CHAPTER 6. PREVENTION

CHAPTER 6. PREVENTION 6.1 Effective preventin f substance use disrders Tim Stckwell Intrductin The use f substances that mdify hw we feel, perfrm r behave is evident in all cntemprary scieties and has been thrughut recrded histry. In mdern times, cncerns abut adverse effects have increased with the greater efficiency f prductin, distributin and marketing f an increasing variety f substances. Nineteenth-century tnic wines cntaining ingredients frm the cca plant were supplanted by injectable ccaine in the 20th century and then mre recently by crack ccaine. Alchl can be manufactured frm almst any seed, plant r crp. In nn-industrial and pre-industrial scieties its use was ften restricted t harvest celebratins (Jernigan, 1997). Tday mst cuntries permit the distributin and intense marketing f thusands f different brands f alchl f widely differing cncentratins at prices t suit every budget and tastes t suit every palate. The case fr gvernments t be invlved in preventing the use f harmful substances and minimizing harms frm cntinued use is a strng ne. Chapter 1 f this reprt makes this case in terms f the extent and severity f the harms invlved. In Chapter 6 we see that many WHO Member States have designated, and ften gvernment-funded, preventin prgrammes. It is als clear that there is much variatin in respnse, in terms f the types f drugs fcused n, the types f activity (e.g. brief interventins, harm reductin, educatin), the main target grups and the settings fr prgramme activity (e.g. schl, wrkplace, cmmunity). Inevitably, the level f investment in preventin is greatest in higher-incme cuntries. Lcal and internatinal agencies can seek t maximize the effectiveness f the verall preventin respnse by drawing n the grwing bdy f evidence regarding the nature f the prblem, what has wrked in ther places, and hw a cmprehensive respnse can be maintained (Babr et al., 2010a, 2010b). The verall effectiveness f a natinal preventin strategy can be increased by thughtfully addressing the fllwing questins. What are the mst prevalent and serius harms caused by substance use and fr which substances? When budgets are tight, it is imprtant t direct gvernment investment t strategies that address the greatest harm. Alchl, tbacc and illicitly-surced drugs cllectively cntribute t almst 100 preventable causes f death, injury and illness (Buxtn, Tu & Stckwell, 2009). The number f preventable deaths acrss the entire ppulatin leads t the cnclusin that, in mst cuntries, tbacc is the first pririty, fllwed at a little distance by alchl, and with the illicit substances sme way behind. If ne were t fcus n yunger peple (i.e. thse under 35 years f age) then clearly alchl demands the mst attentin (Tumburu et al., 2007). Using the metric f DALYs which take accunt f death, disability, illness and lngevity then alchl and tbacc becme equal partners in causing between them abut 9 f harm frm substance use (Rehm & Rm, 2005). If ne includes harms caused t ther peple, and scial and legal harms, then alchl 105

