Side Event: Finding Common Ground: A Civil Society Conversation About Prevention

Organised by Vienna NGO Committee on Drugs

Matej Kosir, Institute Utrip (Slovenia): I am honoured that VNGOCD decided to put prevention as the first topic of this finding common ground event. We have been involved in prevention for more than 20 years; we also classify ourselves as experts in the field. Our role is to bring science to practice – we know that those two communities sometimes live in not just different sides of the river, but different planets – different galaxies. It works both ways.

I am not presenting my own opinion; I am presenting different scientific experts produced in this slide [EMCDDA, UNODC, UNESCO, WHO and others listed]. I am happy to be a messenger for evidence-based prevention.

Here in Vienna we are mostly focusing on illicit drugs. But prevention is must wider. In most evidence-based prevention programmes, we don’t even speak about drugs; it is much more than prevention – we cover all kinds of risk behaviours. In a modern world, there are more and more risk behaviours invented. So prevention science, our focus is not about particular a substance or risk behaviour, but multiple risk behaviour. We have a lot of useful tools produced in the last ten years by different institutions and it is our job to read those guidelines and recommendations, recognise the scientific evidence behind these, and start doing what is evidence-based in practice. Because we still very often do things which have no scientific evidence, or are even harmful for our target groups. And mostly we are dealing with children – with young kids – and it’s particularly important. We have to recognise what relevant institutions have produced and also standards which are a basis for our work in the field of prevention.

We want to invest more in evidence-based prevention. According to the OECD data (2018), we only spend 2.8% of health spending to prevention. In this particular low percentage, we spent a lot on less cost-effective interventions. The most important of prevention is outside primary healthcare systems – it’s before we find out that we have some diseases, etc. We have to spend more on schools, kindergartens, communities, social services, so much more funds should go to settings which are important to prevent health-related consequences. It’s important to deal with prevention in primary healthcare too, but much more important to act before.

[Slide: ‘the olive of prevention’, showing the vast proportion of what we do is not ‘what we know works’]. This is a global problem. We still spend a lot of money on those prevention interventions and activities which don’t have any scientific, or evidence, behind. So we have to switch to evidence-based prevention.

Also, we have a lot of cost-benefit studies, and we know if we invest $1, we can save $4 to $56 of money, which is important, especially when discussing these issues with policy- and decision-makers. It’s not just about the individual: we have macro-level environments; if we don’t have a basis in legislation and policy, it is less likely that we will be successful with interventions. We need legislation and policy in place which is evidence-based and also interventions on a micro-level – like schools, kindergartens. Only with this more comprehensive approach can we tackle attitudes and behaviour of different types of groups (especially kids and young people).

Different factors and characteristics are important in different phases: [slide: picture of ‘user pathways’]. We can imagine that going to school, explaining the consequences of different drugs, this doesn’t work well in schools. So we can skip this information for kids, because this isn’t relevant for kids. It’s more important that we use different approaches in different phases of risk behaviour, of user pathways. We need to know in which phases, which approaches we use. We can tackle different risk behaviours at the same time, because if we tackle risk and protective behaviours, we can be successful towards different risk behaviours. Reducing risk factors and promoting protective factors is one of the most important ways to understand prevention.

We also have different types of prevention: universal; in the community; selective prevention (for target groups); or indicated prevention. The level of risk also matters in the field of prevention. Of course, we also have to start thinking about removing all those harmful approaches from our agenda – it will not happen overnight. We want to improve knowledge and skills so people involved in harmful activities start doing effective and evidence-based intervention.

[Slide: ineffective approaches: scare tactics; approaches based on unstructured discussions; focusing only on enhancing self-esteem & emotional learning] We can use some of these interventions in more structured ways. Only focusing on these kinds of interventions is not OK. Also, moralising does not work. [Picture of Michael Phelps] Kids see this famous swimmer, he admitted he smoked cannabis – and he has how many gold medals? You tell kids that people who smoke cannabis are losers, and then they see this. [Other ineffective approaches: testimonies] It’s all about brain development. It’s easy to say why these approaches aren’t effective; we know the most important part of the brain is developed last-  the pre-frontal cortex between 18-25. Until this age, we are still kind-of teenagers. So it’s a biological reason why some of these interventions don’t work.  [Slide: Effective prevention programmes] We have to focus our activities on these effective components, and forget those [ineffective ones] which I presented before.

