What price drug education? Recent reviews of the literature have suggested that drug education does not work. Peter Stoker argues that there is a way forward

A ROUGH RIDE FOR PREVENTION

It will come as no revelation to reader~of this journal that prevention (meaning primary prevention) has for some tome been taking a hammering. Mere mention of it raises hackles in some and dismissive epithets in others. The hackle-raising comes from those who choose to interpret the word literally: How dare one 'Prevent' others from using? This is a reprehensible, even immoral, infringement of personal freedom. Empowerment, meaning free choice in the use of drugs, should he the right of every individual of whatever age. As part of this educators should stay silent on the use/non-use issue; teaching should be about drugs, not against them (O'Hare et al., 1988). The Jismissive epithets emanate from those who have read a good deal of the literature available and conclude that drug use cannot he prevented.

Over the years that NIDA (USA) biennial household survey results have been readily accepted a,; proof of the need for harm reduction, sueing for peace as the 'War on Drugs' crumbles. However, when the same survey started showing reductions in drug use, it was scorned as no more (or less) than a conspiracy by the American public to make prevention workers feel good. Prevention workers in the area covered by these results have every right to feel good. Whilst the'War'as prosecuted by people in uniforms may well be a depressing sight, it is the 'civilians' in prevention work who are showing real progress. Other than this, there is the occasional reported success, for example the Germans have shown that they are good at rnore than just foot hall, but such reports are rare indeed (Nilson-Giebet, 1980,pp.20-24).
So why bother, the argument continues. If it is impractical and immoral to prevent use then switch to plan B - school the user (or potential user) so as to minimise harm, and switch the drug agencies whoare 'stuck in the outmoded abstinence model' over to a harm reduction role, retraining them to service the user's needs during his or her drug-Lising 'career' (Parry, 1988).
For drug agencies or drug educators world wide having primary prevention as part of their role all the above cuts at the very roots of their philosophy. But far from reacting, the response of many has been to disclain or ignore the criticism and carry on anyway. Too busy or too shy for long, sophisticated debate they have left the rostrum and the printed page to their critics. Small wonder then that the residual impression is that prevention has no case to offer.
Other factors have had their influence on current attitudes. Perhaps the most graphic example of harm reduction is in response to HIV/AIDS; few in Britain would argue against the issue of clean syringes/needles and condoms, plus advice, as part of the effort to prevent the spread of HIV infection. Merseyside has been particularly effective. Many prevention workers, including the author have thought through and accepted this logic, seeing no dichotomy between harm reduction for existing users coupled with prevention for the non-user. The argument starts (or should start) when the above, extremely justifiable, introduction of harm reduction 'in extremis' is opportunistically exploited as a springboard, promoting harm reduction as the educational model across the board, i.e. de-fund primary prevention and even treatment, redeploying the funds into harm reduction (Parry, 1988).

Undoubtedly one spur to this dialogue is an argument about funding priorities in a time of limited resources. Partisan argument will always emerge in this situation, but again prevention workers are leaving the field to their competitors for funds, when a more rational approach would he concerted action pressing for a general increase of funding. Meanwhile the argument against prevention proceeds by endeavouring to classify us all as drug users; your coffee beverage makes you just as much a drug user as someone else's heroin. By this definition'non-drug-users are a deviant minority'. Ergo, use of all drugs should be considered normal. This is but a short step from saying drug use should be the norm.

Norm, normal, normalisation - soft, low-key words lessening the chance of hard reactions from conservative authorities. Credit must be given to liberalist campaigners such as NORML and the Drug Policy Foundation for this sophisticated approach; likewise the 'softly, softly' strategy adopted by EMNDR All of them eschew provocative wording and all of them speak up volubly ,and articulately.

The cause of prevention has hardly been helped by cosmetic campaigns mounted by governments who are more concerned to show that they 'care' than about any lasting effect on drug use. This has happened in several countries and of course Britain has received its share. Advertising screws you up.

Further, where prevention initiatives have taken place evaluation has been the last item on the budget list, or more often has not even appeared at all. Projects short of people and/or cash make a professional judgement at the planning stage as to whether an initiative is worth while, then go for it, leaving any classic proof of worth to the academics. In the case of prevention this is perhaps more understandable, if not excusable, because it is notoriously difficult to evaluate definitively anything to do with attitudes 'and behaviour. We can rarely he Skirel if a behaviour changes, that it is the result of the educational initiative that is being tested, or whether other factors held sway, or whether the person concerned just changed his or her ruind (Edwards, 1984).

