EFFECTIVENESS BANK BULLETIN 15 April 2009: reviews and meta-analyses
EFFECTIVENESS BANK BULLETIN 15 April 2009: reviews and meta-analysesThe entries below are our accounts of documents selected by Drug and Alcohol Findings as particularly relevant to improving outcomes from drug or alcohol interventions in the UK. Entries were drafted after consulting related research, study authors and other experts and are © Drug and Alcohol Findings. Permission is given to distribute these entries or incorporate passages in other documents as long as the source is acknowledged including the web address http://findings.org.uk. However, the original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors; if displayed, click Request reprint to send or adapt the pre-prepared e-mail message. Abstracts are intended to summarise the findings and views expressed in the study. Below are comments from Drug and Alcohol Findings. Links to source documents are in blue. Hover mouse over orange text for explanatory notes.
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Call to extend recovery vision beyond time-limited treatment ...
UK government advisers call for major expansion of needle exchange ...
Methamphetamine dependence reacts well to psychosocial therapies ...
Drug testing school pupils is ineffective and risky ...
Recovery management and recovery-oriented systems of care: scientific rationale and promising practices.White W.L.
Northeast Addiction Technology Transfer Center, Great Lakes
Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health/Mental Retardation Services, 2008.
Sweeping, learned but practice-oriented tour-de-force from the US recovery advocate who sees the creation of a recovery-friendly environment as the best way to ensure a lasting resolution of substance use problems with or without abstinence.
Abstract This booklet defines and distinguishes acute care and recovery management models of addiction treatment, and the terms ‘recovery management’ and ‘recovery-oriented systems of care’. It identifies recovery-focused performance measures Such as access, engagement, retention, service scope, service duration, linkage to communities of recovery, and post-treatment monitoring and support. which can be used to evaluate addiction treatment as a system of care and evaluate the performance of local organisations specialising in the treatment of severe alcohol and other drug problems, and presents research and administrative data related to these measures. Promising practices aimed at improving long-term recovery outcomes are highlighted and measures suggested which can be used to evaluate addiction treatment at both macro (system of care) and micro (individual programme/unit/worker) levels of performance.
The key points made in the monograph are that:
• Findings from scientific studies and systems-performance data relating to intervention for severe alcohol and other drug problems support extending the acute care model to a model of sustained recovery management.
• The findings also support addiction treatment system redesign efforts focused on: infrastructure enhancement; early intervention and improvements in service access and therapeutic engagement; improved systems of individual, family, and community assessment; broadening institutional and professional resources involved in service delivery; a shift in the service relationship to a partnership model; elevating the scope, duration, and quality of services; assertively linking individuals and families to communities of recovery; providing post-treatment monitoring, support and early re-intervention services for all clients/families for up to five years following completion of primary treatment; and the systematic collection of long-term post-treatment recovery outcomes.
• Selected states, local communities, and addiction treatment institutions have already begun this recovery-focused systems-transformation process.
• Model components of the recovery management model (eg. assertive outreach, enhanced service access, evidence-based service ingredients, and recovery check-up pilots) are already in operation and can be refined for system-wide implementation.
• An existing model of intervention and long-term support which incorporates many dimensions of the recovery management model is the network of physician health programmes in the United
States, whose evaluations have revealed the highest long-term recovery rates reported in the scientific literature.
• It is time we proactively managed the prolonged course of addiction and recovery careers rather than focusing on self-encapsulated episodes of biopsychosocial stabilisation.
The booklet summarised its findings as follows:
• Scientific research supports calls for a transformation in the structure and service processes in the United States from a model of acute intervention to a broader model of sustained recovery management. More specifically, the findings call for:
• Strengthening the infrastructure of addiction treatment to ensure sustained continuity of support and accountability to the individuals, families, and communities served by addiction treatment institutions.
• More proactive systems of identifying, engaging, and ensuring service access for individuals and families at the earliest possible stage of development of alcohol and other drug-related problems.
• Individual, family, and community needs-assessment protocols which are comprehensive, strengths-based, and ongoing.
• Use of multidisciplinary and multi-agency service models for supporting long-term recovery for individuals, families, and neighbourhoods experiencing severe, complex, and enduring alcohol and other drug problems.
• Reconstruction of the service relationship from an expert model to a partnership model involving a long-term recovery support alliance.
