Side event: Improving Prevention: Prioritizing Effective Approaches and Secondary Prevention

Organized by the New Zealand Drug Foundation with the support of Canada, and the Centre on Drug Policy Evaluation, the Eurasian Harm Reduction Association (EHRA) and Youth Organisations for Drug Action

Eliza Kurcevic, Moderator, EHRA: Thank you for joining us once again, and in the beginning I would like to inform you that our side event is being recorded and also live streamed on Facebook. In case you will have any questions and questions are very welcome please use Questions and Answers section. At the end of the webinar, we will have some time to go through these questions and answers.

Before starting our event, I would like to give a few simple definitions, which will be very relevant to our side event. So let’s start with the primary prevention. So, primary prevention promotes the non use of drugs and is aimed basically at preventing or delaying the first use of drugs and the transition to more serious use of drugs among vocational users. And also we’ll use a term by definition of secondary prevention. So, secondary prevention programmes is referred also to as initiatives and measures aimed at minimising the adverse public health and social consequences.

So I’m happy to open the side event, and I would like to give a word to Irena Molna who’s graduated in ethnology and anthropology, interested in social aspects of substance use that led her professional career development to engagement in drug policy on a national scale. Irena is also a co founder of the NGO regeneration, it’s a youth led NGO from Serbia, where she’s elected there as an executive director, and she’s also data foundation council member and a steering committee member of the region harm reduction about drug education conducted in Bulgaria, Hungary, Lithuania, Poland and Serbia. Irena you’re very much welcome and please share with us the results of the assessment.

Irena Molnar, Foundation Council Member, Youth Organisations for Drug Action: Thank you, Eliza. Hi all and thank you everybody for joining us today. As Elisa explained, today I will present the results of the research we’ve done last June and July throughout the project Let’s talk about drugs and ways of communication methods with youth. Let’s talk about drugs project is a consortium led project made two years ago. It is co founded by Erasmus Plus programme of European Union, and within the project, our aim was to develop new ways of communication in regard to drug education with young people, that should be given by our youth workers in the first place. Since we are all definite about rapid changes on a drug market rapid changes so we wanted to hear their opinion about effectiveness and the way they have been taught when drugs are in question, and other psychoactive substances. So, the partners in the project are Smart Foundation, Yoda from Poland, Rights Reporter foundation from Hungary, Young wave from Lithuania and regeneration from Serbia and Baku Association from Hungary as well. Most of these organisations are youth led organisations working on the ground with young people who using drugs so we value their opinion in the assessment based on which we are going to create our future activities and manual drug education.

It is mostly methodology that is used in this project, It’s set it up to be completed as in several parts so to achieve the goal that we wanted we first created the best review. That means that organic assists and researchers, the strategies and action plans within their own countries, after which we did the qualitative assessment of things like education practices, and their perceived effectiveness. So we actually ask young people how they think this is effective, what they have been given and the quantitative assessment of technical experiences with drug education and its effectiveness to the analysis of their knowledge and opinions about drugs and drug use, so we went into survey questioning, but we also sit down and did focus groups with youth workers that are actually working with young people in different settings. So, we also did set it up the focus groups to be different depending on who we are talking to. So, we have the focus groups structure then to cater toward not actually working in a field of prevention climate action or education, but are working with young people to see how, how often they come across, drug topics in their work. So then we had the focus groups and semi structured interviews with the youth workers who are peer to peer educator specialists who are working in the field of prevention, harm reduction, drug education and then we had the focus groups and semi structured interviews done with the young people who were willing to share their opinions and knowledge about drug education in the country. We also did interviews with countries organisations, big people who were from the government bodies usually, and who are setting up the prevention programmes in their countries so that being said, we did that in order to have the complete picture of how necessary. So, difficulty in this research was data collection was done in the middle of the pandemic, so we needed more time than we originally thought we’ll need, and also it was difficult to implement the focus groups. So, the only difference among some countries is that some people lose some organisations who couldn’t do it in person, but some of them could do it only online so ethics and confidentiality we took also very important in this research, and we managed to have ethics committee approval in Hungary and Serbia. The use of the width of illicit substances is, as you see most of the people had experiences with drugs, sometimes in their life, and you can see that the most common method of Drug Administration young people reported with smoking, followed by snorting that also has to do with the type of drug that they use so smoking as cannabis is one of the most common method of administration, but what is common for all countries is that everybody reported that easy to find illegal substance in their country. So, 91% people in Poland, 81% In Bulgaria, 78 in Serbia and 72 in Hungary.

