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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] (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]

 

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]

 

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]

 

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.

 

 

Initiatives that fall short of the mark 

When Canada’s Drug Strategy was launched in 1987, the government acknowledged that most federal initiatives had focused on reducing supply and that there had to be more emphasis on prevention. Of the $210 million initially allocated to the first five-year strategy, no less than 32% was earmarked for prevention. In the second phase of the strategy, which ran from 1992 to 1997, the total budget increased to $270 million, with a similar percentage earmarked for prevention.

In 1994, the Government of Canada introduced the National Strategy on Community Safety and Crime Prevention and created the National Crime Prevention Council, now the National Crime Prevention Centre (Department of Justice). When Phase II of that strategy was launched in 1998, funding was $32 million annually; by 2001, funding had increased to more than $65 million. The strategy is aimed at reducing crime and victimization by addressing their root causes through a social development approach. Crime prevention through social development (CPSD) is a long-term, proactive approach. It is directed at removing those personal, social and economic factors that lead some individuals to engage in criminal acts or to become victims of crime. The National Strategy is investing in projects that address risk factors in people’s lives, such as abuse, violence, poor parenting and drug and alcohol abuse. [5]

 

Where do things really stand? The stakeholders are probably in complete agreement that there is a need for prevention. But they are equally unanimous that the actions that have been taken are short of the mark. Otherwise stated, everyone talks prevention, but no one does much about it. The observations made before the Committee cover five sets of considerations: (1) there is not enough prevention; (2) prevention lacks focus; (3) there is not enough evaluation of preventive measures; (4) prevention and social messages about cannabis are contradictory; and (5) there are exemplary practices and successful preventive measures that need to be promoted more widely.

 

Not enough prevention

For many organizations, police departments and government agencies involved in the war on drugs, it is clear that there is not enough prevention. That view is measured in terms of spending levels and cuts in prevention staff.

 

Think of the last time that you saw a drug prevention message on television. Probably one that many of us would recognize is the fried egg commercial representing what happens to your brain. Unfortunately, that was an American ad. I cannot recall a recent anti-drug ad on television. We have produced proactive materials on many other issues in our country. There are campaigns on tobacco and breast cancer. We really have very little material in the drug prevention area. We are not saying that we want more money for policing and arresting people. We agree with the current balance. We think that not only crime prevention, but also drug awareness is a vital tool in making a difference. […] We believe, first, that there is a role for police in prevention and awareness as well as in enforcement. We have excellent partnerships with teachers, parents and community groups. Community policing has really started to come together in the last 10 years. […] One of our problems is that some of our programs are dated. Very little effort is put into the prevention aspect. I do not want to be quoted exactly on dollars. However, a report about a year ago indicated that the United States spent about $12 per capita on prevention and awareness. In Canada, the comparative figure was less than $1. I think it was in the area of 20 cents or 30 cents. [6]

 

Since 1988 and 1989, when we had the Really Me campaign, we have had no federal or, in B.C., provincial campaign speaking about drugs. […] When there was a decrease in consistent prevention messages and the National Drug Strategy ended, I witnessed numerous community coalitions and task forces on drugs that dried up and went away and no provincial funding followed it. I watched in Nakusp, Penticton, the Sunshine Coast, Whistler and many other places as excited people were no longer able to keep going because the attention in the country turned to the population health bandwagon. There was a loss of interest, funding levels and prevention, and at the same time, an increase in messages about hemp, “medical marijuana” and other ideas. […] When you have this going on for years, common sense would tell you we would have some erosion in the gains we had made in consumption. With that, and with some of the changes in drug sentencing and enormous growth in cannabis availability, certainly in British Columbia, it is no wonder we see these changes. [7]

 

[Translation] Third observation: efforts to prevent substance abuse are clearly inadequate. The task involves budget (increase allocations for prevention in various areas), coordination (provide a better framework for practices in this area) and research (establish clear program evaluation parameters, determine the effectiveness of existing programs, promote winning strategies). There is a particular need for more substance abuse prevention initiatives in the following areas:

