DARE – Drug Abuse Prevention that doesn’t work

  • DARE (Drug Abuse Resistance Education) is the largest school-based drug abuse prevention program in the United States.
  • 80% of school districts across the country teach the DARE curriculum, reaching an estimated 26 million children (1).
  • Every year, over $1 billion goes into keeping the program running. A billion dollars may be a small price to pay to keep America’s children drug-free, but there is plenty of evidence to suggest that DARE isn’t doing what it’s supposed to.

What is DARE?

dareFounded in 1983, DARE began as a 17 week long course taught to 5th and 6th graders. The course is taught by a uniformed police officer who teaches the students about drug use and gang violence. The DARE curriculum includes role-playing, written assignments, presentations, and group discussions.

DARE uses a zero tolerance policy towards drug use. Students are told to adopt mottoes like “Drug free is the way to be” and “Just say no to drugs!” Pictures of blackened lungs and drunk driving accidents are methods used to discourage experimentation. The focus of the program is clearly flat out refusal. Students are not taught what to do if they are already experiencing problems with drugs.

Is DARE effective?

The effectiveness of DARE has been called into question since the early 90s. A meta-analysis of 11 studies conducted from 1991-2002 shows no significant effect of DARE in reducing drug use (1). Several studies have even reported an opposite effect, with DARE leading to higher rates of drug use later on in life. Reports from the California Department of Education, American Psychological Association, and U.S. Surgeon General all label DARE as ineffective.

The results seem clear, but statistics don’t seem to be enough to convince concerned parents and policy makers to shut down any drug abuse prevention program. With drug use on the rise, it seems that DARE is here to stay. But perhaps getting rid of DARE isn’t the best option. The framework and funding already exist for a potentially successful prevention program. Maybe all we need to do is apply some science and develop new techniques that will provide results.

*It should be noted that in 2001, DARE made substantial revisions to its program under the title “New DARE.” The effects of these revisions have yet to be measured, so we’ll wait and see.

 

Citation:

1. West, S.L., O’Neal, K.K. (2004) Project D.A.R.E. Outcome Effectiveness Revisited. American Journal of Public Health. 94(6)

Saving lives made easy – Treating opiate overdose with intranasal naloxone

oxycodone-addiction-big1Contributing co-author: Andrew Chen

Imagine that you and your friend have been using heroin (or another opiate). A few hours go by and you notice your friend is progressively becoming more and more unresponsive. You check on him and find that his breathing is shallow, his skin is cold, and his pupils are constricted. You recognize these as signs of opiate overdose and call for help. Now what?

Well… If you had some naloxone around, you might be able to treat the overdose and save your friend’s life before the paramedics even arrive.

Naloxone hydrochloride (naloxone) is the standard treatment for opioid overdose. Naloxone works by blocking opioid receptors, thereby removing opioid agonists, such as heroin or oxycodone, from those same receptors. As a result, the overdose is reversed and death is prevented.

What makes naloxone great is that it has no potential for abuse. In fact, it makes the user feel pretty crappy.

Naloxone is typically delivered through an injection, which makes it pretty much useless in many situations. However, it can also be delivered using an intranasal spray device. This intranasal form of naloxone is getting lots of attention recently because it is relatively easy to administer.

In 2006, The Boston Public Health Commission (BPHC) implemented an overdose prevention program, providing training and intranasal naloxone to 385 individuals deemed likely to witness an overdose. These individuals were often family members of opiate users or drug-using partners.

15 months later, the BPHC conducted a follow-up:

  • Contact was made with 278 of the original participants.
  • 222 reported witnessing no overdoses during the 15-month span.
  • 7 had their naloxone stolen, lost, or confiscated.
  • 50 reported witnessing at least one overdose during the 15-month span. Together, these 50 individuals reported a total of 74 successful overdose reversals using intranasal naloxone!

The BPHC program is not the only example of successful use of naloxone in opiate overdose prevention programs. Similar programs have popped up in Chicago, New York, San Francisco, Baltimore, and New Mexico.

Unlike injections, using a nasal spray isn’t rocket science. All of the participants in the BPHC program were trained by non-medical public health workers, which makes the idea relatively cheap. As the data shows, the participants were able to effectively recognize an opiate overdose and administer intranasal naloxone. By targeting at-risk populations and providing proper training, distribution of intranasal naloxone can help in saving lives.

