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National Institute for Health and Care Excellence and Public Health England.
[UK] National Institute for Health and Care Excellence, 2017
From the UK’s health and social care advisory body, evidence-based guidance on how to improve the delivery of substance use prevention to at-risk children, young people, and adults.
Summary This guideline from the National Institute for Health and Care Excellence (NICE) covers interventions for preventing the misuse of illicit drugs, new psychoactive substances (previously known as ‘legal highs’) and prescription-only medicines, targeted at groups of children, young people and adults most likely to start using drugs or already experimenting or using drugs occasionally, including people whose lives are affected by: homelessness; mental health problems; history of sexual exploitation or sexual assault; involvement in commercial sex work; being lesbian, gay, bisexual or transgender; not being in employment, education or training (including children and young people who are excluded from school or truant regularly); attending nightclubs and festivals; as well as children and young people whose carers or families use drugs, who are looked after or care leavers, or in contact with young offender teams but not in secure environments (ie, prisons or young offender institutions).
This evidence-based guidance from the UK’s health and social care advisory body provides an overview of how to improve the delivery of substance use prevention to at-risk groups of children, young people, and adults.
Although there was limited research to draw upon from the UK and for particular at-risk groups, the evidence was sufficient to make recommendations relating to assessment and incorporating prevention activities into existing services.
Helping children and young people develop a range of personal and social skills is a priority, along with information, advice, and feedback for adults as standard practice.
The term ‘drug misuse’ is used throughout, and defined as dependence on, or regular excessive consumption of, psychoactive substances, leading to physical, mental or social problems.
There was limited evidence on the effectiveness of interventions from the UK. Most studies were undertaken in the US, and although the findings are likely to be transferrable, key differences in social norms, education, care, and criminal justice and healthcare systems may influence the effectiveness of interventions when applied in UK settings.
For some of the at-risk groups under consideration there was no specific evidence of effectiveness, including people involved in commercial sex work or who have been sexually exploited, people not in employment, education or training, and people who attend nightclubs and festivals. Furthermore, there was no evidence of the acceptability of interventions for people with mental health problems, people involved in commercial sex work, people not in employment, education or training, and children and young people whose parents use drugs.
As none of the studies reported any adverse effects such as death or overdose, the expert committee that compiled the guidance concluded that the interventions were unlikely to be harmful.
There were no studies on the cost-effectiveness of drug misuse prevention, and therefore additional work was undertaken to estimate the economic impact of seven family-based, web-based, and motivational interviewing interventions. Most of the interventions did not change drug use by more than 5%, and none of the studies showed a reduction in drug use that was maintained for more than one year. This meant it was difficult for the interventions to make a large reduction in societal costs. In addition, most of the studies looked at cannabis and ecstasy use, and it is not clear how the social costs of using cannabis and ecstasy compare to those of other drugs.
Some interventions were deemed likely to be cost-effective if they could be provided at a lower cost and their effects sustained over a longer duration than was considered in the analysis. For example, an intervention costing £100 per person that reduced drug use by 5% maintained over two years would be cost-effective. If the intervention cost more than £100, the reduction in drug use or duration of effect would need to be higher for the intervention to be cost-effective.
Alongside the featured recommendations, practitioners should consider NICE guidance on individual approaches to behaviour change, which advises the delivery of very brief, brief, extended brief, and high intensity behaviour change interventions and programmes to people who are at risk of damaging their health through their behaviour, and where relevant, guidance on the diagnosis and management of alcohol-use disorders, coexisting severe mental illness and substance misuse, psychosocial interventions, and withdrawal from opioids.
All practitioners who are in contact with people from at-risk groups should be aware of drug misuse prevention and use every contact to identify those at risk. They should also be aware that assessment may raise safeguarding concerns, and will need to think about the immediate safety of the person being assessed, as well as any people under their care, and whether any action is needed.
It is essential to conduct an assessment before any intervention to ensure that it is appropriate and no harm is done. This can be done in routine appointments, such as health needs assessments for children and young people who are looked after, or incorporated into unplanned contact, such as when someone attends an emergency department as a result of drinking.
Practitioners should discuss the person’s circumstances including:
• their physical and mental health, and their personal, social, educational or employment circumstances (which may trigger a more in-depth assessment);
• any drug use (including the type used and how often);
• what their priorities are and how these might affect next steps or referral to other services.
There is no suitable tool for all at-risk groups or for assessing all vulnerabilities. Therefore, this guideline does not recommend a specific assessment tool – instead, advising that a consistent, locally agreed, respectful, and non-judgemental approach be applied.
Practitioners should consider providing information about drug use and available support in settings that reach people who use drugs or are at risk of using drugs including nightclubs and festivals, sexual and reproductive health services, primary care, supported accommodation or hostels for people without permanent accommodation, and gyms (to target people who are taking or considering taking image- and performance-enhancing drugs).
