Preventive and treatment measures to reduce drug abuse : summary of responses to a survey of national programmes
Pages: 33 to 40
Creation Date: 1983/01/01
Preventive and treatment measures to reduce drug abuse : summary of responses to a survey of national programmes
United Nations Secretariat
This article summarizes the salient points extracted from the responses of 67 Governments to a survey of national drug-abuse prevention and treatment programmes. The results of the survey were presented in more detail in E/CN.7/673, which was considered by the Commission on Narcotic Drugs at its seventh special session in February 1982. Most responses indicated that heavy reliance was placed on control and drug law enforcement to reduce the availability of illicit drugs. Some concern was expressed over the possibility that drug information or drug education that was ill-conceived or inaccurately targeted might arouse curiosity and experimentation. There had been relatively little in-depth evaluation of the effectiveness of either preventive or treatment measures that had been undertaken. The involvement of voluntary organizations, families, communities and groups of "high-risk" youth was generally regarded, however, as an essential feature of successful preventive and treatment work. A few responses indicated that the maintenance of heroin or other opiate addicts had been successful in reducing drug-related crime and other undesirable behaviour. Preventive education was most effective when presented within the broader context of health education, as well as civics or similar studies within the curriculum of schools and universities. School programmes were more effective when they involved communities. A considerable effort had been made to train medical personnel and those likely to come into professional contact with persons at risk. Shortages of trained staff and other resources were frequently mentioned as inhibiting factors.
A survey of national programmes to reduce illicit demand for drugs was undertaken in 1976 and reported to the Commission on Narcotic Drugs (E/CN.7/608) in 1977. In order to prepare a document on preventive and treatment measures to reduce illicit demand for drugs, which was requested by the Commission on Narcotic Drugs at its twenty-ninth session, the Secretariat up-dated the questionnaire that was used in the 1976 survey and distributed it to Governments of Member States in April 1981. By January 1982, 67 Governments had replied. On the basis of responses received, information was presented to, and considered by, the Commission on Narcotic Drugs at its seventh special session in February 1982 (E/CN.7/673).
This article summarizes only the salient points of preventive and treatment measures undertaken, while more detailed information by country and region is described in E/CN.7/673. Both prevention and treatment are interpreted using the broadest sense of these two terms.
More countries appeared to be taking a broader range of measures aimed at both prevention and treatment than was the case in 1976. There had been greater concentration in many countries on measures of treatment and rehabilitation although, where evaluation of such measures had been possible, it seemed that the likelihood of success in assisting a genuinely addicted person to achieve a drug-free existence was very limited. A few countries, however, reported that maintenance programmes had been successful in reducing criminal and other undesirable activities associated with the abuse of heroin or other opiates.
In general, there had been fewer programmes directed towards preventing illicit demand for drugs. A number of responses suggested that in future greater attention might usefully be given to prevention, especially taking account of the fact that once addiction was present a complete cure seemed rather difficult to achieve.
Many responses indicated that success was dependent on the full involvement of individual abusers themselves, of high-risk groups, or of families and communities, and that it was essential to generate the maximum input from voluntary organizations at all levels in society.
It was stated or implied in most responses that heavy reliance was placed on control and drug law enforcement to reduce the availability of drugs for illicit use and thereby to prevent the emergence of demand for illicit drugs.
Some countries stated that they did not have a problem with an illicit demand for drugs, and they did not therefore regard preventive measures as necessary.
Many responses described general programmes of information, frequently provided through the mass media. Certain disadvantages were reported : such programmes might not reach the target population ; they provided no opportunity for a dialogue ; and there was consistent fear that such general information might arouse curiosity and experimentation. Where evaluations had taken place, the best results seemed to be achieved by ensuring that all information used was entirely accurate and up-to-date.
A number of responses indicated that information programmes were more effective if they concentrated less on the hazards or futility of drug abuse and more on a positive approach. This included : emphasis on rational drug use ; encouraging alternatives to drug abuse ; the advantages of a drug-free life style ; and deglamourizing drug abuse in general.
There was an increasing effort to target drug information to specific groups including parents, teachers, professionals in contact with youth and especially the youth themselves, particularly youth leaders. The evaluation of such targeted information indicated a reduction of anxiety among youth and an improvement in the early identification of drug abuse.
Some responses indicated that no practical method of assessing the effectiveness of information programmes was possible. Others, where an evaluation had been attempted, indicated that this could be done and that preventive measures had resulted in diminishing use and a rejection of the acceptability of some drugs. Many responses cited the shortage of trained personnel and of suitable audio-visual and other material as inhibiting factors.