For more information, check out our post Addiction and the brain part IV – Opiates

Citation:

Doe-Simkins, M., Walley, A.Y., Epstein, A., & Moyer, P. (2009) Saved by the nose: Bystander-administered intranasal naloxone hydrochloride for opiod overdose. American Journal of Public Health. 99(5)

Tobacco smoking alone isn’t enough: More than smoking important in lung cancer death

Christopher Russell and Adi Jaffe

The tobacco epidemic already kills 5.4 million people a year from lung cancer, heart disease and other illnesses. By 2030, the death toll will exceed eight million a year. Unless urgent action is taken tobacco could kill one billion people during this century. (The World Health Organization Report on the Global Tobacco Epidemic, 2008)

These are some scary numbers, right? Cigarette smoking, according to the WHO, is the single most preventable cause of death in the world today, and in conveying these deadly statistics to the general public, cigarettes have come to be alternatively referred to by smokers and non-smokers as “cancer sticks”, “nicotine bullets”, and “coffin nails”.

But does smoking really ‘kill’ anybody in the literal sense with which we use this word?  To an epidemiologist, tobacco smoking (nor many other drugs of abuse for that matter) does not “kill” a person or “cause” illness or death in the way the words “kill” and “cause” are typically understood by the media and general public. For example, if I shoot someone in the head, stab another in the heart, and strangle a third till he stops breathing, it is reasonable to say that my actions were the direct, sole, and sufficient causes of death – I would have killed them. Smoking, however, is often neither a sole nor sufficient ‘cause’ of lung cancer, coronary heart disease, or myocardial infarction because non-smokers die from these diseases, and for example, because only 1 in 10 heavy smokers die from lung cancer when one looks at the overall numbers. Continue reading “Tobacco smoking alone isn’t enough: More than smoking important in lung cancer death”

Should all drugs be decriminalized? A UK debate

Christopher Russell

In a recent UK parliamentary debate, Bob Ainsworth MP, a former Home Office minister in charge of drugs policy, called for the decriminalization of all drugs. Ainsworth, the most senior UK politician to publicly endorse a system of decriminalization, joins respected figures from the medical and research communities in recent months in suggesting that the decriminalization of drugs would significantly improve public health and reduce crime further than is being achieved under the current system of criminalization. Ainsworth argues that that the past 50 years of the War on Drugs has been counter-productive to its intended goals of reducing the availability of drugs and improving public health. Furthermore, he claims that billions of pounds had been spent without preventing the wide availability of drugs, reducing the wide use of drugs, or weakening the illicit drug market. Consequently, Ainsworth proposes that the drug market be taken out of the hands of organized criminals and be placed into the hands of medical professionals and licensed vendors. Such a change in policy would mark a return to UK drug policy prior to the mid-1960’s in which drug use was treated as a health issue, not a criminal issue.

“It is time to replace our failed war on drugs with a strict system of legal regulation, to make the world a safer, healthier place, especially for our children. This (policy of criminalization) has been going on for 50 years now and it isn’t getting better. The drugs trade is as big, as powerful as it ever was across the world. Prohibition isn’t the answer to this problem” he said.

It is important to understand that Ainsworth is not arguing that drugs like heroin and cocaine should be freely available to buy in the same way that adults can buy alcoholic drinks and tobacco products. Rather, he argues that drugs be decriminalized, which is different from legalized. Decriminalizing would likely mean the government would control all aspects of the manufacture, quality, purity, distribution, and trade of drugs, including who will be licensed to provide drugs. Legalization would mean drugs could be traded in the free market, a position which Ainsworth is explicitly against. “I’m not proposing the liberalization and the legalization of heroin so we can all get zonked out on the street corner” Ainsworth said in an interview with BBC’s Radio 4.

Why decriminalize drugs?

The argument for decriminalization is based on the hypothesis that the legal regulated supply of drugs will draw trade away from the illicit market and so reduce crime related to the illicit sale and purchase of drugs; improve the health of users by providing quality-controlled drugs under the guidance and supervision of licensed individuals; increase the uptake of addiction treatment; allow treatment providers to reconnect with a group of drug users who do not typically seek or know about treatment options or have distanced themselves from treatment providers for fear of criminal prosecution; and improve drug education for current and would-be drug users.