• Expanding the service menu, with an emphasis on evidence-based and recovery-linked service practices.
• Ensuring each client and family an adequate dose and duration of pre-treatment, in-treatment, and post-treatment clinical and recovery support services.
• Exerting a greater influence on the post-treatment recovery environment by shortening the physical and cultural distance between the treatment institution and the natural environments of those served, and by intervening directly to increase family and community recovery capital.
• Assertive linkage of clients and families to recovery mutual aid groups and other indigenous recovery support institutions.
• Models of post-treatment monitoring (recovery check-ups for up to five years following discharge from primary treatment), ongoing stage-appropriate recovery education, sustained recovery coaching, and, when needed, early re-intervention.
• Systematic and system-wide collection and reporting of long-term post-treatment recovery outcomes for all individuals and families admitted to addiction treatment.
The booklet seeks to extend our vision of the addiction and de-addiction process across a life and across the entire social system, calling upon us to locate 'treatment as we know it' (time-limited bout of professional care for a problem which has become intolerably severe or attracted the attention of people in a position to lever the individual in to treatment) within this broader picture. In the process it redirects our attention to the large tracts of this widened vision missing or underdeveloped in current policies and service provision. Primarily these are ways of intervening before things have descended to this point and forms of extended monitoring and care after initial treatment, and the systems outside the clinic which shape the environment within which the patient must eventually sustain (or not) their attempt to reshape their life. Much of this is beyond the direct reach of any treatment institution, hence the emphasis on mutual aid, "communities of recovery", and public and political advocacy aimed at fostering a more recovery-friendly environment, within which de-stigmatisation and the public display of successful recovery are major strategies. This call for a rebalancing towards non-clinical aspects is carried in to the clinical encounter itself, where workers are called upon to see themselves not as experts directing the course of treatment, but as consultants helping the patient and their associates self-manage their problems and achieve their goals. Usefully chapters end with a set of performance measures which services and treatment systems can use to judge how far they have embraced this wider vision.
Last revised 02 April 2009 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Matching resources to needs is key to achieving 'wrap-around' care objectives NUGGET 2006
Peer-based addiction recovery support: history, theory, practice, and scientific evaluation REVIEW 2009
Effective services for substance misuse and homelessness in Scotland: evidence from an international review REVIEW 2008
The power of the welcoming reminder THEMATIC REVIEW 2004
The grand design: lessons from DATOS KEY STUDY 2002
Self help: don't leave it to the patients THEMATIC REVIEW 2005
Continuing care research: what we have learned and where we are going REVIEW 2009
'Real-world' studies show that medications do suppress heavy drinking NUGGET 2005
Improving public addiction treatment through performance contracting: the Delaware experiment STUDY 2008
The primary prevention of hepatitis C among injecting drug users.Advisory Council on the Misuse of Drugs.
[UK] Home Office, February 2009.
To curb hepatitis C, UK government advisers call for substantial expansion of needle exchange provision so that a new set of equipment is available for every injection and for methadone programmes to provide access to injecting equipment and vice versa.
Abstract The Advisory Council on the Misuse of Drugs is appointed by the UK government to provide it with independent, expert advice on drug-related issues in the UK. The featured report drew on and was published concurrently with public health guidance on needle and syringe programmes Such programmes aim to curb the spread of disease and to help prevent other medical problems due to unsafe injecting, in particular the sharing of used injecting equipment. Their core activity is the provision of sterile equipment which may be allied with facilities and/or requirements for the return of used equipment, for which the more familiar term is needle (or syringe) exchange schemes. from the UK's National Institute for Health and Clinical Excellence (NICE).
The featured report ended with the following conclusions and recommendations.
• About half the drug injectors in the UK are infected with hepatitis C. However, there is a greater than threefold difference between sites in the UK. Hepatitis C prevalence among injectors may have fallen during the early 1990s but increased from the mid 1990s. Infection among those who recently started injecting almost doubled from 1998 to 2007. The public health challenge now is to increase action and effective prevention to stem the upward rise. The report endorsed the recommendations from NICE and commended the hepatitis C action plan in Scotland which has already started the process of expanding HCV prevention.
Recommendation 1 Local service planners need to review local needle and syringe services (and be supported in this work) in order to take steps to increase access and availability to sterile injecting equipment and to increase the proportion of injectors who receive
100% coverage
That is, receive as many sets of sterile injecting equipment as they need to use a new set for each injection.
of sterile injecting equipment in relation to their injecting frequency.
