A Theoretical Framework
for Demand Reduction --
Summary of Presentations
Co-Moderators: Dr. Hoover Adger Jr., and Dr. Roberto Tapla-Conyer
Prevention
Dr. Gilbert J. Botvin
Professor of Public Health and Psychiatry,
Director of the Institute for Prevention Research,
Cornell University Medical College, Department of Public Health, USA
Over the past 20 years, Dr. Botvin noted, we have learned much about the etiology of drug abuse, about risk and protective factors, and about how drug abuse progresses. We also have learned a great deal about prevention. In this regard, he noted three critically important points:
- Drug prevention works when conducted under the right conditions using appropriate, research-based models and carefully implemented programs.
- These programs can substantially reduce drug use, sometimes by as much as half, and their effects are persistent.
- There is a serious gap between our research findings and prevention practice.
Dr. Botvin pointed out that phased studies up to and including large-scale, randomized, controlled studies have been conducted and published in the leading scientific journals. In his view, these studies reveal that providing drug information alone does not work, nor do "scare tactics." However, we persist in using both these approaches, he said. A focus on social influences promoting drug use, he claimed, especially when combined with approaches enhancing general competency, does work. He noted that studies in the United States and elsewhere show that it is possible to decrease the use of tobacco and alcohol as well as marijuana and other illicit drugs. Moreover, these programs can be effectively implemented by regular classroom teachers, adult program providers, or peer leaders in school and classroom settings.
Dr. Botvin summarized what has been learned in this area. Accordingly, the critical period for onset of drug use in the U.S. is preadolescence and adolescence. Prevention, therefore, must begin in middle or junior high school, he claimed. Prevention strategies must focus on teaching drug resistance skills to children to enable them to resist using drugs and avoid high-risk situations. Making children aware that drug use is not the norm they often believe it to be is also important, he stated. So is teaching personal self-management skills and general social skills.
Dr. Botvin recalled that for years in the U.S. a distinction was made between so-called legal substances such as tobacco and alcohol and illegal ones such as marijuana. More recently, however, within the past 10 years, he said, there has been a recognition that use of any of these substances is all part of a general context of addictive behaviors. As Dr. Denise Kandell and others have found, children who initially start with alcohol and tobacco often move on to marijuana and other illicit drugs. Apart from their role as "gateway" drugs, Dr. Botvin claimed that cigarettes are a more serious public health problem, from the standpoint of morbidity and mortality, than the use of illicit drugs. He pointed out that prevention efforts targeting cigarette smoking were also found to be effective in dealing with alcohol and marijuana use. This, and the recognition that all these problems are interrelated and involve similar risk and prevention factors, led to the development of a prevention approach that targets all of them.
Drug prevention works when conducted under the right conditions, using appropriate research-based models, and carefully implemented programs.
Rather than focusing on the least we can do to be effective, Dr. Botvin argued that we must recognize the importance of continuing efforts that begin with at least 12 to 15 treatment sessions in the first year. One-, two-, or three-session programs simply do not work, he claimed. Even with a much larger number of sessions, at least two years of booster interventions are also needed. Dr. Botvin stressed that programs must also accurately conform to the model and be "user friendly." That is, he claimed, teachers and students must find them interesting and workable in the real world. He also emphasized the need for quality control to prevent "program drift." By that he meant the gradual adulteration of program content by the introduction of extraneous material or the reduction of essential elements.
Dr. Botvin pointed out that the life-skills training approach designed to enhance adolescent competence, coupled with enhancing drug resistance skills, has reduced drug use generally by 50 to 60 percent and sometimes by as much as 87 percent, with effects lasting at least 6 years. He stated that young adults aged 23- to 24-years-old are presently being studied to determine whether these programs have longer lasting effects. Thus, for the first time, he claimed, drug prevention will not need to rely on guesses and wishful thinking but can be based upon carefully conducted research. In closing, he asserted that we now need to close the gap between the research-based techniques and actual practice.
Mr. Jesús Cabrera Solís
Director General, Youth Integration Centers, Mexico
Mr. Cabrera began by emphasizing that since the U.S. and Mexico agree that drug problems have both supply and demand components, the two nations need to develop actions and policies that focus on both keeping drugs from people and people from drugs. In the immediate and long term, he claimed, we must reduce demand using both specific and nonspecific measures. As he pointed out, nonspecific means include education generally, health education specifically, and the reinforcement of the importance that good health plays in our lives. Specific prevention aims toward complete abstinence from using drugs. Both means reinforce drug-free lifestyles and the capacity to achieve a drug-free community.
We need to develop actions and policies that focus on both keeping drugs from people and people from drugs.
According to Mr. Cabrera, the last national survey conducted in Mexico in 1993 indicated that 75 percent of its children over age 10 have a smoking problem, while 10 percent have an alcohol problem. However, 99.6 percent do not have a problem with illegal drugs, he claimed. Less than one percent -- only 0.4 percent of Mexican children -- reported use of illegal drugs in the previous year. However, 90 percent of 50,000 patients treated for drug abuse had begun using these drugs between the ages of 10 and 12. Thus he asserted that all programs must address drug use in children under 10 and especially those between 10 and 15 years old living in high drug-risk areas. Drug prevention should also include an emphasis on sports, recreational activities, and other skill development through agencies not necessarily directly involved in drug prevention. He also noted that the survey to be conducted this year is expected to show an increase in both the frequency and magnitude of drug use in Mexico.
In terms of prevention research, Mr. Cabrera suggested that we need to reduce risk factors, increase protective factors, and identify which of these are most important for specific groups. We also need valid and statistically reliable, quantitative data that are not inflated, as well as diagnostic information that will enable us to identify high-risk areas at both the neighborhood and community levels.
Mr. Cabrera maintained that the U.S. and Mexico must adhere to the best scientific models available. We must also work to assure that our operational staffs adhere to those models. Prevention programs and the models on which they are based must correspond closely, he stated. The technical quality and the quality of interpersonal services must also be high, and these aspects must be monitored in terms of treatment outcome and behavioral changes that occur both mid- and long-term.
Mr. Cabrera stressed that the assembled conference work groups must also consider the relevance of public information and media dissemination to the groups being targeted. It is important to show the general public that international and interagency bi-national efforts can have a significant impact on drug abuse and addiction.
In the workplace, he claimed that we should be concerned about possible drug-abuse risks and about ways to encourage healthy family interactions that reduce the likelihood of drug use. We should be especially concerned about employees in public transportation and public safety, he noted, and the possible added risk posed by drug abusers in those areas.
With respect to AIDS, Mr. Cabrera stated that both the U.S. and Mexico should be concerned about efficient reduction of high-risk behavior. Outreach to high-risk injection drug users should be included in these efforts, he noted. Antagonist and substitute-drug programs that reduce high-risk drug behavior also need more emphasis. He called for more warnings about the traumatic consequences of drug-related domestic violence and, in particular, the drug-related psychological, physical, and sexual abuse of children. There is a need, he claimed, to emphasize the early detection of psychiatric co-morbidity and to consider possible legislative actions to help reduce alcohol, tobacco, inhalant, and other drug abuse such as stricter law enforcement and laws to discourage drug abuse by drivers. Finally, Mr. Cabrera suggested that we should consider legislative changes to reduce the violent content in mass media that may also contribute to deviant behavior and drug abuse.