If decriminalizing does shift the drug market toward legal vendors, a major benefit could be the medical and addiction research communities’ sudden widespread access to a population of drug users who are notoriously difficult to reach. This access would allow medical professionals and researchers obtain rich first-hand information as to why these people started using drugs and why they use drugs today, to provide drug education, to provide assistance with any problems relating to employment, housing, relationships or physical and mental health. Decriminalizing drugs may therefore better place treatment providers to support those who want help and to minimise harm in those who continue to use. Paradoxically then, while many people believe decriminalization will send a message to the youth that drug use is acceptable as well as maintaining use in current users, proponents of decriminalization argue that, by reconnecting drug users to the health community, legal regulation of drugs will actually increase in the number of people quitting drugs and provide earlier opportunities to deliver educational interventions to ‘would-be’ drug users.

What might decriminalization look like?

While Ainsworth did not describe in detail how drugs should be regulated, Steve Rolles, Head of Research for the Transform Drug Policy Foundation, which campaigns for the decriminalization of drugs, released a ‘blueprint for regulation’ in December, 2009 which described how models of regulation for different types of drug would improve health and decrease crime. The report proposes that cannabis and opium could be sold and consumed on membership-based “coffee shop-style” licensed premises and would likely be subjected to similar trade laws as those currently applied to tobacco products; cocaine, ecstasy and amphetamines could be sold by licensed pharmacists or named purchasers; and psychedelic drugs, including hallucinogens such as LSD or Salvia could be used only under supervision in licensed “drug clubs” or similar venues. Rolles said: “Drugs are here to stay, so we have a choice – either criminals control them, or governments do. By the cautious implementation of a legally regulated regime, we can control products, prices, vendors, outlets, availability and using environments through a range of regulatory models, depending on the nature of the drug, and evidence of what works”.

Rolles also echoed Ainsworth’s sentiments about the futility and counter-productiveness of prohibition in a recent BBC radio interview: “It hasn’t reduced drug use, it hasn’t prevented the availability of drugs, but it has created a whole raft of secondary problems associated with the illegal market, including making drugs more dangerous than they already are and undermining public health and fuelling crime”.

Rolles called on the UK government to consider evidence about the effectiveness of the prohibition policy both in the UK and other countries and health and crime projections under a decriminalized system. Craig McClure, foreword author on the Transform Drug Policy Foundation report and former executive director of the International Aids Society states that several Latin American governments have already realised how their war on drugs have undermined public health goals and fueled crime and have already moved, or are moving, towards decriminalization and a public health model targeting the prevention and treatment of drug misuse.

What next for the decriminalization deabte?

Knowing that drug decriminalization is a sensitive, emotion-laden, divisive idea, and therefore public support from fellow MPs will initially be largely absent, Ainsworth has called for an impact assessment to be conducted on the Misuse of Drugs Act, 1971 – the legislation which introduced drug classification in the UK – rather than calling for drugs to be decriminalized outright.

“I call on those on all sides of the debate to support an independent, evidence-based review, exploring all policy options, including: further resourcing the war on drugs, decriminalizing the possession of drugs, and legally regulating their production and supply” he said. As influential political, medical and scientific forces join to pressure a review of the efficacy of current drug policy, there is a sense in the UK that drug decriminalization is slowly moving from an ideological conviction to an evidence-based alternative to a failing system of prohibition.

Please write your comments about the prospect of drug decriminalization in the box below.

References:

Bob Ainsworth BBC 1 television interview, 16th December, 2010. Accessible at http://www.bbc.co.uk/news/uk-12005824

Bob Ainsworth BBC Radio 4 interview, 16th December, 2010. Accessible at http://www.bbc.co.uk/news/uk-12005824

Transform Drug Policy Foundation (2009). After the war on drugs: Blueprint for regulation. Accessible at http://www.tdpf.org.uk/Transform_Drugs_Blueprint.pdf

Medical and political support for the Transform Drug Policy Foundation’s ‘blueprint for regulation’ (2009) report. Accessible at http://www.tdpf.org.uk/blueprint%20download.htm

Women, Trauma and HIV Transmission

Co-authored by Jamie Felzer

Just how much can the events of a traumatic childhood affect the likelihood of contracting HIV or other serious diseases in later life? Unfortunately, recent research shows that the effect can be profound, especially for women.The silver lining may be in our ability to reduce later HIV transmission by providing better intervention services post-trauma.