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders and sme illegal drugs cme mre int the picture thugh sme f thse harms can be caused, perversely, by their legal status (Lentn, 2005). The pattern f substance use and related harm will vary frm cuntry t cuntry, as will cultural values arund hw the seriusness f these is evaluated. Sme effective preventin prgrammes address nly ne type f harm (e.g. fetal alchl spectrum disrder, rad trauma, r the transmissin f infectius diseases). A cmprehensive natinal strategy needs t address and priritize the full range f harmful utcmes when making high-level decisins abut plicy pririties and investment. Furthermre, the principle f the preventin paradx (Rse, 1985) suggests that strategies shuld address nt nly the substance use f such high-risk grups as pregnant wmen, sex trade wrkers and prisners but als that f many individuals in the general ppulatin whse substance use is usually f lwer risk (Stckwell et al., 2004). Hwever, it is als imprtant t respnd t prblems experienced by smaller ppulatins f ften marginalized and disadvantaged peple experiencing severe health and safety prblems, partly as a result f their substance use. 106 Shuld preventin fcus mainly n brad spectrum and distal r mre specific and prximal causes f harmful substance use? The prevailing scial and ecnmic cnditins faced by peple in different cntexts shape the nature and extent f substance use. Fr instance, patterns f alchl use are related t incme (Huckle, Yu & Casswell, 2010), and the extent f illicit drug use has been linked t levels f unemplyment (Silverman & Rbles, 1999). The physical and psychlgical well-being f children in their very early years predicts the likelihd f their experiencing a range f behaviural, mental health and substance use disrders in later life (Tumburu, 2005). Such scial, ecnmic and childhd develpment issues can be cnsidered as distal antecedents f substance use and related harms (Lxley et al., 2004; Tumburu et al., 2007). Cnversely, preventative interventins may aim t mdify the immediate r prximal antecedents f harm caused by substance use (e.g. the sharing f needles in the spread f bldbrne viruses, impaired driving caused by alchl and/r ther substances, vilence triggered r exacerbated by drunkenness). In general, the effectiveness f effrts t mdify the immediate antecedents f mstly acute prblems caused by substance use are easier bth t determine and implement than effrts t remedy fundamental scial and ecnmic cnditins. While gvernments have a mral imperative t address these latter brad-spectrum issues, it is als vital that preventin strategies are supprted which tackle the immediate envirnmental and situatinal antecedents f risky substance use and related harms. Sme areas f preventin activity particularly thse cncerned with the regulatry envirnment can have an impact n bth distal and prximal risk factrs fr harmful substance use. There is gd evidence that the verall degree f availability f alchl r illicit drugs in a yung persn s neighburhd is a risk factr fr later prblems (e.g. Grube & Nygaard, 2005). Cntrls n the ecnmic and physical availability f alchl have als been shwn t be amng the mst effective ways f achieving immediate and lnglasting reductins in alchl-related harm (Tumburu et al., 2007; Babr et al., 2010a). In ther wrds, what is healthy fr the adult envirnment will be beneficial fr yung peple t. Attentin t the regulatry envirnment and the immediate antecedents f harmful substance use shuld nt be neglected while pursuing the lfty ideals f better living cnditins and strnger families.

Preventin Which strategies have the strngest evidence fr effectiveness? Reviewing the published scientific evidence fr the effectiveness f a range f preventive interventins is in itself becming a science. The material available fr review is s extensive that entire mngraphs (e.g. Lxley et al., 2004) and bks have been dedicated t summarizing evidence in relatin t alchl plicy (Babr et al., 2010a), illicit drug plicy (Babr et al., 2010b) r bth (Stckwell et al., 2005). As a general guide, the greatest weight can be given t evidence derived frm multiple publicatins f well designed studies which include sme kind f cntrl r cmparisn ppulatin and which are identified thrugh a series f systematic search strategies. Cmparable results acrss multiple studies can be assessed by meta-analysis whereby a frmal statistical apprach can be used t estimate and cmpare effect sizes. Beynd that, cst benefit analysis can be used t cmpare likely returns frm investment in different strategies. In the preventin f alchl-related harms the mst effective strategies include: managing the real price f alchlic beverages (e.g. s that it reflects ethanl cntent, is adjusted with the cst f living and des nt fall t lw), maintaining and enfrcing legal drinking ages, restricting the number f licensed premises (e.g. by way f gvernment alchl mnplies), randm breath-testing and lw legal bld alchl cncentratin limits fr drivers, plus brief interventins fr early-stage prblem drinkers. Strategies invlving nly educatin and persuasin have the weakest evidence fr effectiveness, thugh there is sme dispute as t whether schl-based interventins are cmpletely ineffective in relatin t alchl and tbacc (Tumburu et al., 2007; Babr et al., 2010a). Sme preventin experts have als suggested that cmmunity mbilizatin that is partly achieved thrugh awareness strategies can be useful in creating the cnditins under which mre effective envirnmental preventin strategies can be intrduced (Hlder, Saltz & Grube, 1997). Needle exchange schemes and the prvisin f methadne bth have relatively strng evidence f effectiveness and, nce mre, there is scant evidence f the effectiveness f educatin and persuasin strategies in preventing illicit drug use (Babr et al., 2010b). There is sme prmising evidence in relatin t the effectiveness f sme early and later childhd interventins (e.g. hme visits t supprt high risk mthers befre and after birth, preparing preschl children t functin in a classrm, strategies t create gd behaviur in the classrm) (Tumburu, 2005). While sme effective strategies can be delivered under the authrity f gvernment health departments (e.g. prvisin f clean needles, brief interventins), there are many thers which fall under the respnsibility f ther gvernment departments such as finance (pricing and taxatin), and plice and public safety (liqur and drink-driving law enfrcement). One f the challenges f a cmprehensive strategy is t engage multiple gvernment departments and authrities in the delivery f evidence-based preventin strategies. Are effective preventin strategies necessarily unppular? Perhaps because alchl is by far the mst widely used psychactive substance in mst mdern scieties and mst strategies supprted by evidence wuld require alchl t becme bth mre expensive and less cnvenient t btain, it appears that the mst ppular strategies (i.e. educatin and persuasin) are usually thse that are the least effective (Babr et al., 2010a). 107

