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This entry is our analysis of a study considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original study was not published by Findings; click Title to order a copy. Free reprints may be available from the authors – click prepared e-mail. Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text Unfold supplementary text The Summary conveys the findings and views expressed in the study. Below is a commentary from Drug and Alcohol Findings.

Title and link for copying Comment/query to editor

Effectiveness of a universal internet-based prevention program for ecstasy and new psychoactive substances: A cluster randomized controlled trial.

Champion K.E., Newton N.C., Stapinski L.A. et al.
Addiction: 2016, 111, p. 1396–1405.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Champion at k.champion@unsw.edu.au.

An online course implemented in Australian secondary schools improved on standard health and drug education by reducing intentions to use new psychoactive substances and in the short-term increasing knowledge about these substances and about ecstasy.

Summary The short-term effects of new psychoactive substances – including drugs that mimic the effects of cannabis, stimulants, hallucinogens, ecstasy, and amphetamines – can include nausea, agitation, and psychosis, but very little is known about their long-term consequences.

Key points icon

Key points
From summary and commentary

The featured study tested the effectiveness of an online prevention programme in Australian secondary schools for ecstasy and new psychoactive substances.

Pupils receiving the Climate Schools: Ecstasy and Emerging Drugs intervention reported reduced intentions to use new psychoactive substances, and increased knowledge about ecstasy and new psychoactive substances in the short term.

However, against all pre-defined outcome measures, the intervention was still only of limited success.

New psychoactive substances are often misperceived by young people to be low-risk. Reports of fatalities have added a sense of urgency to the need to correct these misperceptions and prevent use.

A UK report recommended that concerns about ‘older drugs’ such as ecstasy should be considered when developing prevention strategies for new psychoactive substances. Given that the age of onset, risk factors and potential harms associated with ecstasy and new psychoactive substances overlap, and that ecstasy is the second most commonly used illicit drug among adolescents in both Australia and the United Kingdom, there is a compelling argument for preventing these substances simultaneously.

The featured study aimed to evaluate the effectiveness of a school-based prevention programme for ecstasy and new psychoactive substances. The online learning module Climate Schools: Ecstasy and Emerging Drugs used cartoon storylines to impart evidence-based information about ecstasy and new psychoactive substances, correct overestimates of peer use, teach refusal skills, and address misconceptions. It was delivered at the beginning of 2014 in four weekly sessions during health education classes. Each session lasted 20 minutes and was completed individually by pupils, followed by optional online and teacher-delivered activities, including discussions and online worksheets.

A total of 90 schools were approached in Sydney (Australia), and 12 agreed to participate in the study; the remaining 78 declined due to other research commitments or limited time in the curriculum. Of the participating schools, 11 (one withdrew) were sorted into clusters, and these clusters then randomly assigned to the intervention group or the control group. Clustering was used to avoid information about the intervention influencing pupils in the control group, which could be a possibility if pupils from different schools in the same geographical area talked to each other.

The researchers met with teachers at the start of the study to show them how to navigate the website, but after that, no further support was required. To ensure complete and consistent delivery of the intervention, the website was programmed so that pupils were required to view the lesson in full before being granted access to the next lesson.

Schools in the control group received their usual health education lessons, which also covered drug education topics. Teachers were asked to complete a survey that assessed the amount and format of any drug education they delivered to their pupils.

A total of 1126 pupils, with an average age of 15, completed the initial survey at baseline. Almost all pupils (96%) provided follow-up data on at least one occasion, and 70% provided data at both follow-up points (six and twelve months after baseline).

The primary outcomes against which the intervention was to be judged were:
• intention to use ecstasy at 12 months;
• intention to use any new psychoactive substances at 12 months.

The secondary outcomes were:
• intention to use ecstasy and any new psychoactive substances post-intervention and at six months;
• intention to use synthetic cannabis and synthetic stimulants (‘bath salts’) in the next six months;
• knowledge of ecstasy and new psychoactive substances;
• life-time use of ecstasy, new psychoactive substances, synthetic cannabis, and synthetic stimulants.

Main findings

Few pupils reported using new psychoactive substances and ecstasy when they were recruited to the study (3% and 2% respectively) or at the 12-month follow-up (1% and 2%).

The headline positive outcomes in the intervention group were:
• reduced intentions to use new psychoactive substances;
• increased knowledge about ecstasy and new psychoactive substances in the short term.

There were no differences between the control group and intervention group on the measure of intentions to use ecstasy and new psychoactive substances either immediately after the intervention or at six months. However, after 12 months, the proportion of pupils who said they were likely to use new psychoactive substances in the next six months was significantly greater in the control group than the intervention group.

Immediately after the intervention, there was evidence of a significant difference in ecstasy knowledge, with control group pupils reporting less ecstasy knowledge than those in the intervention group. However, there were no significant differences at the six- or 12-month follow-ups. For new psychoactive substances there were significant differences post-intervention and at six months, with pupils in the control group reporting less knowledge about new psychoactive substances than those in the intervention group. There was no evidence for these differences at the 12-month follow-up.

There was no evidence of a difference between the intervention and control groups at any of the follow-up points for life-time use of ecstasy. Similarly, there were no differences over time for lifetime use of new psychoactive substances and synthetic cannabis.