Settings where study participants received the drug education so we ask them questions about the educational classes on drugs that they had in school setting, or university setting, and we also ask them questions about the non-formal settings where they could receive the education related drugs so you can see that in Bulgaria 53%, in Lithuania 51% of respondents reported that they had never received any form of drug education in this time frame of the project. The idea that they did not receive any form of drug education, even through their formal school is something that is also quite important in proceeding how we are going to plan further activities. So, in regard to who provided the education, we can see that in most of the cases, it is actually in Poland and Hungary and these are police officers, which you will see later, young people do not really do not really like, and they cannot be trustful in that environment, which they believe it’s important when we are talking about trying to education. So most of the lectures given in the formal settings are provided as one formal lecture, which doesn’t really tackle the idea of being educated on drugs, in the effective manner. Later on, we ask them who who provided the most things, and as you can see, it is the biggest difference where, in most of the countries, youth workers, were the ones delivering the education programmes to young people, when out of school or university. So the most common places where respondents perceive that drug education are festivals and parties, youth organisations, harm reduction organisations. What were the information they’re giving to young people in formal settings are as you can see the most common is information about the effects of viscous substances and least one gave information about drug overdoses and overdose prevention information about available health and social support services, including harm reduction services. So, what was taken out of this question in comparison to the countries is for example 61% says that they did not learn a lot from these sessions, 51% people disagreed with the statement that the education was provided in a non judgmental way and judgmental way of education is something that is most commonly mentioned in the focus groups as well. And 47% stated that could not honestly share their experience when we’re talking about the experience, most of the young people in the focus group discuss things that they have in mind because they do not feel safe in their environment that the education is given to them. So, in most of the countries we could see the similar factors. So in other settings, Schools was evaluated more positively. They were being less judgmental though they received more new honest useful information than during the education delivered at schools and universities.

Eliza Kurcevic, Moderator, EHRA: Thank you so much your Irena for your representation and thank you so much for all the voices of young people, which were brought here to our side events. The second panellist is Ben Birks Ang is the deputy executive director of the New Zealand Drug Foundation. Ben and his team lead projects that bring different sectors together to improve wellbeing and reduce harm from alcohol and other drugs. He has extensive experience establishing and managing school based immunity and residential drug and alcohol progress. In addition, he’s the chair of the professional association that oversees the competence and ethics of the addiction workforce in New Zealand. Ben will present the tutorial programme in New Zealand to reduce drug and alcohol related harm in the secondary schools.

Ben Birks Ang, Deputy Executive Director, New Zealand Drug Foundation: Good evening everyone from New Zealand. So what I’ll cover today it to talk about a programme that aims to prepare all students for a world where alcohol and other drugs exist. The reason why all is in italics is that we know that every young person will make a decision about whether they use substances. Some of them are many of them will try it, some will use it and experience long term problems, and we want to make sure that all of those students get both the education, the support and the community that they need at school, to be able to live healthy and successful lives. What I’m going to focus on in this snapshot is what we learned about from this project around a systems approach to prevention. So we know, probably similar to many countries overseas, that where we’ve come from is not talking about alcohol and other drugs at all. We know from a lot of research that this is effective for people who are probably not going to try it anyway, but really ineffective at reaching young people whose life context and life experiences, tell them something different, And they’ll just disregard that information is being untrue or uncredible where a lot of what we’re finding in New Zealand where a lot of articles are over preparing students for the risks that a few will face, and also teaching about alcohol and other drugs primarily through behaviour management. We’re moving to helping students progressively build the knowledge, values and competencies that they need. And because we’re used to talking about alcohol and other drugs as a topic, we feel like this requires a learning progression for alcohol and other drugs as a topic across all schooling years. And what we know is that many of those competencies are wellbeing competencies that go across any health topic and that ultimately we’re trying to build core health knowledge, values and competencies particularly critical thinking so students are prepared to live in a modern world, and we don’t live our life segregated into different health topics.