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders A mre ptimistic perspective is that (i) there is already public supprt in many cuntries fr a range f effective strategies (e.g. reduced bar trading hurs, plicing f late-night licensed premises, enfrcement f liqur laws, harm reductin services fr illicit drug users), (ii) the level f apparent ppular supprt will depend n hw plicies are described t make them ptentially marketable, and (iii) after cntrversial public plicies have been intrduced there have been examples f public pinin imprving. We are als beginning t knw a great deal abut the effectiveness f islated interventins but less abut hw they perate as part f a cmprehensive strategy. Educatin and persuasin have been part f effective campaigns targeting the preventin f smking, drinking and driving, and bldbrne viruses (e.g. public awareness campaigns, warning labels, schl-based educatin). In islatin they are ineffective in achieving ppulatin-wide behaviur change but they may be crucial ingredients in a natinal strategy. If gvernments wish t shw leadership nt nly by listening t public pinin but als by leading it s as t implement effective preventin strategies, they will need t use scial marketing techniques. Educatin and persuasin strategies are essential als fr cmmunicating the extent f harm assciated with harmful substance use and the evidence fr what cnstitutes effective preventin. An infrmed cmmunity will be mre likely t expect cmprehensive and effective respnses t the prblems f substance use frm its elected leaders. 108

Preventin 6.2 Administratin and budget (Figures 6.1 6.4) Backgrund Nminated fcal pints were asked whether there was a special gvernment unit r gvernment fficial in their cuntries with respnsibility fr the preventin f substance use disrders. Fcal pints were asked abut the presence in the annual budget f the gvernment f a specific budget line reserved fr the preventin f substance use disrders. Salient findings Gvernment unit fr substance use disrder preventin services In 72.4% f cuntries in the survey, ne r mre gvernment units respnsible fr the preventin f substance use disrders were reprted. Acrss the regins, the highest prprtins f cuntries with gvernment units fr the preventin f substance use disrders were reprted frm the Western Pacific (86.7%), (85.7%), (80.) and Suth-East Asia (80.) regins. Over half f cuntries in the n Regin (53.5%) reprted having gvernment units respnsible fr the preventin f substance use disrders. Besides thse in the Western Pacific, the majrity f cuntries in, the,, Eurpe and Suth-East Asia reprted having gvernment units respnsible fr bth alchl and drug preventin tgether. Over half f the cuntries in the Western Pacific (53.3%) reprted having a gvernment unit nly fr drug preventin. Gvernment units respnsible nly fr the preventin f alchl use disrders seem t exist in a few n cuntries. There is an effect f increased cuntry incme n the presence f gvernment units respnsible fr preventin f substance use disrders. Hwever, there is n marked difference between the prprtin f gvernment units which are present in higher middle-incme (82.8%) and high-incme (78.8%) cuntries. Budget fr preventin services Half f the cuntries in the survey (50.) reprted having in the annual budget a budget line fr the preventin f substance use disrders. The highest prprtin f cuntries reprting budget lines fr the preventin f substance use disrders was in the Western Pacific Regin (93.3%). The lwest prprtin f cuntries reprting budget lines was in the n Regin (30.2%). Budget lines reserved nly fr the preventin f drug use disrders appear t be cmmn amng cuntries in the Western Pacific Regin, where 47.7% f cuntries reprted having such a budget line. Budget lines fr the preventin f drug use disrders nly seem t be cmmn in the (30.) and Suth- East Asia (21.4%) regins. Budget lines reserved nly fr the preventin f alchl use disrders were reprted frm nly a few cuntries in Eurpe (2.3%). 109