Fortunately, there is a growing interest to invest in evidence-based prevention. We have to help them to improve this situation. It’s also important to invest in training and education. As well as prevention workforce, and advocacy as well.

Maria Pirker: Everyone who speaks, please tell your story. [Opens the floor] Who will tell me about how prevention works in your country, in your organisation? 

Question: In Sri Lanka we do a lot of prevention programmes, earlier we used a lot of scare tactics and telling young people not to drink or not to smoke, not to take drugs, but after working with people we realised that most of these people they know – when you discuss with them about the effects of drugs – that sometimes they know more than us. Then we felt that we wanted to answer two questions: 1. why people start alcohol, drugs or tobacco use while knowing the harm; 2. even if they know the harm and the consequences […]. To answer these questions we realised that there are several aspects as to why people continue and start. […one of these] is rituals for these drugs. If we tell the target groups how industry groups work, it works. Now in our country tobacco use is going down. I think we can be able to win this race.

From the floor: I would like to commend the board for inviting this – this is a step forward for the Vienna Committee. So I hope this is not the last one, but the first one.

I’ve been working professionally in prevention for 50 years, but the best time is now: I have stopped working and am spending my time as a community activist. My privilege is one of the less privileged communities in Oslo. Concerned people are meeting and speaking together all the time – sometimes at school, social workers, religious leaders, meet and talk about what is the situation for young people in our community. We discuss individual kids (without saying who it is). We meet and try to identify risk behaviour, or groups that need extra support. This is both formal and informal and it makes a big difference because it makes a big difference – mobilising forces in the community. We challenge people to be together.

From the floor: I’m […] from Australia. I don’t think there’s any value in attending to these international standards because the explicitly exclude the harms experienced by those who use drugs. What I’m highlighting is the breadth of preventive concepts. This is just thinking about one kind of prevention: preventing uptake, and moving to more harmful patterns of use. We can think about some of the most effective preventive mechanisms – regulating availability. This reminds us that prevention is very broad. I’d also point to the fact that we often talk past each other because we have different ideas about what prevention looks like. The US government’s framework is a systems approach. For other people, prevention means use of policy instruments (law, behavioural economics…). For others, however, it’s a set of interventions – such as schools, social marketing etc. What I’m pointing to is the breadth of the concept; it has many different dimensions – they look very different and when it comes to turning that into practice, people bring so many different ways of thinking about it.

From the floor (Croatia): I think this is a good opportunity for all of us. I have a testimony. You said that testimonies are not a good tool for prevention. A good friend of mine is doing that for quite a number of years. [X] was an 18 year old coming back on his bike, had an accident, and ended up in a wheelchair. He got a lot of money through insurance, he bought a BMW and went out after drugs. His life went really bad. Then some special thing happened in his life: he started thinking about himself through Christianity, the New Testament. He became clean from drugs, started a really new life, and for a number of years now he’s been going round Croatia in high schools. Whenever he goes into school, he always sends the sentences that the students are writing about the influence of what he’s saying. I think his work is much much better than, for example, what I’m doing in social reintegration. The way these kids are describing how this impacted them, I think it’s great. Whoever said it doesn’t work I would like to show thousands of these sentences from young people saying how it’s influenced them.

From the floor (Nepal): We work directly with children and on children’s participation. We work with child clubs across the nation and are mobilising peer support for the young people, which has been effective. Some role model approaches work and some don’t. [These children] discuss their issues and it is important they are given a proper space in society. Sometimes when experts come in and fill up their minds it might not work, but when we work with peer educators…who come as winners, then that invites a lot of hope. We also train peer educators as social workers and they have contact with social workers and links. We also run child helplines – we have emergency support, short stay homes. We have worked with the government on policy to include views of children. We have also engaged children in small research in their communities.

From the floor (CSSDP): After listening to the presentation, I thought I agree with all of this. The question for me is, I’m not sure I entirely understand what prevention means. Prevention from drugs is easy. But when you talk about risk factors, now I’m curious. In this broader framework, I agree. Are we trying to prevent people from having unhealthy lifestyles? (In which case what is health – is it someone who’s happy, has prevention worked for them?) I’m just wondering, in this broader framework, what’s the goal of prevention – what are we aiming to in fact prevent.