What we are trying to do here, in this approach is help provide the time, particularly in ways that improve student engagement with school as a key predictor factor, their critical thinking and ultimately their well being, as a little bit of context in New Zealand, our schools have a huge amount of flexibility to adjust their learning and what they teach in the curriculum and the disciplinary processes to reflect their communities and student learning needs. So it’s very divested out into the communities and very adaptable to the communities. the review and planning at a local level, the resources that we created for that, and implementation resources helped to change the focus from being punitive and using sanctions to punish students through to pastural support where we support students and help them to learn the skills that they need to live healthy and successful lives. What we are aiming to do is create this ecosystem of learning and support that helps students learn and develop, and you’ll see there that inverted triangle are making those decisions those few students at the bottom, where we’re most of our partnership between health providers and schools fit is that health providers commonly partner with schools at the bottom of that triangle to work with a few students in providing support and this is trying to adjust that level so that it’s schools and health providers working in partnership at the top of the triangle where they can support all students to learn what they need, and make sure that it’s aligned. We were learning that and setting up the team or the leadership team within schools is really important because this innovation takes at least seven years to be able to make school wide changes in our secondary schools, and it feels really overwhelming for schools, so we’re trying to map out a process where they could have a team where they see the vision they may choose one or two meaningful actions a year that can keep them progressing towards their ultimate vision of a healthy school, and some is the elements that they could pick and choose from to align with the communities their priorities of their school or with of their community. What we found was really important is to connect all of this together because disconnected initiatives disrupt how other approaches work. And what I mean by that, for example, if we go back to that triangle again. We know that that if people believe that drugs are bad and people only need to know that extreme and terrifying harm and all of the extreme really well for the primary prevention that sits at the top and the treatment services down the bottom. But what some of that does is creates a blind spot with secondary and tertiary prevention in the middle, becomes less available and less effective and in fact that education around the extreme harms that students who are already starting to use tend to disregard can further stigmatise them from accessing support, making their problems larger before we can support them. One quote from the connect what they learn with their lives, and we found this really strongly that it didn’t really matter what was being taught in the classroom. If it wasn’t going to be role modelled throughout the rest of the school community. So if they were learning about how to seek support in the classroom, and about harm reduction and about the effects and stuff like that, if the rest of the school community was dealing with it through sanctions punishment or turning a blind eye to it, then it was less able for those students to connect those skills and put them into practice in real life because dropping in initiatives into the middle won’t work. We found that we know that people learned through progressive exposure to new ideas or skills. And that we’ve found with that we perpetuate the inequity in these health outcomes, if we’re using a learning approaches that only transfer knowledge, or don’t adjust to the learning needs and experiences of students. I’ll give you a little bit of context on New Zealand around this, we have in our health learning area of the New Zealand current booster of skills and knowledge to be able to make good decisions to communicate with others, and to know what’s important to them. Two thirds of year eight which sits around about 12 years of age, and two thirds of them are below the expected level of critical thinking. So if we only did a manualized programme that had experts going in and delivering in secondary school, they’re less able to translate and adjust that learning and that teaching to the learning needs of their students. And so it might be interesting for those students but if they don’t have the competencies to engage with that effectively, we’re just teaching to people who, who already would do what we want them to do anyway, and not reaching those who don’t. And this long term that burden of this will be carried by young people to health services in school pastoral care. One of the things to keep in mind is that this is the first generation who had mass exposure to alcohol and other drug use. Before learning about it is the hierarchy of learning, helping them to make sense of what they see and hear is now much higher priority than front loading that knowledge, helping, making sure that they have a skill set and a frame to be able to experience and learn from. We need to make sure that they can make sense of what they see in here, and they can go on Google and hear huge amounts of conflicting information anyway. A couple of examples in the last few minutes before I hand over to the next speaker, of what this looks like student driven change. We had students who were involved in creating a Wellbeing Framework for their school talking about what they need from school to live healthy and successful lives. The activities that the school can do to help them and what they want to finish school with this on one page was used by teachers to reflect and plan their teaching and assessment across all learning areas, and student leaders use it to prioritise their action. Now, there’s an 11 week education programme for the whole school community delivered by teachers at that school led by with a four day story Festival, where students at that school are able to present what they’ve learned and get credits in English for that one. Another example of integrated learning for this in other contexts across English, maths and health was where in English they pick the topic that they want to explore, they go to explore some of the health data and graph it all together and then they go back to English to present it as a speech, students were asking and craving more challenges to think critically, and the teachers found that they that were some of the most meaningful teaching experience that they had, because later on in the year when they went on the school camps and stuff like that, those students knew that it was okay to talk about wellbeing issues, and they will bring their whole selves to the conversation, and it was much easier for them to get support. And the last example is one school that focus on creating a student support pathway that students when they different health topics that could MPEG in ways to think critically about a situation, and this could be revisited when there were incidents, through a support plan that used all of those as learning opportunities, and the school also decided to innovate and create harm minimization conversations is a tag in a student management system, so that they could have data to keep track of where and, and the groups of students who would need that conversation. And all of this creates the ability in this ecosystem for innovation to happen into the community. We’re not going to be able to create a system that evolves over time to be what those young people need and to give that context that matches what they have experienced. We had some really good feedback in our evaluation as well that we’re really happy to share that highlight some of the systemic factors across a school, and those health providers that influence the pace of change that helped us to be able to map out what we needed to improve, where we could identify things in that system that would mean it with strengthen that. Thank you very much.

