paper concludes by arguing that it may be time to explore policy alternatives to universal school-based prevention predicated on drug education lessons.  Tentatively suggesting as an alternative approach that:

Taking action on preventing the underlying causes of drug use may be as effective as, or more effective than, preventing drug use directly.

It would be tempting to be irritated by this iteration of the challenge of Marmot but, while I don’t believe in throwing the baby out with the bath water (particularly just at a point when the evidence is stacking up which finds that “certain generic psychosocial and developmental prevention programs can be effective and could be considered as policy and practice options“) I’m attracted by extending our conception of what makes for a prevention programme.

It’s why we’ve been championing the Good Behaviour Game and Preventure, both are school based  programmes that don’t talk about drugs or alcohol, but which have shown longer term outcomes reducing substance misuse harms.

It’s also why we have produced a toolkit to help schools review and improve their drug policy, because we know that the rules that schools have and the ethos they engender have the potential to protect young people.  And it is why we are positive about environmental prevention interventions like Minimum Unit Pricing for alcohol.

But the relationships between early substance misuse and other outcomes suggests this isn’t a simple trade off.  Nor can we be confident that we’ve developed sophisticated screening tools or interventions that will help us identify all of those at risk of developing problems and reduce their numbers.

life course

It is why I think a life course approach, or sunblock as Professor Tom McLellan put it, offers more hope as a strategy, than trying a single track approach, but all of what is tried should try to follow the evidence for what has been shown to be most effective, and where that evidence doesn’t exist we need to develop it and then find ways of bringing it to scale.  

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