Matej Kosir: I agree that sometimes instead of giving information, it’s better to focus on how unhealthy industries try to manipulate young people. Young people are rebellious. So it’s much better to convince them to be rebellious about industries. It’s becoming a very popular evidence-based approach in this group of teenagers. If I had more time, I’d speak about what kind of information might be helpful – information like, getting cancer after getting 30 years of smoking is not relevant to adolescent. But maybe having yellow fingers and yellow teeth? That might be. We should make sure information is relevant to kids and adolescents.

The community approach: it’s proven to be very effective. Investing in leisure time is also important. We know the Icelandic model, they invested a lot of money in leisure time (I think 500 euros for every family to spend on leisure time?) that’s why they’re more successful in sports. Investment is very important, but also besides that I would recommend that investing in education and training of sports coaches and music teachers. When kids live in dysfunctional families, sports coaches can be role models – so they can follow them. So it’s important to invest in coaches, to know how to deal with some challenges and problems of young people.

Prevention standards: in different phases of experimenting with drugs, using drugs, you have different phases of intervention. With young people who already use drugs, they are indicated interventions. You get them together and work with them as a group. People who use drugs are not excluded from prevention standards at all, but it depends which approaches to use for particular groups.

Regulation? It is important, but it doesn’t work all the time. In Slovenia, it’s forbidden to sell alcohol to people under 18. We did mystery shopper research and the compliance rate is less than 5%. So more than 90% of minors can get alcohol very easily. So regulation itself doesn’t work necessarily, always. There are other issues, more related to attitudes of people, social norms etc., these kinds of things more influence perception and also behaviour.

Testimonies: unfortunately society doesn’t agree at all. Satisfaction and endorsement in these discussions does not equal effectiveness. A lot of people are satisfied with lectures but it doesn’t mean these are effective ways of changing behaviour…It is more prevention and therapy for those who are lecturers. It is more beneficial for him than his target group. I’m really sorry, I would like to say – yes you’re right and we would have much less problems with different risk behaviours if this approach worked in practice. Unfortunately it doesn’t work in influencing behaviour of young people.

From the floor (India): On prevention – what we are trying to prevent – the discussion here is revolving around children. As a responsible community, our primary objective is to prevent children from making irresponsible choices. We’re trying our best to make clear to youngsters that there are responsible and irresponsible choices. I don’t know why we should have confusion about what prevention is. To give an example of what we do back home: we work with children to understand how safe their communities are (safe, meaning substance abuse free). We take schoolkids around 100 yards of their school and make them do the audit of their community – to see what is being sold where. That is where we start with a gateway substance introduction; children go and audit around their schools. When this starts happening, the community starts taking responsibility. I’d like to know if this is happening elsewhere.

From the floor (Free Mind Mobilisation, Brazil): We have a clear mission: to help people help other peoples. When we started in Brazil, talking about prevention was something new. [Spoke of changing federal law, providing information]

From the floor: It’s a brilliant question – what is prevention, and what is health. Prevention is to create conditions for people so that they can live up to their full potential. That is the basics. The full potential includes full health. What is health? It’s physical health (very measurable) but also psychological, social and also spiritual health. As soon as we start using other substances to reach these states, we should be able to do it [reach social, spiritual etc. health] without these.

From the floor (VNGOC)When we talk about prevention, we think about the scare tactics – that’s what it was when I was a kid. There’s a real – it’s almost a PR thing. Linked to that, a lot of the things listed as ineffective on your slides, we are still seeing a lot of that here at CND – from different places, different sources (government, NGOs). A lot of these things you had up there, could have been photos taken this week. What do people think about this? We’re talking about something more evidence-based and nuanced than this, but this is still a lot of what people see.