The authors’ conclusions

This online school-based prevention programme appeared to reduce pupils’ intentions to use new psychoactive substances and increased their knowledge about ecstasy and new psychoactive substances in the short term. The study did not reveal any counterproductive effects – in other words, providing pupils with harm-minimisation education did not inadvertently increase use or intention to use the substances, which is a possibility that has been identified in prevention research, especially when addressing low-prevalence substances and emerging issues.

Once the longer-term outcomes are known, international dissemination of Climate Schools: Ecstasy and Emerging Drugs would be feasible as the module is internet based, though adaptations would likely be needed to ensure the programme content remained accurate and relevant to the local audience. Previous successful adaptations demonstrate this can be done.


Findings logo commentary Prior to the trial, the effectiveness of the Climate Schools online lessons had been affirmed with interventions for problem drinking and cannabis use. The authors of the featured paper reported that the interventions significantly reduced consumption, related harms, and intentions to drink, and significantly increased knowledge about alcohol and other drugs (1 2 3 4).

There were numerous reasons for bundling ecstasy and new psychoactive substances into one prevention activity in this new Climate Schools module, including their similar age of onset, risk factors, and potential harms, as well as the overlap between ecstasy and new psychoactive substances in the form of drugs that mimic the effects of ecstasy. However, against the primary outcomes of the trial, the programme had only limited success. Pupils assigned to the intervention reported a significant reduction in their intention to use any new psychoactive substances at 12 months, but not in their intention to use ecstasy. Against the secondary outcomes, the module also had limited success. The intervention increased knowledge in the short term about ecstasy (post-intervention) and new psychoactive substances (post-intervention and at six months), as well as intentions to use synthetic cannabis (at the six and 12 month follow-ups only). Meanwhile, there was no significant difference between the intervention and control groups on the measures of lifetime use of ecstasy, new psychoactive substances, synthetic cannabis, and synthetic stimulants, and intention to use synthetic stimulants at six months.

A 24-month follow-up was scheduled for 2016 to gather long-term data and allow for continued monitoring, but the findings of this have yet to be published.

The control group in the featured study received health education classes including a component of drug education, meaning that the Climate Schools online lessons (a novel form of drug education) were being compared with standard drug education, as opposed to ‘no intervention’. Teachers were surveyed to assess the content of classes in the control group. This information was available in a separate document (see Appendix S1), and read as follows:

“All schools delivered some form of education about ecstasy and/or [new psychoactive substances] over the course of the year. Topics included short- and long-term effects, refusal skills and how to stay safe. The number of lessons spent on ecstasy and [new psychoactive substances] education ranged from one to 2.5 lessons, with a mean lesson time of 58 minutes. Three schools reported using computers and the internet to deliver the information and three schools indicated that guest speakers (police, drug and alcohol professionals) spoke to students.”

The appendix did not say whether this drug education was delivered over the same time period as Climate Schools (ie, in weekly sessions over a four-week period).

School-based drug education was and for many remains the great hope for preventing unhealthy or illegal substance use and the dominant form of universal prevention applied to all regardless of their risk for developing substance use problems. Across almost an entire age group, it offers an opportunity to divert the development of these forms of substance use before they or their precursors have taken root. Though the promise is clear, an Effectiveness Bank hot topic examines why the fulfilment is less so.

One possibility is to switch the objective to harm reduction rather than preventing or delaying substance use as such (1 2). Yet another possibility is to treat drug education as education, divorcing it from prevention objectives. According to an international authority on alcohol prevention, “curricula might well be based on general educational principles, rather than framed by ideology. Students are citizens and potential future consumers, and with respect to these roles, it is appropriate to provide them with biological and social science information about psychoactive substance use and problems, and to encourage discussion of the intellectual, practical, and ethical issues these problems raise.” In this vision, in drug education as in other topics, schools are seen as ‘teaching about’ agencies rather than the ‘teaching to’ (or not to) implied in a preventive role.

Previously referred to as ‘legal highs’, in May 2016 the Psychoactive Substances Act imposed a ‘blanket ban’ on all new psychoactive substances. These substances continue to pose unique challenges for treatment, harm reduction, and education professionals as relatively little is known about their potency, their effects on people, or what happens when used with other substances. Some new psychoactive substances are purposely designed to mimic wider known drugs. Synthetic cannabinoids (synthetic forms of cannabis), for example, are designed to resemble herbal cannabis, can be consumed in the same ways (eg, smoked or inhaled), and the names also often deliberately have cannabis connotations. People wishing to take cannabis may be initially unaware that they have been sold the synthetic form, or may believe from the look of it that it will produce similar sought-after effects – risks which are discussed in an expanded Effectiveness Bank hot topic, initially covering cannabis and now including this “new high”.

Among young people in contact with specialist substance misuse services in England between 2015 and 2016, 1,605 cited problematic ecstasy use (9%), and 1,056 (6%) concerns around the use of new psychoactive substances. As a primary problem substance cannabis dominated, accounting for three-quarters (or 12,863) of all patients in treatment in 2015/16.

Last revised 15 July 2018. First uploaded 25 June 2018

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