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.  

The public on drugs…

YouGov have published the results of an opinion poll they conducted on behalf of the Sun asking people about their views on drug policy.

Has drug policy been working?

Interestingly younger people are more likely to feel that the government’s policy has been reducing drug use than older age groups – 21% of 18-24 year olds said they felt the policy had been going well compared to 11% of 40-59 year olds and 13% of those over 60.

Also of interest are the different reaction of different regions with Londoners being much more likely to think the policy has been working (18%) to those in Scotland (7%).

Cannabis lawIn terms of what to do about controlling cannabis (and other ‘soft’ drugs) the public seem split with just under half (43%) favouring the current position and the other half (49%) favouring either decriminalisation or legalisation.  Since YouGov last asked these questions in June there seems to have been a move away from the current regime and a slight increase in those favouring decriminalisation.

In terms of ‘hard’ drugs such as heroin and cocaine the mood seems to have gone the other way with an increase in those saying they favour the current criminal penalties for possession, up from 79% to 83%.

A Royal CommissionThe poll then turns to the main recommendation made by the Home Affairs Select Committee, that the government set up a Royal Commission to consider different drug policy options.  The public seem well disposed to the idea of doing this by a 3:1 margin, but there are some interesting differences when looked at by age group.  It is younger people who are much less likely to offer support for a Royal Commission, but it appears that this may be because they are less certain of what a commission might be able to achieve.

Another aspect of this poll may explain why politicians are responding in the ways that we have seen to the idea of a commission.  The poll finds that Conservative voters are much less likely to support a Royal Commission (59%) compared with their Lib Dem counterparts (75%), with Labour’s supporters in between (62%).

The final questions are about introducing a regulatory regime similar to Portugal’s and here it appears that support is waning, both in terms of limited trails (down from 60% to 54%) or adopting the same approach across the whole country (down from 46% to 40%).

Home Affairs Select Committee report on Drug Policy

The Home Affairs Select Committee have published their report into drug policy.  Given the comprehensive nature of what they cover it’s not that surprising that the media attention has been on the most controversial recommendation, that the HASC - Compelling Casegovernment should constitute a Royal Commission to consider whether to move to a regulatory regime that is similar to the one that Portugal has in place – in other words the decriminalisation on possession.

What has not had any focus is what the committee has to say about our area of expertise; education and prevention.

Here they have been just as radical and I think we can say that our evidence to the committee – both written and verbal – have been influential in the committee’s thinking.

It is surprising that apparently cost-effective programmes to dissuade young people from using drugs — Life Skills Training, Unplugged or Preventure—are not more widely used in schools. While we do not wish to endorse these particular programmes over others which might be equally good but were not drawn to our attention, we believe that there is a compelling case for the use of behaviour-based interventions in schools which are proven to reduce the chances of young people taking drugs.

The report notes:

The Department for Education told us that the National Curriculum requires infant school children to be taught about drugs as medicines whilst junior school pupils are taught about the impact of alcohol, tobacco and drugs on the human body and how they can effect health as well as what drugs are legal and illegal.

Strangely the DfE don’t seem to have mentioned that all mention of drugs have been removed from the draft of the new primary curriculum that the government want to introduce.

It goes on to quote Mentor extensively, pointing out that much of what is taught hasn’t proven effective, and picking up on the need for prevention science to play a greater role in the drug strategy and the report specifically mentions four evidence based programmes; the Good Behaviour Game, Life Skills Training, Unplugged and Preventure – all of whom Mentor discussed in our evidence to the Committee.

The Committee say:

When we asked the Department for Education how often either of these programmes [the Good Behaviour Game and Preventure] along with two others—Life Skills Training and Unplugged—were used in schools, we were told that they “do not monitor the programmes or resources that schools use to support their teaching.” We contacted a number of local authorities and asked them to survey the secondary schools in their area, asking them whether they used Life Skills Training, Unplugged or Preventure. None of those that replied used any of the programmes.

HASC - Cost EffectiveThe report goes on to quote our evidence about the relatively small cost of delivering these sorts of programmes against the much larger overall cost of education and the huge costs associated with lifetime problematic drug use.

The Committee say:

It is surprising that apparently cost-effective programmes to dissuade young people from using drugs — Life Skills Training, Unplugged or Preventure—are not more widely used in schools. While we do not wish to endorse these particular programmes over others which might be equally good but were not drawn to our attention, we believe that there is a compelling case for the use of behaviour-based interventions in schools which are proven to reduce the chances of young people taking drugs.

The report notes evidence that we and Crime Reduction Initiative gave about disinvestment in drug services despite increasing evidence that early interventions can be a very cost-effective way of reducing problematic drug use. Having been convinced of the case for prevention the Committee conclude with two clear recommendations:

  • the next version of the Drugs Strategy contain a clear commitment to an effective drugs education and prevention programme, including behaviour-based interventions.
  • Public Health England commit centralised funding for preventative interventions when pilots are proven to be effective.

Both of these recommendations are very welcome and if accepted by the government could lead to significant change in the way that young people in England are supported and protected from the harms associated with drug misuse.

I don’t think we could have asked for a clearer endorsement of our position and the evidence we supplied the Committee was clearly influential in their thinking about this section of the report.