• The strength of the evidence for the effectiveness of many interventions in reducing hepatitis C transmission among injectors is weaker than the report's authors expected. However, there is emerging epidemiological evidence (supported by preliminary UK studies) that the combination of opiate substitution therapy and needle and syringe programmes is the most effective way to reduce hepatitis C (and HIV) incidence among active injectors. Neither alone may be sufficient to prevent hepatitis C. A comprehensive hepatitis C prevention and harm reduction service needs to ensure both are provided and working together, and that the focus is on reducing injecting frequency and duration.
Recommendation 2 Local services need to provide a comprehensive intervention so that those offering opiate substitution therapy also provide access to sterile injecting equipment and those providing sterile injecting equipment facilitate entry into opiate substitution therapy.
• The frequency of hepatitis C testing by prisons, specialist drug agencies, and other agencies managing current injectors, has been poor. About half of injectors are unaware they are hepatitis C positive. This needs to change. Dried blood spot tests, which are non-invasive and easy to learn, provide part of the solution. Hepatitis C testing and knowledge of hepatitis C status provides an opportunity to initiate further health education advice and harm reduction interventions of benefit to the patient (such as managing alcohol use if infected), to other injectors and society (reducing injecting risk behaviour), and potentially to both patient and society (referral for hepatitis C treatment; see recommendation 7). Information on hepatitis C testing may also be used to improve local and national estimates of the numbers infected with hepatitis C.
Recommendation 3 All services (especially specialist drug clinics, low threshold agencies, and prisons) in regular contact with injectors need to increase the frequency of hepatitis C diagnostic testing among their clients.
Recommendation 4 Review workforce and training needs of needle and syringe programmes and other drug workers and if necessary develop further training in order to ensure that staff are competent and confident in providing hepatitis C and other blood-borne virus antibody testing.
Recommendation 5 Establish a monitoring programme to measure success against recommendations 3 and 4 such as: the proportion of specific agency caseloads (including prisons, specialist drug clinics, and patients in opiate substitution therapy shared care) tested for hepatitis C and other blood-borne viruses, and the proportion of injectors tested anonymously who are unaware of their hepatitis C status.
• There is an urgent need for UK-based research on the effectiveness and cost-effectiveness of needle and syringe programmes, opiate substitution therapy, and other interventions to reduce hepatitis C incidence.
Primarily
Though improving the evidence on certain biological and behavioural factors that determine hepatitis C transmission is also important.
better evidence is needed on the 'intervention effect' of opiate substitution therapy and needle and syringe programmes. This will enable researchers and modellers to provide service planners with clearer recommendations on optimal service provision in relation to their different epidemics. The expansion of services and development of novel techniques to estimate hepatitis C incidence provide an ideal opportunity to generate better evidence. Cost-effectiveness modelling suggests that hepatitis C treatment of active injectors could have both a primary (reducing hepatitis C transmission) and a secondary (preventing hepatitis C morbidity) prevention role. The models
suggest
However, assumptions on the level of immunity and re-infection rates following successful hepatitis C treatment need to be tested.
that the combination of opiate substitution therapy, needle and syringe programmes and hepatitis C treatment will have the greatest impact on hepatitis C.
Recommendation 6 Studies are required that directly test the effectiveness of opiate substitution therapy and needle and syringe programmes on reducing hepatitis C incidence (ie, that generate evidence on the intervention effect).
Recommendation 7 A study is required to measure the re-infection rate of injectors who have been treated for hepatitis C and to evaluate the effectiveness of providing hepatitis C treatment to current injectors in order to reduce hepatitis C incidence.
• There has been much
innovation
Such as the provision of injecting paraphernalia and colour-coded syringes and most recently the 'harm reduction works' health education programme.
of prevention initiatives in the UK. Innovation and development need continued support, but more attention needs to be given to evaluation and to modelling potential impact and cost-effectiveness.
Recent injectors
Who started injecting perhaps in the past six months or year.
have an elevated risk of hepatitis C infection, but no reviews provide evidence on which interventions successfully target, and reduce hepatitis C incidence, among this population. People with a prison history have a greater risk of infection but we cannot explain fully why and have no good quality review-level evidence or UK research on the effectiveness of prison-based harm reduction interventions. Homelessness also increases the risk of hepatitis C infection.