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders There is an effect f cuntry incme level n the presence f budget lines fr the preventin f substance use disrders. In 33.3% f lw-incme cuntries and 69.7% f high-incme cuntries, budget lines fr the preventin f substance use disrders were reprted. The prprtin f cuntries reprting integrated budget lines (i.e. a budget line which is reserved fr mental health, alchl and drug preventin tgether) decreases with increasing cuntry incme. Ntes and cmments The presence f a budget line fr the preventin f substance use disrders des nt imply anything abut the amunt f mney spent n preventin activities. A questin n the amunt f the budget line fr preventin f substance use disrders was nt pursued. The presence f a budget line des, hwever, prvide an interesting insight int the structure f a cuntry s system f preventin, and whether r nt the cuntry has the capacity t budget its resurces ratinally. 110

Preventin Fr alchl and drug use disrders separately Fr drug use disrders nly Fr alchl use disrders nly Fr alchl and drug use disrders tgether 86.7% 85.7% 80. 80. 76.6% 72.4% 53.5% 82.8% 78.8% FIGURE 6.1 WITH A GOVERNMENT UNIT RESPONSIBLE FOR PREVENTION OF SUBSTANCE USE DISORDERS, BY REGION, 2008 59.5% 73.2% Wrld Suth-East Asia Eurpe n=145 FIGURE 6.2 WITH A GOVERNMENT UNIT RESPONSIBLE FOR PREVENTION OF SUBSTANCE USE DISORDERS, BY INCOME GROUP, 2008 n=145 High Higher-middle Lwer-middle Lw Fr alchl and drug use disrders separately Fr drug use disrders nly Fr alchl use disrders nly Fr alchl and drug use disrders tgether Fr mental health, alchl and drug use disrders tgether 93.3% 70. 57.9% 48.8% 50. 42.9% 69.7% n=144 30.2% Wrld Suth-East Asia Eurpe FIGURE 6.3 WITH A BUDGET LINE IN THE ANNUAL BUDGET FOR PREVENTION OF SUBSTANCE USE DISORDERS, BY REGION, 2008 n=144 57.1% 46.3% 33.3% High Higher-middle Lwer-middle Lw FIGURE 6.4 WITH A BUDGET LINE IN THE ANNUAL BUDGET FOR PREVENTION OF SUBSTANCE USE DISORDERS, BY INCOME GROUP, 2008 111

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders 6.3 Availability and cverage f preventin services (Figures 6.5 6.10) Backgrund Nminated fcal pints were asked whether any preventin activities fr substance use disrders were available in their cuntries, and they were required t indicate the main fcus f these preventin activities. Mre specifically, fcal pints were asked whether prgrammes fr the preventin f substance use disrders such as schl-based prgrammes, cmmunity-based prgrammes r wrkplace prgrammes were available in their cuntries. Fr each f these prgrammes, fcal pints were requested t indicate the estimated level f cverage f the ppulatin. Salient findings Presence and fcus f substance use disrder preventin activities Apprximately 95% f cuntries in the survey reprted having sme kind f preventin activities fr substance use disrders. Cuntries reprting nt having any preventin activities fr substance use disrders are in the lw-incme and lwer middle-incme grups. In apprximately 5 f cuntries in the survey, preventin activities were reprted t fcus equally n alchl and drug preventin. Arund 13% f cuntries reprted fcusing t a larger extent n alchl preventin, 28% reprted fcusing t a larger extent n drug preventin, and 4% reprted having nly drug preventin activities. N cuntry in the survey reprted having nly alchl preventin activities. The highest prprtins f cuntries reprting preventin prgrammes fcusing t a larger extent n drug preventin were in the (46.2%), Suth- East Asia (66.7%) and Western Pacific (35.7%) regins. There is n effect f cuntry incme level n the presence and fcus f preventin activities acrss different incme grups f cunties. Preventin prgrammes fr substance use disrders and cverage Schl-based prgrammes, cmmunity-based prgrammes and wrkplace prgrammes fr the preventin f substance use disrders were reprted by 77.9%, 68.5% and 58.6% f cuntries respectively. Schl-based prgrammes, cmmunity-based prgrammes and wrkplace prgrammes fr the preventin f substance use disrders were reprted by all regins. The lwest prprtin f cuntries reprting schl-based prgrammes, cmmunity-based prgrammes and wrkplace prgrammes were in. 112