Many responses indicated that education for specific target groups was undertaken. It was emphasized that the involvement of parents and other groups able to influence youth was important. The best results appeared to be obtained where the youth were educated to help themselves, where education on drugs stressed rational use rather than risks and dangers and where education on drugs took place within the context of broader relevant disciplines concerning health in general. Such education directed at youth should, with appropriate adjustments, be supplemented by education for parents, teachers and others in contact with and able to influence youth. Many responses emphasized the importance of the family as an essential element in preventing the emergence of drug abuse. Rather fewer stressed the importance of teachers, although their role was clearly seen as being of great significance. There was widespread acceptance that appropriate drug education should become a normal part of school curricula.
A number of responses reported education for students in medical schools and for pharmacists in order to promote better prescribing habits.
Several responses outlined preventive work being done by encouraging youth groups, individuals, families and communities to promote healthy alternatives to drug abuse and a drug-free life style. There was a need to identify youth leaders, to encourage youth to become involved in community projects, to improve children's recreational environment and to promote contact between youth and adults. This not only improved the acceptance of youth by the community as a whole but also provided constructive peer pressure, enabling youth to see how they could change their environment in a positive manner. In this context, one country stressed the need to diminish social injustice and to provide appropriate supervision and adult contact at a very early age for young children with working parents.
A number of countries stated that professional counselling, drop-in centres, "hot-lines" and other mechanisms were valuable in ensuring that early intervention was possible before the demand for illicit drugs was far advanced.
In general, on the basis of responses received, the following appeared to be effective:
Continued control to reduce the availability of drugs of abuse;
The greatest possible involvement of volunteer organizations at all levels;
The production of accurate and up-to-date information:
The development of flexible programmes based on this information that could be adjusted for target groups;
Built-in evaluation of the effects of all preventive programmes;
The involvement of the community, with particular emphasis on families, schools, youth leaders and professionals able to influence youth;
The inclusion of drug education for youth within broader educational disciplines;
Emphasis on rational drug use in addition to material on the dangers of drug abuse;
The importance, above all, of generating a response from among the youth themselves that would deglamourize drug abuse and encourage the positive involvement of youth in developing the communities in which they lived.
Countries where treatment (in the broadest sense of the term) was necessary reported that the best results were achieved with a multi-disciplinary approach. As with prevention, emphasis was placed on the need to involve the individual, the peer group (generally youth), the family and the community. The key factor was individual motivation. Without it, the individual would probably not seek treatment or assistance and might reject any efforts to supply them. A number of responses described efforts to engender such motivation by stimulating encouragement from within the family or the community and especially from peer groups.
Many responses described counselling, consultation and advice services which, when readily available, were helpful in identifying drug-related problems at an early stage.
Responses indicated that detoxification alone was not enough. The rapid establishment of a drug-free condition, whether in a hospital or through out-patient facilities, was of no lasting value unless appropriate follow-up action was continued.
Most responses described drug-free psychological or behavioural treatment, usually on an out-patient basis. This treatment involved individual, group, family and other therapy and, in a few cases, the use of acupuncture to alleviate withdrawal symptoms. The advantages of this, as of all out-patient treatment, were that it allowed the client to continue a normal existence and was relatively inexpensive. The main disadvantage, naturally, was that out-patient treatment did not prevent the client from having access to drugs for abuse.
Maintenance as a treatment modality was reported from a number of countries. Some used opium. A few either used or were experimenting with methadone maintenance, mainly for heroin addiction. There was a reported danger of leakage into illicit channels. Some national responses indicated that the issue of methadone maintenance was controversial ; however, responses based on evaluative studies in a few countries indicated that methadone maintenance had decreased illicit heroin use and drug-related criminality and had improved the general health, employment prospects and social responsibility of the persons being maintained. This modality was used where total abstinence from opiates (mainly heroin) was unrealistic in the short term. Research continued on longer-acting substances, which might also be used for maintenance or to prepare clients for detoxification, as did research into the use of narcotic antagonists.
Residential programmes, including therapeutic communities, were frequently available. There was some difficulty in achieving an objective evaluation because of the high drop-out rate within the first few weeks of treatment. However, the proportion of clients that successfully overcame early problems appeared to have a relatively high rate of eventual abstinence from drugs.