Recommendation 8 Evaluate whether new health education messages have changed the perception and views of injectors about the risk and inevitability of hepatitis C; and whether campaigns to teach and encourage injectors to use bleach to clean injecting equipment (when sterile equipment is not available) have resulted in safer re-use of equipment.
Recommendation 9 Studies are required to determine why injectors with a prison history are at greater risk of hepatitis C, and to develop and trial appropriate harm reduction interventions within the prison service and in the community to reduce the risk.
Recommendation 10 Develop and promote effective strategies to target and reduce hepatitis C risk among recent injectors.
Recommendation 11 A study is required to investigate hepatitis C risk and prevalence among people who use performance- and image-enhancing drugs
• Compared to many other countries, the UK has a well developed public health surveillance system for measuring the prevalence of hepatitis C. Though there is a need to improve
some of the epidemiological evidence,
Including recruitment and coverage of routine surveillance, and risk of hepatitis C among some groups, eg, see recommendations 3, 9 and 11.
greater priority should be given to supporting and monitoring the impact of interventions to reduce hepatitis C infection.
Recommendation 12 The public health surveillance of hepatitis C needs to be developed and extended so that it can monitor and provide evidence on the impact of interventions on hepatitis C risk; and if required the roles and responsibilities of public health scientists and public health agencies need to be extended in order to support the development and evaluation of hepatitis C interventions.
Last revised 30 March 2009 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Needle and syringe programmes: providing people who inject drugs with injecting equipment REVIEW 2009
Hepatitis C therapy cost-effective for injectors NUGGET 2005
Hepatitis C is spreading more rapidly than was thought OFFCUT 2005
International review and UK guidance weigh merits of buprenorphine versus methadone maintenance NUGGET 2008
Drug and alcohol services in Scotland STUDY 2009
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
Substitution treatment of injecting opioid users for prevention of HIV infection REVIEW 2008
Prescription of heroin for the management of heroin dependence: current status REVIEW 2009
Critical issues in the treatment of hepatitis C virus infection in methadone maintenance patients REVIEW 2008
A systematic review of cognitive and behavioural therapies for methamphetamine dependence.Lee N.K., Rawson R.A. et al. Request reprint
Drug and Alcohol Review: 2008, 27(3), p. 309–317.
After trawling the world literature for randomised trials, reviewers found it is less the case that 'nothing works' with methamphetamine users, more the case that, within reason, everything works for some people to some degree and for some time.
Abstract After cannabis, methamphetamine is the most widely used illicit drug in the world and poses significant challenges for treatment providers. Much of the treatment knowledge about methamphetamine users has been extrapolated from studies of treatment for cocaine dependence. Medications have been shown to be of limited effectiveness, making psychological interventions the treatment of choice. This review focuses upon randomised trials of cognitive-behavioural or behavioural (such as contingency management) interventions for methamphetamine users. A systematic search of published literature discovered just 12 reports of intervention studies which tested cognitive-behavioural or behavioural interventions using randomised trial methodology. Most commonly, studies examined cognitive-behavioural therapy and/or contingency management. Cognitive-behavioural therapy appears to be associated with reductions in methamphetamine use and other positive changes, even over very short periods of treatment (two and four sessions). Contingency management studies found a significant reduction of methamphetamine during application of the procedure, but it is not clear if these gains are sustained at post-treatment follow-up. The review highlights that there are effective treatments for methamphetamine dependence. Alcohol and other drug clinicians are familiar with these types of interventions and should use them and convey to clients that they are effective. Services and policy makers should ensure that best practice interventions are implemented in alcohol and other drug services.
The authors concluded that psychological intervention is effective in addressing methamphetamine use and dependence. Cognitive-behavioural therapy and contingency management are two accessible interventions easily implemented in current services. There is still more work to conduct in improving methamphetamine treatment, however, and further research into cognitive-behavioural and behavioural treatments for methamphetamine users is required, with a focus on improving longevity of the effect of intervention and improving effectiveness among more complex presentations.