Preventin Cverage f the ppulatin in need with schl-based prgrammes, cmmunitybased prgrammes and wrkplace prgrammes fr the preventin f substance use disrders appear t be lw. Fr example, ver 5 f cuntries indicated that the cverage f schl-based prgrammes fr the preventin f substance use disrders wuld be prvided fr less than half f the ppulatin in need. Similarly, in nly 1 f surveyed cuntries wrldwide, cmmunity-based prgrammes cver as much as 75 10 f the ppulatin. Cverage f wrkplace prgrammes seems t be lwest, with ver 6 f cuntries reprting less than 25% f the ppulatin cvered. Ntes and cmments An interesting finding is that the fcus f the preventin effrts in the cuntries in the survey is either n drugs r equally fcused n alchl and drugs, despite the predminance f alchl-related harm ver drug-related harm in all but the Eastern Mediterranean Regin. The reasns fr this were nt examined in this survey. It is ntewrthy that this questin elicited a much higher psitive respnse frm cuntries than the treatment questinnaires, with an almst universal uptake f preventin activities. This questinnaire did nt distinguish between effective and ineffective preventin activities. Sme widely implemented preventin prgrammes have been fund t be ineffective with regard t sme key utcme measures. 113

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders Fcused n drug preventin nly Fcused n alchl preventin nly Fcused t a larger extent n drug preventin Fcused t a larger extent n alchl preventin Fcused equally n alchl and drug preventin 10 8 6 Percentage f cuntries n=140 4 2 Wrld Suth-East Asia Eurpe FIGURE 6.5 PRESENCE AND FOCUS OF SUBSTANCE ABUSE PREVENTION ACTIVITIES, BY REGION, 2008 10 8 6 Percentage f cuntries n=140 4 2 High Higher-middle Lwer-middle Lw FIGURE 6.6 PRESENCE AND FOCUS OF SUBSTANCE ABUSE PREVENTION ACTIVITIES, BY INCOME GROUP, 2008 10 10 59.5% 51.2% 50. 90.5% 85.7% 81. 76.9% 61.5% 46.2% 84.1% 63.6% 59.1% 70. 90. 60. 77.9% 68.5% 60. 58.6% Schl-based prgrammes [n=145] Cmmunity-based prgrammes [n=146] Wrk place prgrammes [n=145] FIGURE 6.7 WITH PROGRAMMES FOR THE PREVENTION OF SUBSTANCE USE DISORDERS, BY REGION, 2008 Suth-East Asia Wrld Eurpe 114

Preventin Cverge f 75 10 f the ppulatin Cverage f 50 74% f the ppulatin Cverage f 25 49% f the ppulatin Cverage f < 25% f the ppulatin 10 8 Percentage f cuntries 6 4 2 Wrld [n=107] [n=15] Suth-East Asia [n=6] Eurpe [n=34] [n=10] [n=17] [n=25] FIGURE 6.8 ESTIMATED POPULATION COVERAGE OF SCHOOL BASED PROGRAMMES TO PREVENT SUBSTANCE USE DISORDERS, BY REGION, 2008 10 8 10 Percentage f cuntries 6 4 2 Wrld [n=95] [n=15] Suth-East Asia [n=8] Eurpe [n=28] [n=7] [n=16] [n=21] FIGURE 6.9 ESTIMATED POPULATION COVERAGE OF COMMUNITY BASED PROGRAMMES TO PREVENT SUBSTANCE USE DISORDERS, BY REGION, 2008 8 Percentage f cuntries 6 4 2 Wrld [n=83] [n=9] Suth-East Asia [n=6] Eurpe [n=26] [n=5] [n=16] [n=21] FIGURE 6.10 ESTIMATED POPULATION COVERAGE OF WORK PLACE PROGRAMMES TO PREVENT SUBSTANCE USE DISORDERS, BY REGION, 2008 115