-         schools (beginning in middle school) and other areas of young people’s lives (e.g., streets, parks, youth centres);

-         workplaces;

-         front-line services in the health and social services system. [8]

 

We had an excellent Canadian program developed in Nova Scotia in conjunction with the Nova Scotia Addictions Foundation known as PACE, the Police Assisted Community Education. We, along with a pharmacist, a doctor, a nurse and some athletes were among the people that went to schools to talk to the students about peer pressure, why some students feel compelled to use drugs, about stealing and different moral ethics, and other subjects relating to drug use. Unfortunately, because of the budget cuts, the programs were cut. The money for evaluations, for increasing the program, or for improving the program no longer exited. [9]

 

In the 1970s and 1980s, there was support for community-based ongoing prevention efforts. However, in the 1990s, the federal and provincial governments cut a lot of the funding and there has been commensurate rise in drug use. During that same period, multi-faceted prevention efforts such as those directed at tobacco, seat-belts, fire safety, fitness, and dental health, to name a few, made major inroads. [10]

 

Prevention of social and health problems is often the poor cousin of practice. Whether in health or in justice, the reality is that much more is spent on treatment and intervention after the fact than on prevention. This is true for health issues in general and illegal drugs in particular.

According to the study by Single et al.,[11] the direct and indirect cost of illegal drug abuse in 1996 was approximately $1.5 billion. Of that amount, $400 million was spent on law enforcement (police, Customs, courts, correctional services, etc.), and approximately $35 million was spent on prevention, that is, roughly 2% of the total, compared with more than 25% on efforts to fight drugs. Put a different way, the per-capita cost of illegal drugs is roughly $48; by comparison, about $12 is spent on drug control, and about $1 on prevention.[12] We agree with other stakeholders that spending on prevention is woefully inadequate.

Prevention lacks focus

Preventing cannabis use probably requires a different approach than preventing the use of heroin or ecstasy. By the same token, prevention of use by students will not be handled the same way as prevention of use by street kids, and preventive measures aimed at Aboriginal youth will be different from those aimed at white youth. We will see in the next section that the risk factors and protective factors are not the same for all social groups.

However, stakeholders point out that prevention messages and the way they are delivered are often inaccurate. We see either universal messages the real effectiveness of which is hard to measure, or messages that are aimed at specific social groups but are not necessarily geared to the reality of the people being targeted. 

 

[Translation] Of particular note are weaknesses in secondary prevention. Programs aimed more specifically at high-risk groups are not enough. There is little effective screening where early intervention might make all the difference in preventing problems from getting worse, and this is true not only of youth, but of client groups of all ages. There is at present a lack of consistency in the messages being conveyed and the initiatives being taken. There is a lack of program stability. And in some areas, a great deal of ground has been lost (e.g., gradual loss of substance abuse prevention educators). [13]

 

Prevention is not ‘one size fits all.’ Broad population approaches are needed, but so too are narrow focussed activities that target a specific risk group. Of course, prevention is proactive. It promotes personal responsibility. It is highly cost effective: For the cost of one treatment centre, you can fund prevention initiatives that reach hundreds and, indeed, thousands of kids. [14]

 

If the focus is prevention, the objectives have to be clarified: is the goal to prevent use, at-risk behaviour or abuse? The chosen preventive measures will be fundamentally different depending on what objectives are set. This point was made in a recent document produced for Health Canada on best practices in the area of prevention:

 

Clear and realistic goals that logically link program activities to the problems and factors found in a community are necessary to guide implementation. Clear and measurable goals will permit evaluation to determine whether the program achieved its objectives. Goals will vary with the community and the circumstances; however, important considerations for all programs are the points at which use and problematic use of different substances generally begin. […] Accordingly, for youth who are not yet using (i.e., either not considering use or thinking about use) the program aim would be primary prevention. Programs working with a population largely consisting of youth who have initiated use and continue to use, a secondary prevention or harm reduction aim makes most sense. Each of these aims logically lead to particular activities and messages (e.g., use of more intensive approaches with those using or preparing to use). [15]

 

With respect to prevention, there is also a sense that anything and everything is possible by adopting anti-drug rhetoric. However, as we will show in the next section, preventive measures have to zero in more on known risk and protective factors. And because there are many risk factors, preventative action should be multifaceted and involve the community.