This review gives the lie to the common assumption that 'There are no effective treatments for stimulant users.' It is true that there are no effective pharmacological treatments, like methadone or naltrexone for opiate dependence, and no specifically effective psychosocial therapies. Psychosocial therapies have been developed which are tailored to stimulant dependence and to the characteristics of the users of these drugs, but these have yet to be shown to be consistently more effective than other therapies, and are not different in kind from the therapies used with other caseloads. However, it is less the case that 'nothing works', more the case that, within reason, any bona fide therapy works for some people to some degree and for some time. This is true of cocaine use and, as the authors of the review concluded, also true of methamphetamine use. As they observed: "Based on the studies reviewed, methamphetamine use appears to be reactive to intervention. In many studies the control group also made significant reductions in methamphetamine use ... assessment and assertive follow-up alone may have a significant impact on use and ... should be a routine part of good clinical practice with methamphetamine users ... The use of assessment, follow-up and a self-help booklet may be good practical advice for a group that is considered to attend treatment for relatively short periods."
In the main study which led to this conclusion, when all patients were assessed and regularly followed up by the researchers, face-to-face therapies led to only modest and statistically non-significant extra reductions in amphetamine use compared to a self-help booklet. Interrupting stimulant use is generally not considered a major difficulty and often happens without any treatment. The review shows that offering therapy and in particular rewarding abstinence through contingency management procedures extends and deepens the interruption, but especially in respect of contingency management, it is unclear whether the gains are sustained.
However, any conclusions are tempered by the limited range of interventions tested and by the limited periods over which patients were followed up. As the authors imply, so far as we can tell, the most important thing is to offer easy-to-access, acceptable and credible treatments (which for many people need not be intensive), and to regularly follow up patients to establish whether the resultant interruption in excessive stimulant use has been sustained and if not, to offer further support.
Thanks for their comments on this entry in draft to Nicole Lee of the Turning Point Alcohol and Drug Centre in Australia and Richard Rawson of the University of California at Los Angeles, USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 05 April 2009 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
Toward cost-effective initial care for substance-abusing homeless STUDY 2008
Brief interventions short-change some heavily dependent cannabis users NUGGET 2005
Cognitive-behavioral treatment with adult alcohol and illicit drug users: a meta-analysis of randomized controlled trials REVIEW ABSTRACT 2009
Continuing care research: what we have learned and where we are going REVIEW 2009
Review of treatment for cocaine dependence STUDY 2010
Aftercare calls suit less relapse-prone patients NUGGET 2005
A randomized trial of individual and couple behavioral alcohol treatment for women STUDY 2009
Behavioral couples therapy (BCT) for alcohol and drug use disorders: a meta-analysis REVIEW 2008
Drug testing in schools evidence, impacts and alternatives.Roche A.M., Pidd K., Bywood P. et al.
Australian National Council on Drugs, 2008.
Australian review supports UK guidance indicating that testing school pupils for illegal drugs is a risky procedure of unproven effectiveness and questionable ethics which may backfire by alienating pupils.
Abstract Australia's National Centre for Education and Training on Addiction was commissioned by the Australian National Council on Drugs in March 2007 to undertake an independent, comprehensive and critical examination of all relevant issues involved in drug detection and screening in the school setting. The results of the review are presented in this report.
Overall, the body of evidence examined indicates a strong case to be made against drug detection and screening strategies in schools.
• Most drug tests are insufficiently reliable for use in schools. Accuracy can vary greatly according to conditions and circumstances. Generally a test is considered acceptable if it identifies 90% of people who have actually used the substance being tested for, correctly 'clears' 90% who had not used it, and overall correctly identifies or clears 95% of the people tested. Many tests which might be used in schools fall well below these levels. Even if they did reach these standards, 1 in 10 children would be falsely accused of illicit drug use, risking a range of negative legal, social and psychological consequences which would need to be catered for.
• The cost of testing is very large and would represent a substantial impost on any education system's budget.
• A wide range of moral and legal issues act as serious concerns, if not impediments. In the report consideration was given to the rights of the child, invasion of privacy, protection from assault, and the school's duty of care.
• Prevalence of illicit drug use by schoolchildren is very low, making detection a technically challenging task.
• The highest use levels occur among high risk and vulnerable groups of children, including poorer academic performers and (in Australia) indigenous pupils, suggesting that punitive and inquisitorial methods of deterrence are ill-advised.