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders 6.4 Preventin services in special ppulatins and harm reductin Figures (6.11 6.16) Backgrund Nminated fcal pints were required t indicate the presence f preventin prgrammes fr substance use disrders in special ppulatins, namely yung peple at risk, prisners, persns living with HIV, pregnant wmen, cmmercial sex wrkers and ther minrity grups. These ppulatins are all particularly imprtant frm a public health perspective and are ften nt well reached by mainstream health services. Fcal pints were required t indicate the presence f harm reductin prgrammes in their cuntries. Harm reductin prgrammes describe plicies r prgrammes that fcus directly n reducing the harm resulting frm the use f alchl r drugs, withut necessarily affecting the underlying drug use. Salient findings Prgrammes fr the preventin f substance use disrders in special ppulatins Prgrammes fr the preventin f substance use disrders in special ppulatins vary acrss cuntries. Preventin prgrammes fr children and families at risk were mst ften reprted by cuntries (45.2%), fllwed by preventin prgrammes fr prisners (43.2%), fr peple living with HIV/AIDS (41.1%), fr pregnant wmen (32.2%), fr cmmercial sex wrkers (29.5%) and fr minrity grups (17.8%). The highest prprtin f cuntries reprting prgrammes fr the preventin f substance use disrders in prisners was in the (66.7%). The Eurpean (65.1%), (57.1%) and Western Pacific (53.3%) regins have the highest prprtins f cuntries with prgrammes fr children and families at risk. N cuntry in the Regin reprted having prgrammes fr the preventin f substance use disrders in pregnant wmen. There is n effect f cuntry incme level n the presence f preventin prgrammes in special ppulatins acrss different incme grups f cuntries. Fr example, prgrammes fr the preventin f substance use disrders in pregnant wmen were mre ften reprted amng lw-incme cuntries (33.3%) than amng lwer middle-incme cuntries (9.8%). Als, the prprtin f cuntries reprting preventin prgrammes fr substance use disrders in minrity grups decreases frm lwincme cuntries (11.9%) t higher middle-incme cuntries (3.4%) befre increasing t 52.9% in high-incme cuntries. 116

Preventin Harm reductin prgrammes The presence f needle/syringe exchange prgrammes differs within cuntries. In 41.1% f cuntries, cmmunity-based needle/syringe exchange prgrammes were reprted. In all, 6.6% f cuntries reprted having syringe exchange prgrammes in prisns. The highest prprtins f cuntries reprting cmmunity-based needle exchange prgrammes were in Eurpe (88.6%), (41.7%) and Western Pacific (42.9%). N cuntry in, the, Suth-East Asia r Western Pacific reprted having syringe exchange prgrammes in prisns. There is n effect f cuntry incme level n the availability f harm reductin prgrammes acrss different incme grups f cuntries. Ntes and cmments In the cntext f this reprt, children and families at risk cmprise street children and children in families with alchl, drugs and mental health prblems. Many cuntries, althugh still the minrity, have develped special prgrammes fr these hard-t-reach and mst at-risk ppulatins. This mdel culd ptentially be expanded as an alternative apprach t scaling up treatment fr substance use disrders. The presence f preventin prgrammes in special ppulatins des nt indicate that there is infrmatin abut access t the prgrammes r cverage f the ppulatin in need. Cmmunity needle and syringe prgrammes are recmmended in WHO guidelines (WHO, 2010). On the basis f the data here, there wuld appear t be significant scpe t increase effrts t make sterile injecting equipment available. 117

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders WITH PROGRAMMES FOR THE PREVENTION OF SUBSTANCE USE DISORDERS IN SPECIAL POPULATIONS, BY REGION, 2008 Prisners [n=146] Cmmercial sex wrkers [n=146] Peple living with HIV/AIDS [n=146] Pregnant wmen [n=146] Children and families at risk [n=146] Minrity grups [n=146] FIGURE 6.11 FIGURE 6.12 32.6% 23.3% 37.2% 66.7% 19. 38.1% 42.9% 21.4% 21.4% 48.8% 46.5% 41.9% 30. 30. 50. 40. 33.3% 46.7% 43.2% 29.5% 41.1% 57.1% 34.9% 28.6% 32.6% 9.5% 9.3% 65.1% 53.3% 45.2% 48.8% 37.2% 32.2% 26.7% 17.8% 20. 13.3% 14.3% 7.1% 10. 10. Suth-East Asia Wrld Suth-East Asia Wrld Eurpe Eurpe WITH PROGRAMMES FOR THE PREVENTION OF SUBSTANCE USE DISORDERS IN SPECIAL POPULATIONS, BY INCOME GROUP, 2008 Prisners [n=146] Cmmercial sex wrkers [n=146] Peple living with HIV/AIDS [n=146] Pregnant wmen [n=146] Children and families at risk [n=146] Minrity grups [n=146] FIGURE 6.13 FIGURE 6.14 70.6% 55.2% 50. 47.1% 55.2% 58.8% 52.9% 33.3% 31. 42.9% 39. 26.8% 36.6% 17.2% 37.9% 41.2% 33.3% 31. 31.7% 31. 11.9% 9.8% 4.9% 3.4% Lwer-middle Higher-middle High Lwer-middle Higher-middle High Lw Lw 118