Prevention activities should be incorporated into a range of existing statutory, voluntary or private services, including:
• health services, for example primary care, community-based, mental health, sexual and reproductive health, drug and alcohol, and school nursing and health visiting services;
• specialist services for people in groups at risk;
• community-based criminal justice services, including adult, youth and family justice services;
• accident and emergency services.
Practitioners should consider skills training for children and young people who are assessed as vulnerable to drug misuse (as well as their carers or families), ensuring it helps them develop a range of personal and social skills, such as listening, conflict resolution, refusing offers of drugs, identifying and managing stress, making decisions, coping with criticism, dealing with feelings of exclusion, and making healthy behaviour choices. For children and young people who are looked after or care leavers, skills training should put particular emphasis on how to deal with feelings of exclusion.
Practitioners should take into account the age, developmental stage, vulnerabilities, cultural context, religion, ethnicity and any other specific needs or preferences of the child or young person when deciding:
• whether to offer training sessions to children and young people and their carers or families together, or whether to offer separate sessions;
• the content of the skills training;
• whether to provide individual or group-based sessions;
• the number of sessions needed (though a minimum of two sessions is recommended);
• where to hold the sessions;
• how long each session should last.
Skills training is likely to be a more cost-effective way to reduce the risk of drug misuse than family-based and motivational interventions as it is more likely that skills training could be delivered as part of existing services for less than £100 per person. Skills training is also likely to improve a range of outcomes, including those not related to drug misuse.
Information on how to provide young people-friendly services is available courtesy of the Department of Health.
Based on the evidence, the guideline cannot recommend skills training or motivational interventions for adults who are vulnerable to drug misuse. In studies which found current practice as effective as motivational interviewing, current practice included brief information and education on drugs and their effects, plus feedback on the recipient’s substance use. It is therefore recommended that adults who are assessed as vulnerable to drug misuse should receive these components as part of standard practice.
At the same time as the assessment, adults who are vulnerable to drug misuse should be offered information and advice both verbally and in writing. This should include clear information on drugs and their effects, advice and feedback on any existing drug use, information on local services, and where to find further advice and support.
Advice should be offered in a non-judgemental way, tailored to the person’s preferences, needs, and level of understanding about their health.
Practitioners should discuss and agree a plan for follow-up at the assessment to determine whether additional information or referral to specialist services is needed.
commentary This guideline from NICE, the UK’s health and social care advisory body, recommends that practitioners working with at-risk groups use every contact to identify those most likely to start using drugs, or who are already experimenting or using drugs occasionally, through an assessment process that is a consistent, locally agreed, respectful and non-judgemental. For children and young people, helping them develop a range of personal and social skills is a priority, including how to listen, resolve conflict, refuse drugs, identify and manage stress, make decisions, cope with criticism, deal with feelings of exclusion, and make healthy behaviour choices. For adults, the guideline was less prescriptive, but encouraged standard practice that incorporated brief information and education on drugs and their effects, plus feedback.
Based largely on existing reviews, a report for the German Federal Centre for Health Education comprehensively assessed substance use prevention approaches. Among its many conclusions were that approaches based solely on information provision are ineffective, in contrast to the more positive evidence for life skills and multi-component community programmes. For the type of targeted prevention work covered in the featured guideline, the international literature recommended the following measures:
• In the family: the supervision and assistance of first-time parents by midwives; lifeskills training for children displaying problem behaviours and for their parents; family programmes for families affected by alcohol dependence.
• In schools: lifeskills programmes with additional elements for individual young people up to the age of 20 who are at high risk of illicit drug use.
• In colleges: personal, brief interventions; online and computer-based feedback of assessment or screening results and ‘normative’ feedback comparing the individual’s substance use with that of their peers; web-based programmes; gender-specific ‘expectancy challenge’ interventions which ‘challenge’ assumptions about the effects of drinking by asking participants to identify who (including themselves) has drunk alcohol versus an identical non-alcoholic drink; multi-component approaches consisting of providing information, motivational interviewing and feedback of assessment or screening results.
• In leisure/community settings: for alcohol, mentoring programmes with teenagers; for alcohol and illicit drugs, multi-component projects in family and leisure settings.
• In healthcare settings: for alcohol and cannabis, face-to-face brief interventions in hospitals.
Pregnant women were not included as an at-risk group in the featured evidence review. The committee that compiled the guidance agreed that studies on drug use in pregnant women are most likely to be studies of treatment for dependent drug users rather than prevention studies and therefore would not be relevant, and furthermore that existing NICE guidance on pregnancy and complex social factors already includes substance misuse in pregnant women. The Effectiveness Bank features an example of ‘pre-conception’ prevention work, documenting the findings of a US-based trial of a bundle of services for risky drinking, smoking, and ineffective contraception designed to prevent substance use-exposed pregnancies.
Try this search of other entries related to targeted (also known as ‘selective’ or ‘indicated’) prevention.
Last revised 14 December 2018. First uploaded 05 December 2018
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