Eliza Kurcevic, Moderator, EHRA: Thanks and I would like to present Dr. Dan Werb who is an epidemiologist and Drug Policy Analyst also is the director of the Centre on Drug Policy Evaluation. Dr. Werb is an assistant professor in the division of infectious diseases and Global Public Health at the University of California San Diego and in the institute of health policy management and evaluation at the University of Toronto. Dr. Werb, will present data on drug policy violations work on primer, multi country mixed methods study that can be framed as evaluating secondary prevention efforts and highlights how harm reduction can achieve objectives related to preventing injecting drug abuse.

Dr Dan Werb, Centre on Drug Policy Evaluation: Hi, thank you so much for the kind introduction, and thanks to the other speakers for some really amazing remarks. So I’m going to be focused today on one specific aspect of prevention which is preventing injection drug use. The vast majority of people who use drugs do have many harms arising from their substance use and that extends to people who inject drugs as well. So I just want to start by just clarifying that when I’m speaking about preventing injection drug use. So, just to note that I have no conflicts to declare and as was mentioned all of this work is related to the primer study which is on prevention or pathways to injection drug use and how to prevent them. So I just want to start by noting that despite the fact that there is so much made of injection drug use, so much focus on the harms of injection drug use, there actually is a very small scientific evidence based approaches that are effective in preventing injection drug use. So that’s in preventing people from starting to inject drugs. There was just only eight scientific studies that had ever looked at interventions to prevent injection drug use, and among those eight studies, it was clear that the vast majority of these evaluations today have been ineffective. So there’s lots of work to be done here, especially given how much of a premium, governments and communities place on preventing injection drug use.

