Reducing the harm of adolescent substance use Patricia G. Erickson, PhD CMAJ 1997;156:1397-9 [ résumé ] Patricia G. Erickson is Professor of Sociology at the University of Toronto, where she directs the graduate collaborative program in Alcohol, Tobacco and Other Psychoactive Substances, and Senior Scientist with the Addiction Research Foundation, Toronto, Ont. The views expressed here are the author's and do not necessarily represent those of the Addiction Research Foundation. Reprint requests to: Dr. Patricia G. Erickson, Addiction Research Foundation, 33 Russell St., Toronto ON M5S 2S1; fax 416 595-6899; perickso@arf.org © 1997 Canadian Medical Association (text and abstract/résumé) See also: Substance abuse and developments in harm reduction [Commentary] Abstract Recent increases in adolescent drug use have focused attention on school-based drug education programs. The effectiveness of traditional programs has been questioned, and some researchers have advocated the adoption of new methods based on the principles of harm reduction. The harm-reduction approach recognizes that the goal of preventing all drug use is unrealistic. It focuses instead on minimizing the harmful consequences of use, on providing credible information and on developing the capacity of young people to make responsible choices. The author supports the recommendation by Drs. Christiane Poulin and David Elliot (page 1387) that this approach be developed and tested in the context of drug education. Résumé Des hausses récentes de la toxicomanie chez les adolescents attirent l'attention sur des programmes scolaires d'éducation sur les drogues. On a remis en question l'efficacité des programmes classiques, et des chercheurs préconisent de nouvelles méthodes fondées sur les principes de la réduction du préjudice. Une stratégie de réduction du préjudice reconnaît qu'il est irréaliste d'essayer de prévenir toute toxicomanie. Elle vise plutôt à réduire au minimum les conséquences préjudiciables de la consommation de drogues, à fournir de l'information crédible et à développer chez les jeunes la capacité de faire des choix responsables. L'auteur appuie les Drs Christiane Poulin et David Elliott (page 1387) qui recommandent d'élaborer cette stratégie et d'en faire l'essai dans le contexte de l'éducation sur les drogues. The recent upswing in both licit and illicit drug use by adolescents in Nova Scotia, documented in this issue by Drs. Christiane Poulin and David Elliott (page 1387), is justifiable cause for concern. Of the students surveyed on their drug use in the preceding 12 months, 37% had used no alcohol or other drugs, 22% had used all of alcohol, tobacco and cannabis, 27% had experienced at least 1 alcohol-related problem and 6% had experienced at least 1 other drug-related problem. These findings, along with the results of other research,[1] demonstrate the need to minimize the risks of nonmedical drug use by adolescents. They also raise questions about the role of school-based drug education. Why aren't current programs more effective? What alternative strategies might be deployed? Would programs based on the principles of harm reduction be more effective, as Poulin and Elliot suggest? Harm-reduction interventions focus on mitigating the harmful consequences of substance use rather than on eliminating such use altogether. Implicitly and explicitly, they accept the existence of a range of drug use patterns along a continuum of risk. Consensus has emerged with respect to the following premises of harm reduction:[2] nonmedical use of psychoactive drugs is endemic in modern societies, nonmedical drug use produces varying degrees of social and personal harm, policies and programs to reduce harm must be judged by their impact, not their symbolism, the health of drug users and the community is best served by an approach that integrates rather than isolates the drug user, the complex relation between drug use and harmful outcomes necessitates multifaceted interventions. Although harm reduction has gained credibility in specific areas (e.g., needle- exchange programs) it is still controversial when applied to drug education. A number of educators have articulated a framework for a harm-reduction approach to drug education.[3,4] Their point of departure is to accept the principles of harm reduction and apply them pragmatically, offering education about drugs rather than against drugs. The goal is to provide accurate and credible information that will promote responsible behaviour. This approach acknowledges the appeal of drug use from the young person's perspective as well as its potential medical, social and legal consequences. It is rooted in an appreciation of adolescent psychosocial development, in which curiosity, a willingness to experiment and the definition of personal boundaries come into play. Thus, the more general educational aim of developing the young person's capacity for autonomous decision-making is extended to the issue of drug use. Traditional programs attempt to prevent drug use by emphasizing its negative aspects. They present non-use as normative and equate use with abuse. The effectiveness of such programs has not been demonstrated. DARE (Drug Abuse Resistance Education), a police-delivered program widely used in the US and Canada, has been tracked and evaluated by several investigators, all of whom have concluded that it has no long-term effect on behaviour.[4,5] A comprehensive literature review of school-based programs reached similar conclusions about the effectiveness of the conventional approach.[6] The recent upswings in adolescent drug use are further evidence of failure. Some researchers have suggested that school-based prevention programs cannot be effective because they are inconsistent with the messages that adolescents receive from the larger social environment. Some have concluded that it is unrealistic to expect these programs to prevent or change adolescent drug use and have proposed more realistic goals, such as promoting safer use, delaying use, preventing the escalation of use and encouraging users to take responsibility for themselves and others. Some critics of drug education geared solely to prevention have suggested that it may actually be harmful.[7,8] First, they argue that an emphasis on abstinence as the norm isolates and stigmatizes young people who are using drugs and may reinforce other forms of deviance. Second, they argue that those who are experiencing problems may be deterred from seeking help.