 

There is not enough evaluation of preventive measures

Another reason there is not enough prevention is that no one takes the time or devotes the resources to evaluate programs and demonstrate their effectiveness. As the saying goes, an ounce of prevention is worth a pound of cure. Similarly, one dollar invested in prevention saves five dollars down the road. That may be true, but proving it is something else.

Conducting evaluation studies is not an easy task. If they are to be credible, studies often require a complex methodology. They are also expensive. And most importantly, they cannot – or at least should not – be rushed in order to meet political timelines: to determine, for example, whether a program aimed at preventing drug use among youth is effective, “graduates” have to be monitored for no less than a year (normally at least three years) after they received the program. Canada is not in the habit of doing evaluative research, and, as we saw for Canada’s Drug Strategy, we did not set clear objectives or provide the means to evaluate initiatives.

As a result of this situation, prevention – a weak segment if ever there was one – pays the price when even the smallest budget cut is made.

 

One of the biggest problems is that our programs have never had an evaluation component. Whenever we had the opportunity to implement new programs, it was done “quick and dirty.'' There was very little money. Our only approach was to pump something out and see if it worked. We have all learned that if you are going to do something, do it properly. We should set up new programs with evaluative components in order to know that we are doing the right things at the right time for the right people. In other words, programs should consider the message, the messenger and effectiveness. [16]

 

The Committee is of the opinion that any future Canadian drug strategy will have to include mechanisms and resources to evaluate the various components and in particular to evaluate preventive measures.

 

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. [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. [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. [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. [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. [21]

 

 

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. [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. [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. [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.[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. [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.      Family factors

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

 

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.      Peer factors

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

 

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.[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. [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. [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

Ø     Address protective factors, risk factors and resiliency

Ø     Seek comprehensiveness

Ø     Ensure sufficient program duration and intensity

·                Strive for accountability

Ø     Base program on accurate information

Ø     Set clear and realistic goals

Ø     Monitor and evaluate the program

Ø     Address program sustainability from the beginning

·                Understand and involve young people

Ø     Account for the implications of adolescent psychosocial development

Ø     Recognize youth perceptions of substance use

Ø     Involve youth in program design and implementation

·                Create an effective process

Ø     Develop credible messages

Ø     Combine knowledge and skill development

Ø     Use an interactive group process

Ø     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. [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. [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.[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:

 

Ø         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;

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

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

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

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

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

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

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.      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. [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. [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. [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. [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. [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. [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.

 

Risk reduction and harm reduction

 

The harm reduction approach has become a preferred tool in preventing AIDS/HIV contamination through intravenous drug use. It was discovered in the late 1980s that IV drug users were a key vector for the transmission of HIV. Needle exchange programs came about as a result.

However, the harm reduction approach creates a number of conceptual and theoretical problems. The first problem is terminology. “Harm reduction” is the term most commonly used in English, but “risk reduction” is also sometimes used. In French, “harm reduction” has been rendered as “réduction des méfaits”, but also as “réduction des dommages” and “réduction des risques”.

Further, the concept and practice of harm reduction have been criticized by some observers who see them as veiled strategies for legalizing drugs.

 

When I say a ‘harm reduction drug policy,’ I do not mean as we have already initiated in the response to drugs so far. We have tried many things such as needle exchanges and we have tried a harm reduction approach to drinking and driving. I have developed many programs for youth, which is my specialty. If I were called upon to develop a program to teach youth with any certainty about how to use drugs that are now illegal in a safe and moderate way, I do not think I could do so. Drugs fundamentally have effects. They do affect us. For example, it may be the cleanest heroin in the world, but is the person functioning in the family and at work, and are they able to pay for the habit that they will develop? Those are questions that need to be answered.