Childhood Trauma, Women and HIV/AIDS

In ways both surprising and predictable, it seems that even very early childhood trauma can be firmly linked to high risk behaviors and a higher risk of contracting HIV. And with AIDS now reported by the US Department of Heath & Human Services as the leading cause of death for African-American women between the ages of 25-34 (and the perhaps even more sobering H&HS assessment that African-American women are a staggering 21 times more likely to die from AIDS compared to non-Hispanic white women), this crisis has a particular impact on women of color.

The obvious conclusion is that those subjected to childhood trauma are more likely to engage in risky behavior in an attempt to relieve some of the chronic stress that often accompanies such experiences. Drug use, unprotected sex, heavy drinking and other accompanying behaviors can all seem like appropriate responses to mental and emotional stress, but that stress can also inhibit one’s ability to make safe choices in this context. This naturally leads to an increased risk for contracting sexually transmitted diseases and blood-borne pathogens. Factor in the simple biological reasons why women may be at an elevated risk of contracting HIV through any one encounter, and it becomes clear that many at-risk young women are not receiving adequate education on how to protect themselves against this threat.

Many young women with a history of trauma and elevated lifetime stress from sexual assault, violence or any of the myriad stressors that accompany low socioeconomic status may be inadvertently putting themselves at greater risk for contracting HIV and AIDS. As mentioned, these risks can commonly come from unsafe sex and the abuse of unknown drugs, potentially with non-sterile needles. Without a strong support system to help them adequately process the short and long-term effects of trauma, many young women end up developing symptoms of chronic anxiety and depression, conditions that can alter behavior and even ultimately lead to demonstrated higher rates of mortality. That these conditions also often co-exist with other health issues linked to lower socioeconomic status such as obesity and heart disease serves to further compound this risk. Stress has even been shown to speed the progression of the AIDS virus, making the disease itself more deadly.

And with a full 1/3 of the female population having reported some form of sexual assault or similar violent trauma, the sad reality is that the risks for contracting HIV among young women are, if anything, growing. It seems that one way to attack the HIV pandemic is by improving prevention, as well as intervention, services, for women affected by such early trauma. It might be a way to kill two, or even more, birds with one stone.

Heroin Addiction and HIV infection – Dirty needles and a place for harm reduction

Co-authored by: Jamie Felzer

Many people today know about the dangers and risky behaviors (sharing needles, unsafe sex, and mother-to-child transmission) that can increase the risk for HIV/AIDS infection. The question lies in whether or not they are able to take appropriate actions to prevent contracting the disease themselves.

Heroin addiction, dirty needled, and HIV infection

Many heroin addicts, especially those that are homeless or extremely poor, will use whatever heroin they can get, regardless of the risk it puts them in.  A study done in a San Francisco park frequented by almost 3000 IV drug users found that in times of heroin withdrawals, addicts would use dirty  needles, sometimes with visible traces of blood still on them. The need to overcome their withdrawal was more important to them than worrying about the risk of contracting HIV or any of the other countless diseases that can be contracted from such use.

Many of the users surveyed were poor and sometimes didn’t even have enough money to buy their own supply of heroin so they often pooled together what they had with others. They all shared the heroin, cooker and needle to get a fix for the time being.

Regardless of the consequences of HIV contraction, users needed their heroin.

In this community many of the users knew about the risks of sharing needles and were well aware of recommendations that they not share needles or bleach them.  The users actually found health outreach workers slogans patronizing because although they would have  loved not to have to worry about sharing needles, often the more imminent need is getting that fix or suffer being extremely sick from withdrawals.  Given the relatively rare harm-reduction sources available, they were able to use the clean needles given out by some health organizations but at other times had to be resourceful and use what they had regardless of the possible consequences.

