I’ve been researching and working in the drug prevention and education field for about 15 years, and have been lucky to meet many dedicated people working in policy and practice both in the UK and internationally. My research has looked at what kind of approaches are effective, and knowing this, how we might best deliver and implement support for those who need it. I’ve also been fortunate to have been involved in a lot of national UK and European policy work as well, where I’ve been able to promote evidence and science based approaches, and advocate for prevention in strategies to promote health and social development. This has sometimes been difficult, as the prevention and education field sometimes attracts people and organisations who have very good intentions but who might not appreciate that prevention is difficult to ‘get right’. If done badly, some approaches can actually increase harm, whether through directly increasing risk, or indirectly through wasting scarce resources that could have been spent on approaches we know can help.
For me, prevention activities are justified on the basis that they serve to protect health and promote healthy development – the fact that drug prevention also concerns illegal behaviours is irrelevant to me. Prevention activities are all around us, and are not just delivered in the classroom. They can include those approaches that aim to improve health and social decision-making more generally, and foster positive social relationships between participants and protective family, community, and social structures. This means that discussions of drug prevention are sometimes also political discussions, and we should be willing to challenge politicians and decision makers when we feel that their policies are creating the conditions that make drug use, and harms from drug use, more likely.
If I remember back to my own secondary school years in the late 1980s and early 1990s, we didn’t receive anything that could be considered evidence-based prevention. On one occasion, a local church group came into our class and informed us that all drug use leads to disaster and that it was only a matter of time after taking our first LSD tab that we would be jumping out of windows or putting our head in a jet engine (!). Even today I hear of drug education and prevention approaches that still rely on these fear arousal tactics, that make the assumption that all drug use leads to harm, or that we just need to give recipients ‘the facts’ in order to help them make healthy choices.
An unhelpful distinction is also sometimes made between drug prevention and harm reduction approaches, particularly for young people. Some people have argued that harm reduction is incompatible with prevention – but I disagree. I think this is a throwback to those assumptions underlying my experiences of prevention at school; that prevention should be focused on abstention at all costs. To be clear, not using substances or delaying substance use for as long as possible reduces the risk of harm, but prevention is just one component of a series of responses to substance use, and this also includes treatment, recovery, and harm reduction. Harm reduction approaches don’t necessarily seek to prevent drug use, but aim to reduce the adverse consequences of use if people do decide to use drugs. So this might include practical strategies such as breaking up an ecstasy tablet and only taking a small part of it, or giving advice and information about keeping safe and looking out for friends. But this is seen as controversial to some people, because it suggests that we are giving our approval for people to break the law and to put their health at risk by taking drugs.
In the public health field we talk about a concept called ‘proportionate universalism’, and applied to drug prevention this means that everyone can potentially benefit from education and support, but more specialist and intensive activity might be needed for those people at greater risk of harm. So in schools, for example, all pupils can benefit from universal activities delivered through relationships, sex and health education, or through structured programmes such as Unplugged or SHAHRP. Those groups of people who might be more likely to use drugs, whether because of leisure choices (e.g. active participants in nightlife) or other factors (e.g. involvement with youth offending teams), or who might already be using drugs, benefit from what we call selective approaches. Similarly, individuals screened at a higher risk of drug related harms because of particular personality or behavioural factors, benefit from what we call indicated prevention actions. For each of these categories of activity, the types of work delivered and the aims and outcomes of prevention will be different. In universal approaches, the aim is to prevent the onset of substance use completely, or for as long as possible. These are still important aims for selective and indicated prevention, but because participants might already be using substances then prevention might instead aim to stop their use becoming more regular, or to persuade them to use less frequently and to eventually stop use. We can begin to see here why harm reduction approaches might also be useful. For those young people who have chosen to use drugs and want to continue their drug use – despite our advice – harm reduction approaches might be more appropriate, as the priority in the first instance is to reduce the risk of immediate harm.
I still think we need to be cautious about harm reduction approaches. We need to make sure that all activities are age appropriate and relevant to the experiences of participants. Despite media headlines suggesting otherwise, only a minority of young people use substances and so more traditional prevention and educational approaches are still the most appropriate approach for most young people. In keeping with my criticism of those prevention approaches that are just based on ‘good intentions’, we also must be honest about harm reduction, as we still don’t know a great deal about the impact of many approaches in young people and if they are even effective. Someone might be provided with lots of advice and information about drugs, but that does not necessarily equip them with the skills to apply that information to their own particular circumstances. This is why the solid foundation provided by good drugs education and prevention is important, because these focus on developing core health decision making skills and behaviours, upon which any harm reduction advice can be built.
Harry Sumnall is Professor in Substance Misuse at the Public Health Institute, Liverpool John Moores University.