From the floor (SSDP): I had a testimony based drug education. Everyone agrees that youth are the centrepoint of this discussion. The best way to reduce the harms of drugs is to not do drugs at all. But this isn’t realistic. … By the time people reach their teenage years, they see through these messages, so need a different type of approach. There are multiple approaches that have been implemented: DPA in the US has safety first education; SSDP has the ‘just say no’ programme – both are focused on honest approaches. It’s a form of prevention; it still maintains that the safest way to keep safe is not to use drugs at all. But this also works for those who are going to take drugs regardless. When I had the [scare tactic] education, it was effective – but for making people sad. … The testimony of these other education-based preventions – they might work for those who weren’t going to take drugs anyway. But if honest approaches are going to work for those who are going to use drugs anyway, why don’t we use these approaches.

From the floor (SSDP): Following up on the credibility of drug education: sometimes, some prevent messages may lose their credibility, when they lead with the most severe side effects – then people use them, and people see it’s not true – and that discredits the body that spoke to them. It’s important to have a credible source who can tell you what the situation is. The Just Say No message can make the source seem not-credible. The safest way to lower risk of harm from drugs is to not use them, but because we don’t promote that ‘say no’ objective, and people that we’re talking to do choose to incorporate harm reduction measures – because the reality is that lots of people are going to, at least, experiment.

From the floor (Belgium): In my career I could see we didn’t invest enough in prevention. It was decided in 2016 that Rotary International would invest in prevention. We aim at evidence-based programmes that you can have from your own NGOs or that we help to develop. In every project we involve a university for evaluation and follow-up. We are working with Oxford and Cambridge for new data analysis and evaluation research. … we have discussed more community involvement. But again, we offer only support to NGOs – NGOs that work professionally, you can ask for support – we will contact our local clubs to help you. We bring in logistic, networks and finances.

From the floor (Australia): We run large programmes building protective factors, on the evidence you’ve described. We live in the real world, and many people use drugs to add value to their lives. So we also advocate for supervised injecting facilities, needle programmes … [We need to manage the tensions between not using drug messages and harm reduction messages.] We recognise that prevention has a role to play, but it can’t play a role on its own – we need to prevent among those that’s possible, and make it so that if individuals do choose to use drugs they do it in the safest possible way, and to do so without stigmatising those who use drugs.

From the floor: All of us are here – we’re happy this conversation is about prevention – we’re not prevention only people. We’re never going to solve anything this way. Just because we’re promoting prevention doesn’t mean that we want to do away with harm reduction – we’re just asking for equal space and funding. There’s not this one message that is gonna solve all our problems, we have to have a message for people who are currently using – but also a message to prevent that initial use. What the member here said – I loved the question [on what is health]. We’re not just talking about drugs, we’re educating ourselves on mental health, ACEs, and what we can see in 3 year olds, 12 year olds, and stopping high risk behaviours before they start. … It’s super exciting to see that we might be helping the 4th grader who’s extremely anxious but doesn’t know how to verbalise this [and then ends up using substances later on].

From the floor: In Macau, I started programmes – we didn’t have many resources. … We saw the scare tactics and started to use these. The guy dying, all that stuff. But then, later on, we started to continue searching and read later on that the UN does not endorse these kinds of prevention tactics. Then we saw some harm reduction tactics and saw that these make sense – because, despite all our efforts, some people will take drugs and we don’t want these people to pass away. We get confused, because there’s so much information that we don’t know which one is right – which one is better for our community. Even here today we’re discussing disagreements. [Spoke asking why the UN building has posters which the UN would not endorse as effective prevention tactics] It’s good to have a consensus that: yes, we want to prevent the youth start using drugs, but unfortunately some will do it – and these need to at least be educated to not die.

From the floor (CADCA): I’ve done a lot of work in Mexico, Central America, cocaine producing countries. One of the things that I found fascinating on the way was that, really, when it comes to drug prevention – it’s really looking at the consequences of substances in the community. A lot of these communities are plagued with not only drug, but gang violence. The communities can tell you the problems, but are desperate for solutions. Substances give us something identifiable that you can recognise within a community [to fight against]. It’s amazing what communities can do once they start to recognise the consequences. … A lot of [these communities] don’t have the expectation to live into their 20s, they can sell drugs, extortion, and a lot of these become instead of positive opportunities. Some of the best solutions are not only looking at the substances and the use around it, but the consequences. Knowing what’s linked and how it manifests itself in the community context.

