5. Ineffective Approaches
What doesn't 'work'?
There is much stronger evidence of prevention approaches that have consistently been shown to be ineffective at improving drug use outcomes, than approaches that have shown to be effective. The table below summarises evidence on approaches shown to be ineffective from a much larger review of effectiveness of policies and interventions to address young people's addictive behaviours (Brotherhood et. al, 2013 in ACMD, 2015). As above, the approaches in bold are those that deal specifically with illicit drug use.
Table 2 - Ineffective interventions and approaches in substance use prevention for young people - a summary of Brotherhood et al., 2013
Interventions and approaches which produced negative effects on substance use behaviours when compared to a standard intervention or no intervention.
The ACMD (2015) summarise these and other findings on approaches for which there is evidence of ineffectiveness, as including: information provision ( standalone school-based curricula designed only to increase knowledge about illegal drugs), fear arousal approaches (including 'scared straight' approaches), and stand-alone mass media campaigns.
The information provision model assumes a 'rational consumer' or 'information deficit' approach to drug use in young people, put simply, the idea that young people do not have a clear understanding of the potential consequences of participating in risky behaviour, and giving them this information would make such behaviour less appealing. This hypotheses is not supported by the evidence ( ACMD, 2015). As highlighted above in the Cochrane Review, at best, information provision improves drug-related knowledge, but there is no evidence that information provision alone changes behaviour and reduces drug use (Stead and Angus, 2004). Chowdry et. al. (2013) point out that there is limited information as to why this approach is not successful at reducing risky behaviour. For example, whether the lack of success is due to the approach itself, the behaviour it tries to deter, or because of the method of delivery. Whatever the answers to these questions, information provision approaches continue to operate both in Scotland and internationally, despite the lack of evidence to show that they reduce drug use. If the stated aim (usually of schools based drug education) is to improve drug related knowledge rather than to change behaviour then this is perhaps less problematic, provided that the limitations of the information provision approach are made transparent.
Public Health England write that it is vital that accurate and relevant information is made available to people about health harm, and that while there is no evidence to support information provision as effective in changing behaviour on its own, it can nonetheless reduce harm and inform choice (Public Health England, 2015). Midford and Munro (eds., 2006) also write that while the information only approach is now well understood to be a 'failure', a study by Tobler et. al (1999) found that effective drug education programmes must provide relevant knowledge, and even the best delivery method is not sufficient for an effective programme (Tobler et. al, 1999 in Midford and Munro eds., 2006). Midford and Munro also write that further research is needed to delineate what constitutes essential content knowledge (Midford and Munro (eds.), 2006, 225).
Stand-alone mass media campaigns for illegal drug use are at best ineffective, and at worst associated with harmful effects (also known as 'iatrogenic effects' - i.e. they increase a behaviour that is trying to be prevented). The ACMD recommend that mass media campaigns are therefore only delivered as part of multiple component programmes to support school-based prevention ( ACMD, 2015).
Below is a table from the UNODC review which adds some further points on the components of programmes likely to be ineffective. As stated earlier, in Scotland there is little knowledge about what types of prevention activity are being delivered in schools and in the third sector. Anecdotally however, it would seem that the last two on the list below - the ex-addict 'in the classroom' approach and using police officers to deliver the programme or session - are reasonably common, despite being classed by the UNODC as 'programmes with no or negative prevention outcomes'.
Characteristics associated with no or negative prevention outcomes
Available evidence indicates that the following characteristics are associated with no or negative prevention outcomes:
x Utilizing non-interactive methods, such as
lecturing, as a primary delivery strategy
x Information-giving alone, particularly fear arousal
Moreover, programmes with no or negative prevention outcomes appear to be linked to the following characteristics:
x Based on unstructured dialogue sessions
x Focusing only on the building of self-esteem and emotional education
x Addressing only ethical/moral decision making or values
x Using ex-drug users as testimonials
x Using police officers to deliver the programme
UNODC, International Standards on Drug Use Prevention (2015), page 21.
Given that there is strong evidence that these approaches are ineffective or iatrogenic, the ACMD (2015) suggest that for ethical reasons, local commissioners should carefully consider their investment in such approaches, and whether such interventions and approaches should be discontinued. The EDPQS (2015) are less equivocal and argue that such programmes should not be funded, even if popular. However, Foxcroft (2005 in ACMD, 2015) suggest a 'precautionary pragmatism' when there is uncertainty about the effectiveness of an approach. Considerations to be weighed up include: whether the prevention activity is likely to be associated with harm, the potential costs and harms of withdrawing this activity/not delivering any prevention activity, and potential benefits to other health and wellbeing outcomes, even if these are not apparent for drug use. The section below on considerations for policy makers includes the recommendation for commissioners to use quality standards and guidelines on intervention development and delivery to guide these decisions ( ACMD, 2015).