Preventin Cmmunity-based needle/syringe exchange prgramme [n=141] In-prisn needle/syringe exchange prgramme [n=136] 88.6% 41.7% 42.9% 41.1% 30. 4.8% 15.8% 16.7% 16.7% 6.6% FIGURE 6.15 WITH NEEDLE/SYRINGE EXCHANGE PROGRAMMES, BY REGION, 2008 Eurpe Suth-East Asia Wrld 41.1% 34.2% 37.9% 6.6% 17.5% 5. 5.6% FIGURE 6.16 WITH NEEDLE/SYRINGE EXCHANGE PROGRAMMES, BY INCOME GROUP, 2008 Lw High Higher-middle Lwer-middle 119

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders 6.5 Screening and brief interventin prgrammes (Figures 6.17 6.20) Backgrund Fcal pints were asked abut the availability f screening and brief interventin prgrammes implemented in primary health care fr alchl and drug use disrders. Salient findings Screening and brief interventins fr harmful alchl and drug use implemented in primary health care were reprted by 47.9% and 46.2% f cuntries respectively. The and Western Pacific regins reprted the highest prprtins f cuntries with screening and brief interventins fr harmful alchl use (76.2% and 69.2% respectively) and drug use (65. and 71.4% respectively). The lwest prprtins f cuntries with screening and brief interventins fr harmful alchl and drug use were reprted in (30.2%), (21.4%), and Suth-East Asia (30. fr alchl use and 4 fr drug use). There is an effect f cuntry incme level n the availability f screening and brief interventins fr harmful alchl and drug use. A higher prprtin f cuntries in the higher incme grups reprted having screening and brief interventins fr harmful alchl and drug use implemented in primary health care cmpared t cuntries in the lw-incme grup. The majrity f cuntries, hwever, reprted using screening and brief interventins fr alchl and drug use nly rarely. This als applied t high-incme cuntries. Fr example, apprximately 43% f high-incme cuntries reprted using screening and brief interventins fr harmful and hazardus alchl use disrders nly rarely, with apprximately 25% f high-incme cuntries reprting using these appraches n a rutine basis. Ntes and cmments Brief interventins have been shwn t be effective ways t reduce alchl and drug use, substance use disrders and assciated harms, and are recmmended in WHO guidelines (WHO, 2010). The adptin f this strategy in a significant prprtin f cuntries demnstrates its feasibility in multiple settings. The lack f use f brief interventins in the remaining cuntries, and the lw rates f uptake within cuntries that d have sme brief interventin prgrammes, demnstrates significant ptential fr this strategy t be scaled up. It is interesting that the use f brief interventins appears t apply mre t drugs than t alchl, despite the fact that the greater burden f disease is due t alchl and the impact n alchl use and related harm is strnger. The reasns fr this cannt be determined by this survey. 120

Preventin Rarely used Rutinely used 76.2% 69.2% 58.6% 47.9% 30.2% 21.4% 30. FIGURE 6.17 IMPLEMENTING SCREENING AND BRIEF INTERVENTIONS FOR HARMFUL AND HAZARDOUS ALCOHOL USE IN PRIMARY HEALTH CARE, BY REGION, 2008 68.8% 62. Wrld Suth-East Asia Eurpe n=142 29.3% FIGURE 6.18 IMPLEMENTING SCREENING AND BRIEF INTERVENTIONS FOR HARMFUL AND HAZARDOUS ALCOHOL USE IN PRIMARY HEALTH CARE, BY INCOME GROUP, 2008 n=142 40. High Higher-middle Lwer-middle Lw 71.4% 65. 54.8% 46.2% 40. 30.2% 21.4% FIGURE 6.19 IMPLEMENTING SCREENING AND BRIEF INTERVENTIONS FOR HARMFUL DRUG USE IN PRIMARY HEALTH CARE, BY REGION, 2008 57.2% 64.7% Wrld Suth-East Asia Eurpe n=143 31.7% High Higher-middle Lwer-middle Lw FIGURE 6.20 IMPLEMENTING SCREENING AND BRIEF INTERVENTIONS FOR HARMFUL DRUG USE IN PRIMARY HEALTH CARE, BY INCOME GROUP, 2008 n=143 37.5% 121