We do know some key things about how people start to inject drugs so from the scientific evidence from cohort studies that people who inject drugs from cohort studies involving youth. We know that the majority of people who inject report that they were assisted in their initiation by someone else, that other people who inject drugs were present when they initiated injection drug use, and that they were offered injection drug use prior to being initiated or were exposed to injection drug use practices prior to initiation, and in a subsequent systematic review that we took undertook recently, we found that the proportion of people who said that they were assisted in their initial injection drug use ranged from about 88% to 100% of sample of people who injected drugs so really this is a pervasive phenomenon whereby people who initiate injection drugs are generally assisted in that initiation by somebody else who injects. So what’s the implication there. The implication is that we know that there are a number of factors that increase the risk that somebody is going to initiate injection drug use and here I’ve listed some of them, but we all almost always include somebody being somehow familiar with drug injecting, and generally being assisted in their injection initiation. So what that means is that in isolation,  exposure to injection drug use, and being assisted is a key is a risk factor. There is a relationship between these factors, which are not on their own going to necessarily lead somebody to inject drugs, and the factor of being exposed to injection drug use and these in combination are what influence people’s pathways into injecting. So to give you a sense of sort of how this phenomenon operates in the real world, there’s data suggesting that, on average, people who assist others in injection initiation events so these are people who inject drugs, who assist others in their injection initiation events report, on average, assisting about 15, other people across their life. So that means that for every single person who assists others, there’s about 15 other people who may be exposed and maybe assisted in their injection initiation of it. So, and then of course one of those people could potentially. Well that means that if we want to prevent people from starting to inject drugs, then we should look at what makes people who inject drugs who assist those more likely to do so. So really what we’re looking at is drilling down to make prevention efforts as effective as possible because we know that classical drug prevention, these broad based social marketing programmes are simply not effective, and in some cases in the case of the US is multibillion dollar national youth anti-drug media campaign that these could actually be harmful. So, we need a different approach, we need to think about what it is that we’re actually looking to prevent and we need to drill down to those populations that might actually benefit. So understanding the role of people who inject drugs and assisting others, we sought to understand what makes them more likely to assist others into injection drug use. And what we found, in fact, is that classical approaches to preventing drug markets are for policing drug markets and preventing the initiation of injection drug use, which is aligned with this theory of deterrence that was popular in the 1990s and through the 2000s. We found that actually law enforcement interactions with people who inject drugs may increase drug use. So this can see that drug law enforcement is an effective way to prevent new people from starting drugs, appears to not actually be correct and in may, in fact, it may in fact be the inverse, where you see the people who have two to five times, and these are data from Vancouver, Canada, by the way, people who report interacting with law enforcement two to five times. We also found that people who report that they’re likely to assist others into initiating drug injection are vulnerable to infectious disease. So people who had a higher number of syringe risk behaviours so sharing syringes, distributing syringes, receiving syringes, were reported being more likely to assist others into initial initiating injection which again suggests that focusing on this population and meeting their needs, and understanding the risks and vulnerabilities that place them in a position in which they’re assisting others. Now, while there isn’t a lot of data on what can prevent people who inject drugs from or prevented people from initiating injection drug use, there’s one real world example that I think has been sort of lost in the literature and lost in the conversation, but it’s quite, I think, impactful. Here is the example of Switzerland. So in 1993, Switzerland scaled up a public health oriented drug policy. Essentially to address what they saw as an epidemic of public disorder, related to injection drug use so that involved scaling up supervised injection facilities, medication assisted treatment, needle and syringe programmes. And what they found and what happened was, while the proportion of people who were injecting drugs dropped dramatically. The proportion of new injectors, also dropped just as dramatically. And that has been sustained over now, about 25, almost 30 years. So, this shift in the orientation of the drug policy from a law enforcement oriented drug policy to a public health oriented drug policy action injection drug use initiation. So that is quite remarkable. So we wanted to understand why and what we did was we looked at specifically at medication assisted treatment or opioid agonist therapy, essentially methadone buprenorphine these kinds of therapies, and found that people who had a lifetime history of enrollment and opioid agonist therapy, were 40% or so less likely to assist others into injection drug use. When we looked at current enrollment in opioid agonist therapy, We found that almost 45% of people, or there was a 45% reduction in the risk that people who injected drugs assisted others. And when we modelled these we found that over a 10 year period, if you scaled coverage of opiate agonist therapy, up to 60%, then you could see a 25% relative reduction in the incidence of people here. I just want to know what are the implications here. Well, we understand that starting to inject drugs is a rational response, for some people to pressures from trauma poverty and pain. So the, the goal of zero incident cases of injection drug use initiation is not realistic or where the public health goal, but we should be tailoring interventions to the population of people who inject drugs who are morally ambivalent about, and at high risk appears that we can do that by tapping the potential role of opioid agonist therapy in reducing the risk that people who inject drugs will assist others into injection drug use. Thank you very much.

Eliza Kurcevic, Moderator, EHRA: Thank you so much then. And thank you also for all the presenters for sharing your work on the improving prevention efforts globally. And we are actually coming to the end of our assigned event but we still have one presenter, so I’m very happy that our event was supported, also by the Government of Canada and today we have representative who has been involved in the area of drug policy since 2017.

Canada: Thank you very much for all your interesting presentations. Thank you for that information on your prevention and drug injection approaches to target certain populations. Definitely also agree with this shift from a law enforcement towards a public health approach. And, as you know, for Canada harm reduction is one of our key pillars under our federal strategy which includes a focus on supervised consumption sites needle exchange, as well as opioid agonist therapies, so I’ll just leave it there but just I get to thank all the panellists for that discussion.

Q & A

How can you get students to share their experiences?

Ben Birks Ang, Deputy Executive Director, New Zealand Drug Foundation: I think there’s a few points around this that the environment that students experience at school and what they see around them is really important, as an addiction practitioner for several years within schools, if the school purely had a disciplinary approach where students knew that they would go straight for a punitive consequence, they ended up trying to gain the system, rather than being able to reflect honestly. And so that anything that could bring their authentic self, that change for the adults in the system can take quite a while. But what we found was that change for students can be really quick. So in that student led example that I spoke about. That was the second year that that school has student leadership, the first year, the students did a lot of work around that. The second year that was just what was expected of the school the next students who were coming through as student leaders they didn’t realise that that hadn’t been there before. And that’s how quickly that students can experience change. And the last point around that that I’d say is take into account the context and make sure that your ask is appropriate for them. So what we’re recommending for schools early on was that their ask of students is to think critically about what they see and hear, so they are not necessarily required to share their own personal experiences, but they can choose to. And it wasn’t until they got into a supportive approach, together with a counsellor or a support worker or somebody like that, that they will be asked to bring more of their whole self.

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