Week 5 Substance Use Disorders - Prevention Flashcards
What are the two possible goals for prevention use in substance use disorder programs
Stop the problem before it starts
Prevent negative outcomes (e.g., HIV transmissions)
Preventing Substance Use from Starting
Information and fear
Media
Inconsistent results about effectiveness
Hard to study
It is hard to find people not exposed to this media coverage so how can you have a study which covers this?
D.A.R.E.
Drug Abuse Resistance Education
Developed in the 1980s during Reagan’s “War on Drugs”
Zero-tolerance approach to drug use
Happens in schools
Police officers deliver substance-use prevention curriculum to students
Teaching students skills needed to recognize and resist pressure to use drugs
Decision-making skills
Building self-esteem
Also includes parent education and summer and after-school programs
Dissemination of D.A.R.E
Used in 80% of school districts in the United States and in 54 countries
In 2009, $5.5 million dollars spent on D. A. R. E.
Evidence for Effectiveness of D.A.R.E
Meta-analysis (Ennet et al. 1994)
Quantitative synthesis of different studies
Do we see a significant difference between students who got the intervention and those who did not across studies
Found no effect of D.A.R.E. on extent to which participants report using drugs (small effect on tobacco use)
Effects are smaller than those seen for other programs
Clayton et al. 1996; Lynam et al., 2006
2000 sixth-grade students in a city-school system
Compared youth getting DARE to TAU (health teachers doing drug education)
DARE was associated with initial improvements but these were not maintained over time
In fact, some evidence suggests that programs like D.A.R.E. may be iatrogenic
Werch & Owen (2002) found seventeen studies in which programs similar to D.A.R.E. (and, in one case D.A.R.E. itself) resulted in negative effects
Most common was increases in use of alcohol among students who got the program
Where is D.A.R.E. now?
Federal funding for D.A.R.E. was cut
Currently developing a new program within the original framework
Evaluating this new program and following students for 5 years after
receiving the program
Syringe-Exchange Programs
Sharing of needles contributes to the spread of HIV and hepatitis among IV drug users and their sexual partners
Exchanging new, sterile needles and syringes for used ones
Most programs also include other services:
HIV testing and counseling
Condom distribution
Referral to drug-abuse treatment
Developed around the same time as D.A.R.E.
In the 1980s, rapid increase in rates of HIV infection among intravenous drug users
Harm-reduction approach
No expectation that use will stop completely
Trying to limit the negative effects on the individual and society that are associated with using
Dissemination of Syringe-Exchange Programs
and their evidence
Evidence for effectiveness played a key role in the dissemination of syringe-exchange programs
Amsterdam, 1984
Large pharmacy stopped selling injection equipment, making it much more difficult to get clean needles
The local health department and a drug-users group set up a syringe exchange program
Found that subsequent to the introduction of this program, rates of HIV among iv drug users decreased
Disseminated to other cities in the Netherlands
United Kingdom, 1987
Conducted a study evaluating the efficacy of a pilot syringe-exchange program
After finding evidence for effectiveness, implemented a national system of syringe-exchange programs
Amsterdam; United Kingdom; Tacoma, WA; Portland, OR; New Haven, CT
All found that syringe-exchange programs were associated with reductions in rates of HIV infections
Note that none of these studies were randomized clinical trials
Case-control designs, pre- and post-comparisons
More evidence for syringe exchange
2001 literature review
42 studies examining syringe-exchange programs and HIV risk behavior and infection
28 showed positive effects of syringe exchange programs, two found negative associations, and 14 found no association or mixed effects
Pretty good!
Syringe-Exchange Programs:
Where are they now?
In 1988, US government forbid any federal dollars being spent on these programs until they were shown (a) not to be associated with increased rates of drug use;
(b) to be associated with decreased rates of HIV infection
1995 a research summary by the National Academy of Sciences showed that these programs met these requirements
US government continued not to provide federal funds through 2015
UPDATE: In January 2016, US government ended the ban on federal funding for needle exchange program
Harm-reduction in Canada
In Canada
“Harm reduction is one of the four pillars of Canada’s Drug Strategy “…. Health centered approach with the goal of reducing the health and social harms related to substance use …Harm reduction adopts a value neutral view of drug use, accepting the fact that some users
cannot or won’t stop using” (adopted from Canada’s Federal Drug Strategy)
Federal and provincial governments have provided funding for needle exchange programs and for evaluations of these programs
In January, 2017 Ontario government committed to fund supervised injection sites in Toronto, which now has 9 supervised injection sites
Montreal now has 4 supervised injection sites