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders 6.6 Grups and agencies invlved in preventin f substance use disrders (Figures 6.21 6.24) Backgrund Nminated fcal pints were asked t indicate grups and agencies which are invlved in the preventin f psychactive substance use and substance use disrders in their cuntries. Salient findings Different grups and agencies appear t be invlved in the preventin f substance use disrders in cuntries. In 78.1% f cuntries, schls are invlved in the preventin f substance use disrders, fllwed by cmmunity grups (49.3%) and emplyers (29.5%). The invlvement f law enfrcement agencies in the preventin f substance use disrders was reprted by 68.5% f cuntries. Invlvement f internatinal rganizatins in the preventin f substance use disrders was reprted by 56.8% f cuntries, fllwed by the invlvement f labur rganizatins (19.2%). A higher prprtin f cuntries in the higher incme grups reprted the invlvement f schls, cmmunity grups and emplyers in substance abuse preventin activities than cuntries in the lwer incme grups. Cnversely, there was n bservable effect f cuntry incme level n the invlvement f labur rganizatins, law enfrcement agencies and internatinal rganizatins in substance abuse preventin activities. Ntes and cmments Bradly speaking, these data shw that mst cuntries have sme activities t prevent substance use and related harms, and that there is cnsiderable variability as t which rganizatins carry ut the preventin activities and in which settings these preventin activities take place. A particularly high prprtin f cuntries reprt the engagement f schls in the preventin f substance use prblems. Althugh perhaps cunter-intuitive, nt all schl-based preventin prgrammes have prven effective, and sme have the ptential t raise the level f interest amng their adlescent targets in the cnsumptin f alchl and drugs. The ATLAS questinnaire did nt distinguish between thse schl-based prgrammes that were evaluated and prved their effectiveness and thse that were nt, s it is difficult t cnclude frm these data whether the mst value is being btained frm such preventin effrts. 122

Preventin Schls Cmmunity grups Emplyers 86.7% 86. 80. 80. 78.1% 81. 78.6% 65.1% 57.1% 58.1% 60. 49.3% 47.6% 35.7% 34.9% 40. 26.7% 29.5% Percentage f cuntries 27.9% 18.6% 14.3% FIGURE 6.21 GROUPS INVOLVED IN THE PREVENTION OF SUBSTANCE USE DISORDERS, BY REGION, 2008 n=146 Eurpe Suth-East Asia Wrld 93.1% 91.2% 66.7% 68.3% 62.1% 67.6% 41.5% 41.4% 44.1% 33.3% Percentage f cuntries 19. 19.5% FIGURE 6.22 GROUPS INVOLVED IN THE PREVENTION OF SUBSTANCE USE DISORDERS, BY INCOME GROUP, 2008 n=146 Lwer-middle Higher-middle High Lw 123

ATLAS n substance use (2010) Resurces fr the preventin and treatment f substance use disrders Labur rganizatins Law enfrcement agencies Internatinal rganizatins 90. 80. 80. 76.2% 68.5% 65.1% 58.1% 66.7% 64.3% 57.1% 62.8% 53.3% 56.8% 44.2% 30. Percentage f cuntries 16.3% 28.6% 20.9% 20. 19.2% FIGURE 6.23 AGENCIES INVOLVED IN THE PREVENTION OF SUBSTANCE USE DISORDERS, BY REGION, 2008 n=146 Eurpe Suth-East Asia Wrld 71.4% 66.7% 63.4% 58.5% 72.4% 72.4% 73.5% 23.5% 23.5% Percentage f cuntries 19. 14.6% 20.7% FIGURE 6.24 AGENCIES INVOLVED IN THE PREVENTION OF SUBSTANCE USE DISORDERS, BY INCOME GROUP, 2008 n=146 Lwer-middle Higher-middle High Lw 124