Rehabilitation, after-care and social reintegration together with treatment must form part of a continuum to ensure full re-establishment of the client into normal community life. The inadequacy of these services, owing sometimes to insufficient trained staff and facilities, was one reason for high relapse rates following various treatment modalities, including those mentioned above. One difficulty, for instance, was that of readjusting to a normal existence in society following discharge from long-term institutional rehabilitation. Many responses indicated that more emphasis was being placed on the involvement of the whole community to increase the effectiveness of the process leading to complete social reintegration.
Responses received covered a wide range of treatment settings. Some mentioned the expense of in-patient treatment, although this was essential in some cases. Others found the success rate relatively low, particularly in the absence of supportive measures following discharge from in-patient treatment.
Many responses described treatment in out-patient facilities. Success depended very heavily on the motivation of the client, but the relatively inexpensive nature of such treatment was an advantage. Most types of drug-free treatment and maintenance could be effectively provided, and out-patient facilities could be associated with long-term follow-up services.
Treatment in prisons often included therapy and vocational rehabilitation but was often reported to have a low success rate.
Among other treatment settings used, in either a direct or a supportive role, were: therapeutic communities and other residential programmes; day-care, which was especially suitable for younger clients; half-way houses, providing an additional after-care measure; supportive family programmes, including care within a family environment; vocational counselling and training; and job-finding and placement. Some or all of these sometimes formed part of overall field activities providing support at all stages of rehabilitation.
Evaluations described in a few responses claimed that the treatment of drug-addicted persons in terms of complete long-term abstinence was effective in no more than one third of the cases. Success elsewhere was much lower. There was a variation depending on the source of information and the criteria utilized in the evaluation. In general, the longer clients stayed in treatment, the better the results that were obtained following detoxification.
On the basis of responses received, the conclusions that might be reached included the following :
Realistic treatment objectives should be based on an individual client's motivation and needs and his or her assessed ability to achieve a drug-free existence in the short or long term ;
Treatment should respond to individual needs wherever possible ;
In view of the frequent paucity of trained personnel and other resources, it was important to utilize all available facilities including those from voluntary sources ;
Clear distinctions should be drawn between experimental or occasional drug users and those with a prolonged history of addiction. Counselling or supportive persuasion by peers might be an effective way to deal with the former group ;
It was necessary to generate "out-reach'' or other programmes to persuade and motivate addicts to recognize their problems and to seek solutions ;
Detoxification alone was not enough. It must be linked to broader-based measures including treatment, rehabilitation, after-care and social reintegration. Such measures should involve peer groups, families and local communities ;
It seemed essential to reinforce constructive, positive activities that could motivate an individual or a group away from drug abuse and prevent the emergence of drug sub-cultures ;
Any planning of treatment or associated services must be based on as accurate an assessment as possible of the extent, patterns and other characteristics of drug abuse ;
It was important, at the beginning of any treatment programme, to include evaluative mechanisms. Outcome indicators to be sought by evaluation might include, in addition to ending drug use, the extent to which the individual maintained stable employment, did not engage in criminal activity and participated in educational, vocational and other community programmes.
Responses from countries reinforced the validity of the old saying that "prevention is better than cure". There were no miracle treatment modalities in sight. There was general acceptance that the relatively quick detoxification process, by whatever means, should be followed by a long period of additional supportive measures if an addict was to achieve total drug-free reintegration into society. In many countries the provision of adequate support of this kind would require the full involvement of all voluntary bodies likely to have resources available to assist.
Even with support of this kind, the proportion of addicts who achieved a genuine drug-free existence in the long term was very small. That being so, maintenance was regarded in some countries as a viable alternative; the advantages, in terms of reducing criminal and other undesirable activity associated with drug abuse, outweighed the disadvantages.
A more fundamental problem was to reach the addicts who never came forward for treatment or assistance of any kind and who rejected all informational and educational material that authorities presented.
Techniques of prevention seemed generally less researched and applied than those for treatment and rehabilitation. The classical use of control and enforcement to reduce the availability of drugs for abuse was clearly fundamental. However, numerous factors, including the virtually unrestricted illicit supply of drugs in many parts of the world, made it impossible to rely on control alone.
Prevention also seemed to be developing, albeit slowly, as a multi- disciplinary approach. Basic requirements appeared to include: accurate information that was carefully developed for intended recipients to avoid arousing curiosity and experimentation; targeted education, provided as part of a broader institutional process; the provision of recreational and other alternatives to drug abuse; the mobilization of youth to support a drug-free culture and environment in which they felt themselves to be an active, useful and influential component; the mobilization of the family and the community in a combined effort to reduce dependence on drugs; and the discovery of means of communicating with those already involved in drug subcultures so as to break up those groups and prevent them from spreading.