Matej Kosir: Defining prevention? The easiest way: of course, it’s not about drugs. The best way to explain it is that prevention is equal socialisation. Whatever we have in our minds about what socialisation could be, is actually prevention. And, far away from speaking only about drugs or alcohol or other risk behaviours, we socialise – we live in the world and we socialise with each other. We socialise with kids, teachers in the community, etc. so everything around us is socialisation. The best way to do it is that we are all satisfied with these attitudes, behaviour. I agree, to some extent, that people have a right to use whatever they want so long as they don’t harm others – that should be the limit. If we harm other people in the society then it’s not really our right or freedom to do it. If we harm health insurance then that as well is a harm to others because we all pay taxes. So it’s not as simple as to say we have a right to use X; we have to realise that if we are doing some harm to others, then it’s questionable.

Reputation and perception: sometimes this is a very big barrier to get funding and approach decision makers and get funding for prevention. It’s our responsibility to explain and increase the reputation of prevention. We need to prove the effectiveness of what we do, evaluate what we do, which is based on evidence – based on what we know from science. Invest more money in evidence-based prevention – that’s how we increase the reputation and change perception. I love discussions with people from harm reduction fields about what approaches should be used in prevention. Half of the discussions, we agree: you have strong support from science on just say no approaches. But, the other half of the discussions, we completely disagree. Because, giving information to youngsters about the consequences of using drugs: at universal level, is not effective and could be harmful to some extent. Not every child has resilient skills etc. For some part of children in the classroom, they don’t have any problems to receive this information – they’re strong personalities, good relationship with parents, good school performers – normal kids with strong resilience. For these, this information could be beneficial, it could even empower them in their own decisions, so they are even more sure that they’re on the right track. But you have a smaller group of kids, who live in a not-too-well situation, socially deprived communities, with dysfunctional families, they’re at risks, and they’re trying to find a way (and usually risk behaviour is the most popular way). If you give them some information about drugs, they can see this information as exciting. There are sensation-seekers in this period of adolescence – we know it’s dangerous for them to start using drugs. … So, providing information to kids depends on the age (12-14: explain how drugs work and how dangerous they are – not a good idea. We know from studies that as far as we keep kids from substances, the less likely they will develop risk behaviours in the future). The best, family-based, programmes, empower parents to set the rules on substance misuse, as long as they keep the rules alive in their family settings. Those kinds of studies show that kids from families with strict rules, there is less likelihood that they will develop risk behaviours (or they’ll be less extensive). We have to be careful with this information: at what age, what risk level they are, and what interventions we use. Providing information on ecstasy for people who are going to use, this information is valuable – but not kids 12-14 explaining how drugs work. Not even how alcohol works.

Icelandic model: we have to be careful, because it’s not really a good idea to copy and paste different interventions from one culture to another. It might work well in Iceland, it took them 30 years to get to this point, and some other countries now want to copy-paste this. It’s culturally sensitive. You might face a lot of culturally related issues and resistance from the communities and governments.

From the floor: We don’t have a consensus that drugs are harmful. Probably some of us don’t think that all drugs are harmful. It would be interesting to find a point, or speak about, at what point drug use becomes problematic. How can we define this? … Coming from the position of thinking that drugs are harmful, I want to be clear that, at at no time, do I want to stigmatise or put pressure on any individual who is using drugs. Because I personally think that this is not good, these are individuals that need help because of different risk factors.

From the floor: Scare tactics: … What about fentanyl? Two people died, what shall I say about fentanyl? Or ordering white powder from Latvia over the internet in an envelope? At a certain point you come into the grey zone: the difference between scaring people and normative messaging. Here, we appear very Western. Please don’t be too Western. It’s a warning to all of us, people are different in different parts of the world and we have to be culturally sensitive. Drug policy is about balancing individual rights to communal rights – our western societies have problems with this.

From the floor: I wanted to talk on stigmatisation vs. normalisation. I think that, when we look at stigma objective, not stigmatising a person – but stigmatising certain behaviour helps prevent certain harmful behaviour. Harm reduction can also normalise certain behaviour, and this is also problematic. Of course we need to make sure to prevent certain harm when using drugs, but assuming that everyone is using drugs … that is also harmful and we need to be careful. Already harm reduction in this context is telling us that we accept that drugs are harmful. The Icelandic model? Of course, we are not supposed to copy-paste the model, but we can follow the principles: evidence-based, community-based – these principles can be multiplied in other countries, but how they are used – this is culturally sensitive.