There are 1.2 million people living with HIV in the US right now out of a 33.2 million total in the world. 2.5 million people recently acquired the disease and 18% of those new infections were from injection drug users (IDU).  HIV/AIDS is a preventable disease. If we allow users to have easier access to clean needles, we can help decrease the number of IDU infections. If you aren’t sure what your status is, get tested! HIV Testing

Here’s a great resource for finding needle exchanges operating in the U.S. : NASEN

Citation:

Social Misery and the Sanctions of Substance Abuse: Confronting HIV Risk among Homeless Heroin Addicts in San Francisco. Philippe Bourgois; Mark Lettiere; James Quesada. Social Problems, Vol. 44, No. 2  (May, 1997), pp. 155-173. University of California Press on behalf of the Society for the Study of Social Problems.

UNAIDS Website

Drug use norms and expectations: Obsessions and compulsions in our society.

teensI used to always say, back in my using days, that speed (methamphetamine) was The American drug. Why? Meth makes its users sharper, more alert, and more focused, and it allowed me to spend entire nights up studying like I’d never been able to study before.

Unfortunately, like many other aspects of The American Dream, speed will also leave you spent before you know it, leaving the memories of those productive, focused, days far behind with little hope of coming back.

We live in a society that celebrates excess, be it in celebration or dedication to work, success, and achievement. Is it any wonder then that so many Americans turn whichever way they can to gain the edge that they feel they’re lacking when they compare themselves to those around them?

I read recently that many executives now keep a supply of medications like Adderall, Ritalin, and other attention deficit cures around for times when they need that extra push to stay up late and work.

We are skirting a dangerous line by putting out the message that everyone should be the best though of course, with no cheating… or at least no getting caught.

Teens are now using more and more prescription drugs while reducing, or at least not increasing, their use of many illicit, or illegal substances. How is this crisis we’re experiencing with our teens any different than the recent steroid stories exploding the mythic innocence of every American sport?

One of the things I want to inform my readers about in writing this blog is the process of addiction and the ways in which its development is often not under the control of the users, at least not the users likely to eventually develop into addicts. But, there’s also a different issue, the one having to do with what it is about our society that makes Americans so much more likely to turn to these substances in the first place???

It is estimated that more than a third (110 Million to be exact) of American have used at least one drug at some point in their lives. I don’t necessarily think that there is anything wrong per se with recreational drug use given the relatively low rates of addiction that develop from it. However, I think that drug use, even recreational use, that is meant to solve a problem or that is done as a normal part of life, is more likely to become problematic.

Some theories of addiction specifically assert that “self-medication”, as in using a drug to alleviate problems, especially psychological problems, can be a major indication of likely addiction potential. The problem is that the unsupervised use of the drug often does little to help the initial difficulties, and if anything, makes things worse as the drug user becomes more involved in the illegal drug culture. I probably don’t need to tell many of you about the social withdrawal and added psychological stress that goes along with becoming, or living with, a drug user.

My point is that we need to change the way we think about drugs in general. Drugs can be useful for many specific medical and psychological benefits, and possibly even for their recreational benefit (think Van Gough, or The Doors). But, in order to make sure that those we care about most don’t abuse and misuse drugs, we need to move away from the current attitude that seems to drive children and teens towards irresponsible, ill-informed, and dangerous drug use. By educating kids, not scaring them away from, the things that are dangerous for them.

You wouldn’t dream of teaching a child to look both ways before crossing the street by yelling at them that they better not EVER dream of setting a foot on the road without looking left first, would you?!

We teach our kids everything we think they need to know about life in order to prepare them for what’s ahead. Why is it that when it comes to drugs (and often sex), we shy away from bringing the subject up and still expect them to be well prepared when a friend says “Hey, want to pop one of these pills with me?”

There will always be those who for one reason or another are more likely to develop a problem with drugs regardless of how well prepared they are. Genetic influences on things such as low impulse control and sensation-seeking are known and are probably closely linked to some bad decision making. But even these people will benefit from being better prepared and more educated about their own choices so that when the time comes, even if a problem develops, they can hopefully acknowledge it, and deal with it, in a more capable, informed way.

We need to stop turning away from a problem and thinking it will solve itself. It’s time for us to look for answers and not rely on solutions appearing magically. They most likely won’t…

Question of the day:
Do you think that enforcement (of drug laws) or treatment (of heavy drug users)is the more effective way of dealing with the drug problem?