• Evidence indicates that drug testing is an ineffective deterrent. The evidence is limited, derived exclusively from the United States, and poor in quality. No studies provided appropriate controls or baseline data to adequately determine whether changes in the proportions of pupils who tested positive could be attributed to a drug testing programme. Only two studies were found which evaluated impacts on issues such as psychological wellbeing or behavioural and educational outcomes. Of these, one found that while most pupils were undisturbed by the drug testing experience, over a quarter were distressed or angered. The other reported that drug-tested pupils had more negative attitudes and beliefs about drug testing, the school, and drug use outcomes, compared to pupils who had not been tested. Several uninvestigated
potential harms
Including: damage to the child–school or child–parent relationship and erosion of school connectedness; truancy to avoid testing and school exclusion for positive tests (particularly pertinent for pupils who are at risk and most in need of a supportive educational environment); reduced participation in healthy activities; conversion to other less detectable, but potentially more harmful substances; diversion of school resources from education to manage drug testing; psychological distress and embarrassment due to unwarranted invasion of privacy; breach of confidentiality when pupils may be required to declare use of prescribed medication; false sense of a drug-free environment when children with problematic drug use evade tests or are not detected and, therefore, are not referred to appropriate treatment.
were also identified.
• An effective array of school-based prevention interventions is now available to schools, offering alternatives to drug testing. The review identified three different but complementary evidence-based strategies schools might implement to prevent drug-related problems among their pupils. These were: supporting and developing connectedness between the child and their school; providing targeted early and brief interventions for high risk youth; and offering family strengthening interventions. Measures that encourage pupils to bond with their schools as social institutions and to form trusting, nurturing relationships with staff and other pupils represent the most important and empirically validated drug prevention strategies available to schools.
In 2009 a journal article based on the featured review concentrated on whether drug testing does deter use, the accuracy of the tests, and the ethical and legal implications of testing Australian school-aged children.
The review was unable to include a very recent study, the first to randomly allocate schools to testing versus no testing and then to follow up the pupils to test the results. However, had this been available to the reviewers it would simply have strengthened their conclusions. At best the results were inconclusive about impacts on substance use and if anything negative in terms of the pupils' attitudes to risktaking and their beliefs that the authorities were opposed to drug use.
In contrast with the USA, Britain has merely flirted with the idea of testing school pupils for drugs. It was tried in at least two schools and was recently being considered by several others, though a planned large scale trial in Kent fell through when (as the review suspected they might) schools were unwilling to divert funds from other activities. Police sniffer dogs are an alternative also tried in the UK. An evaluation commissioned by Bedfordshire police concluded that the costs and the risks (among others, of alienating pupils Many felt the aim was to 'catch them out' and that they should not be made to parade past sniffer dogs. and publicly and potentially falsely stigmatising individuals – risks identified in the featured review) were balanced by little in the way of benefits. Pupils in the school where the dogs were used actually became less likely to believe that the experience would deter youngsters from having drugs inside school.
Official guidance for England published in 2004 did not explicitly rule out testing or sniffer dogs but did advise "extreme caution" and raised serious concerns such as whether such measures are consistent with a school's pastoral responsibilities. None of the recent UK national policies (for England, Scotland, Wales and Northern Ireland) mentioned these measures, a sign perhaps that initial governmental interest has receded. If so this would be in line with expert opinion from the UK government's drug advisers who recommended against sniffer dogs and testing in schools. As in Australia, in the virtual absence of research, their concerns were over ethics, practicality, cost, and the potential impact on relationships with pupils. Overall, the slim evidence to date and these other concerns give no reason to subject pupils to drug testing or examination by sniffer dogs at random or without cause.
Thanks for their comments on this entry in draft to Ann Roche of the National Centre for Education and Training on Addiction at Flinders University in Australia. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 16 May 2010 Comment on this entry Give us your feedback on the site (one-minute survey) Back to contents list at top of page
British study queries use of sniffer dogs to detect pupils' drug use NUGGETTE 2004
Testing school pupils for drugs does not reduce drug use NUGGETTE 2003
False dawn for drug-free schools in Taiwan FOOL'S GOLD 1999
UK-style school drug prevention programme helps prevent regular drinking NUGGET 2003
Substance-focused initiatives not only way schools help prevent risky substance use NUGGET 2008
Drug education: inspections show that tick box returns are no guarantee of quality NUGGETTE 2003
Drug prevention best done by school's own teachers not outside specialists NUGGETTE 2005