From the floor (Australia): It’s really nice to see the way that different areas (harm reduction, prevention) work together. I’d like to share a reflection on prevention in Australia. We used to do all the things in the ‘doesn’t work’ column. We still do some of this in some places. But one really important thing was the Australian government funding a long-term activity of drug education in schools programme, and funded researchers to develop this programme with schools in Australia. Before this, we were doing piecemeal work – this is much more systematic, integrated into the curriculum, age-appropriate, teacher-led, links in with mental health. The reason I wanted to highlight this is because: it’s available online, I wanted to highlight a helpful resource to other people, I’m happy to provide links [caveats given re: cultural sensitivity].

From the floor: I come back to what we know works. We know that scare tactics don’t work; we want people to make informed choices. But if you look at primary prevention programmes, it is about strengthening protective factors – which you can do without mentioning drugs at all. The Icelandic model calls itself a youth programme. If we use these strength-based approach, we can avoid a stigmatising approach. We want to create the safe, protective factor among young people, we want to make sure that those who do choose to use drugs with harms potentially reduced, and we have to do this all together. We can practice prevention without stigmatising – and normalising.

From the floor: The origins – going upstream to the source of the drug problem – there’s money to be made. There’s legal/illegal industries behind this. Looking at the industry around marijuana, some of the things that are happening there to increase availability, and also change norms and attitudes around use. We end up seeing that use will increase, that’s the intended goal to increase sales. They’re not going school to school, but they’re creating a market and changing the conditions on the ground to favour that specific market [draws comparison with alcohol industry].

VNGOC: I’d like to give an open invitation – if you’d like to share resources, we can include these.

From the floor: I’d like to emphasise the point about cultural relevance. Although I’m American, I just graduated from a school in Abu Dhabi. There were always questions about how we tailored these activities for a diverse audience. Although this challenge remains, there’s still a case to be made for honest education. Maybe explicit information about what drugs will do doesn’t work for 10 year olds, but as people get older, this information is important, because one of the biggest advantages is that people will still take seriously the other messages you have – unlike with scare tactics. … There is also a distinction between ‘use’ and ‘abuse’ of drugs. This relates to the question of whether it’s possible to normalise non-problematic use. Being honest in this distinction is important in any educational programme.

Matej Kosir, Institute Utrip (Slovenia): I’m glad that we started these events, and we started with prevention. This shouldn’t be a controversial topic. There is good science behind what I was talking about. But, I think that prevention is much more than agreeing on whether drugs are dangerous or safe or whatever. I hope that you noticed and realised that prevention has much wider direction/process – it’s much more than just talking about drugs, or even risk and protective factors. It’s a very wide area of work. I want to emphasise also a challenge: informed choices. We are challenging these issues in prevention quite often. An informed choices approach could be extremely challenging: there is prevalence of smoking in nurses and doctors. They are informed about all the dangers of smoking etc., but still they struggle with this. But putting children and adults in the same position, to act or behave on the basis of informed choices in the process of brain development, it’s even more challenging and difficult to go with such approaches to young people. We have to take this into consideration: informed choices is a very challenging in a world of commercialisation, consumerisation etc. – we’re all attacked by different marketing strategies. How free are we to choose? We have to ask ourselves as adults. It’s much more difficult to go with the same approach to kids.

A final thought: I hope that your perception of prevention improved today, and that you will be good advocates in your own countries to evidence-based policies.

Maria: Feedback as to VNGOC having these kinds of events?

From the floor: In general, very good discussion. I’m very thankful. It’s exciting to think about other topics.

From the floor: I appreciate all the contributions, and I did learn some new things – and started thinking. In these two hours – time just [flew by]. It was good, thank you.

From the floor: I’d just like to say that I’ve been coming to CND for some time, and the entire week I’ve seen the topic of prevention covered more than ever before, and I really enjoyed that we had this open deliberation on prevention. It’s such a beautiful way to end the week. … Clearly there’s a lot of work ahead in terms of everybody sharing those perspectives and gaining new knowledge, but I thoroughly enjoyed the dialogue.

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