 

When I use the term, I mean harm reduction as it has been promoted. The term has become sullied, unfortunately. It began as a noble thing, but has become a key code word for decriminalization or legalization of substances. I would caution you against using the term as it is. [41]

 

Granted, harm reduction strategies are often on a collision course with law enforcement strategies: the situation has arisen often in cities across Canada where heroin addicts leaving needle exchange clinics come face to face with police.

The term “harm reduction” refers more specifically to strategies aimed at reducing the adverse effects of drug use on health, economic status and the social environment for users and those around them.[42]  In addition to needle exchange, harm reduction strategies for drug users include such measures as prescription methadone for heroin addicts, medically supervised prescription heroin programs and “safe injection rooms”, or clinics where no prescription is required.  Canadian stakeholders agree that these measures are underdeveloped in Canada. Health Canada recently announced that a prescription heroin program would be tested in three major cities. The number of methadone places is said to be insufficient. Moreover, there are no safe injection rooms.

What are the implications of a harm reduction strategy for cannabis? What applications might there be for such a strategy? Harm reduction strategies related to heroin, for example, have been based on knowledge of some of the harmful effects of injecting the drug: HIV and hepatitis C for users (needle exchange programs), unsanitary conditions and risk of violence in places where the drug is injected (safe injection rooms), and petty property crime to get money to buy drugs (prescription heroin). In order to develop harm reduction strategies, we therefore have to know at least something about the ways the drug is used and its direct and indirect harmful effects. What are the harmful effects of cannabis?

We identified some of those harmful effects in Chapters 7 and 8. They include:

·               risks for youth under 16 because of their physiological immaturity, in particular the immaturity of their endogenous cannabinoid system;

·               risks associated with use that could be described as “occupational” (as opposed to recreational): the person uses marijuana alone, in the morning, to do school work or to carry out a job;

·               risks associated with heavy, frequent use over a long period;

·               risks associated with inhalation over a long period;

·               risks associated with impaired driving, especially when the marijuana is mixed with alcohol.

 

Based on this knowledge, harm reduction strategies could be developed for cannabis:

·               discourage use by youth under 16;

·               detect at-risk users, especially among youth;

·               provide information on the risks of inhaling and point out that deep inhalation is part of the folklore and is not necessary to obtain the effects;

·               use strong measures to discourage impaired driving.

 

Obviously, like harm reduction strategies for other drugs, these tools are based on recognition of use and an approach that does not call for abstinence. We know full well that these two points may elicit strong reactions from those who believe that cannabis is fundamentally dangerous and may put us at odds with the current legal context.

 

Conclusions

 

Prevention is necessary. Keeping our guiding principles in mind, prevention must be part of a vision of the role of governance as a way of fostering human initiative and a vision of ethics and public health that focus on autonomy. In that sense, it is not an instrument of control, but rather a tool to help set people free. And in the case of cannabis, being set free does not mean not using, but rather having the ability to take a position on and think about the reasons for using and the ability to deal independently with at-risk behaviour.

 

Conclusions – Chapter 16

On prevention                     On evaluation               On harm reduction

Ø            A national drug strategy should include a strong prevention component. Ø            Prevention strategies must be able to take into account contemporary knowledge about drugs. Ø            Prevention messages must be credible, verifiable and neutral. Ø            Prevention strategies must be comprehensive, cover many different factors and involve the community. Ø            Prevention strategies in schools should not be led by police services or delivered by police officers. Ø            The RCMP should reconsider its choice of the DARE program.   Ø            Prevention strategies must include comprehensive evaluation of a number of key measurements. Ø            A national drug strategy should include mechanisms for widely disseminating the results of research and evaluations. Ø            Evaluations must avoid reductionism, involve stakeholders in prevention, be part of the program, and include longitudinal impact assessment.   Ø            Harm reduction strategies related to cannabis should be developed in coordination with educators and the social services sector. Ø            Harm reduction strategies related to cannabis should include information on the risks associated with heavy chronic use, tools for detecting at-risk and heavy users, and measures to discourage people from driving under the influence of marijuana.