[9] Third, they assert that it is questionable whether anti-drug programs equip young people for life in the real world, where even those who do not use drugs may need to assist and understand people who do. Fourth, they argue that drug education programs can undermine the authority of classroom teachers by relying on police officers, former addicts and sports figures to recount sensational stories of drug abuse. Critics of the harm-reduction approach warn that it may increase drug use by portraying its attractions and making it seem acceptable or even expected. They argue that the risks are too great to experiment with such programs without evidence of their efficacy and that, at most, harm reduction may be appropriate for young people who are already heavily involved in drugs.[10] Some argue that anything but a strict abstinence message may be viewed as surrender in the war on drugs. Such a view is epitomized in the statement by Robert Dupont, White House drug "czar" under US presidents Ford, Nixon and Carter, that teenagers "need to know that drug use is unacceptable and will be punished, . . . including [the use of] alcohol and tobacco."[11] This approach is also reflected in the remark by Barry McCaffrey, director of the US Office of National Drug Control Policy, that the administration's stand against the medical use of marijuana is intended to "[protect] the scientific process and youth."[12] While the dust swirls over the ideological debate as to who should control what is taught in our schools, Poulin and Elliot are correct to ask whether the time has come to change our reliance on prevention-based drug education. The proponents of harm reduction argue that the prevailing absolutist perspective ignores reality. The wide availability of licit and illict drugs is a fact of modern life that has not been altered by devoting vast amounts of money to law enforcement. Many adolescents will not try drugs, many will experiment without adverse effects and some will use drugs in amounts or situations that lead to serious harm. We must seriously consider introducing new health- and safety-oriented programs that have the potential to reduce these harms. Society does adolescents a disservice by not equipping them for the challenges of a world in which legal and illegal drugs are omnipresent. Of course, the harm-reduction approach to drug education cannot be systematically evaluated until pilot projects are in place. The priority should be to fund and implement such efforts, building on existing groundwork. Educators who favour the harm-reduction approach have already developed core materials and a framework for curriculum development.[3,4] The aims of any program must be clearly stated, realistic and measurable, and the ultimate test must be that of effectiveness. There will be more than 1 way to measure success in reducing harm, and to do so objectively will be essential. Despite the dismal record of conventional programs in preventing drug use, few have been assessed in terms of their ability to reduce harmful outcomes. Among the array of programs that have been tried, it may be possible to identify particular features that show more promise for harm reduction than for outright prevention, as well as characteristics that may actually promote harm.[13] Prevalence rates should not be ignored as an indicator of harm reduction, but they must be kept in perspective. An upswing or downturn in use tells us nothing about patterns of harmful use; more significant indicators are rates of heavy use and of polydrug use. There is no reason to suppose that a well-integrated curriculum, rooted in an understanding of psychosocial development, cannot be effective in supporting choices to refuse or delay the use of drugs. Moreover, public acceptance of the harm-reduction approach will require that non-use be included as 1 of several viable goals. Finally, we should remember that another approach to prevention is widely applied in Canada, namely, the criminal prosecution of drug users. Despite the lack of evidence of any deterrent effect, the current law threatens the 1 in 4 adolescents who try cannabis with criminal records and potential imprisonment. This threat is not hollow: several thousand young people are charged annually.[14] In trying to prevent or reduce the harm of adolescent drug use we must consider the difficulty of reconciling the punitive policies of our criminal justice system with the aims of educational programs that are concerned with the well-being of youth. Effective strategies do not emerge in isolation, but blend health services, education and law enforcement to a common purpose. The evolving harm-reduction model can provide a pragmatic and flexible response to the problem of adolescent drug use.[15] It is time for harm-reduction education programs to be given the opportunity to demonstrate this. References Adlaf EM, Ivis FJ, Smart RG, Walsh GW. Enduring resurgence or statistical blip? Recent trends from the Ontario drug use survey. Can J Public Health 1996;87:189-92. DesJarlais DC. Harm reduction: a framework for incorporating science into drug policy. Am J Public Health 1995;85:10-2. Cohen J. Achieving a reduction in drug-related harm through education. In: Heather N, Wodak A, Nadelmann E, O'Hare P, editors. Psychoactive drugs and harm reduction: from faith to science. London (UK): Whurr Publishers; 1993. Rosenbaum M. Kids, drugs and harm reduction. San Francisco: National Council on Crime and Delinquency; 1996. Ennett ST, Tobler NS, Ringwalt CL, Flewelling R. How effective is Drug Abuse Resistance Education? A meta-analysis of Project DARE outcome evaluations. Am J Public Health 1994;84:1394-401. Dorn N, Murji K. Drug prevention: a review of the English language literature. London (UK): Institute for the Study of Drug Dependence; 1992. Cohen J. Drug education, politics, propaganda and censorship. Int J Drug Policy 1996;7:153-7. Saunders B. Illicit drugs and harm reduction education. Addiction Res 1995;2:i-iii. Adlaf EM, Smart RG, Walsh GW. Trend highlights from the Ontario student drug use survey, 1977­1991. Can J Public Health 1993;84:64-5. Tupker E, Poland B, West P. Concerned youth promoting harm reduction (CYPHR): a participatory research and development project with street involved youth [abstract]. 8th International Conference on the Reduction of Drug Related Harm, Paris; Mar 23­27, 1997. DuPont RL. Harm reduction and decriminalization in the United States: a personal perspective. Subst Use Misuse 1996;14:1929-45. McCaffrey B. Letter. The Economist 1997;Feb 1:10. Tobler NS. Updated meta-analysis of adolescent drug preventions programs [summary]. Proceedings of Evaluating School-Linked Prevention Strategies conference, University of California, San Diego (CA); Mar 17­20, 1993. Fischer BF, Erickson PG, Smart RG. The new Canadian drug law: one step forward, two steps backward. Int J Drug Policy 1996;7:172-9. Erickson PG, Riley DM, Cheung YW, O'Hare PA, editors. Harm reduction: a new direction for drug policies and programs. Toronto: University of Toronto Press, 1997. In press. 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