LACK OF PROOF

The blunt suirmiation of all this is that there is very little solid evidence to show that prevention works.

The skills for Adolescence programme developed from the American QUEST programme was subjected to evaluation in sevend schools in 1988 by workers from Christchurch College, Canterbury (Parsons et al., 1988). It won praise for reducing truancy, improving class discipline and performance, and strengthening pupil-teacher and school-parent relationships. But when it came to appraising drug, use prevalence, before ind after, the researchers ducked the question, making superficial remarks such as 'How can you measure it ?' and thus another opportunity for proper evaluation was lost.

The PRIDE organisation in America (Parent's Resource Institute for Drug Education) has pl~nty to be proud about. Its 1991 conference, the fourteenth, attracted almost 7000 attendees, youth and adult, and nearly 300 workshops were held during the week, involving delegates froin over 80 countries. But for an organisation boasting over 60 full-time staff, the resources applied to evaluation are regrettably slight; Al the more surprising when considering that the PRIDE President is a University of Georgia professor (of physology). Perhaps the single most tangible evaluation tool PRIDE has is a confidential questionnaire (though its original raison d'&tre was to awaken and galvanise communities previously unaware or in denial). This questionnaire has been run now for over 8 years and respondents run into millions; in one month alone (October 1987) 450 000 students in PRIDE's home state of Georgia completed the survey.

Co-authorand coordinator of the computer analysis of these questionnaires is Ronald D. Adams, another professor (of education), this time at Western Kentucky University. His location may explain why one of PRIDE's most detailed evaluations - a 5-year longitudinal study - is hased in Bowling Green, Western Kentucky (1989). Graphs of usage of various substances anild various school grades almost all show sustained reduction in the 5-year period. A specimen graph is given as Figure 1. As is usual with most statistics there is more than one way of viewing the results. For example, use of cannabis by twelfth graders may have dropped from 45 per cent to 30 per cent (= success?) but it is also true that even after 5 years of this programme 30 per cent are still using (= failure?) - depends where you stand!

Similar results are described in a more recent PRIDE newsletter (Summer, 1990) concerning 30 schools in California and Oregon. A 5year study of 4000 students showed reduction in cannabis and tobacco LISC, but no reduction in drinking (Ellickson and Bell, 1990).

A BRITISH INTERVENTION/PREVENTION STRATEGY

The author's practical experience with a west London drug agency is similar to that with many agencies in the work done with users, their families and friends: nonjudgemental and not insisting on abstimenceas a condition of attending, greater emphasis placed on the user appraising his or her own life and making informed choices, having considered actions and consequences. Other similarities exist in much of the education, training and HIV/AIDS work in schools and community. Harm reduction gu id ance/ass i stance for known users and also those perceived to he at risk is and always has been included, in work over more than 8 years.

Meanwhile self-funded study tours by the author to the USA (several) and Hong Kong (once) augmented desk study of prevention programmes operating in many countries. Among several good contenders the Illinois Teen Institute's I 5-year experience of weeklong experiental training camps looked particularly promising, together with the PRIDE youth programme and Youth to Youth (Columbus, Ohio). The author's wife and professional collegue created this international research and developed a prevention programme appropriate to the British culture, with the aim of empowering youth to stay drug,abuse free and maybe help others to achieve the same. In 1988 the first home-grown version was launched. In 1989 we saw a repeat with guest delegates from Sweden, Switzerland, Portugal and America; camps of 1990 and 1991 have been held with a sprinkling of international youth. The programme was named TEENEX, ineaning'teen experiental' learning.

Attendees at the camp are predominantly non-users but with a small proportion of casual users and other youngsters at risk in some way or other, the intention being to facilitate a positive peer environment to the benefit of all. In addition to the annual camp there are evening meetings and, when funds permit, residential weekends.

Besides TEENEX, another innovative project introduced has been TRIBES, a cooperative learning process 5. applicable to primary and secondary schools and used  for many years in several American states, with multiple  benefits. Other initiatives have included Kangaroo   Creek Gang, a video-based training programme currently in use in every primary school in Australia, and utilisation of the Life Education Bus (also Australian based) for which funding comes from TVAM and the Dire Straits rock band.

The striking aspect in comparing contributions by hundreds of international delegates at American conferences with those of the 400 or so delegates in Hong Kong (very few of whom were American) was the unity of commitment to prevention and the broad similarity of initiatives. Another commonality was the universal absence of British delegates! Prevention workers would say that this shows that Britain is behind most countries; doubtless hardened xenophobes would say it 7. shows Britain is ahead, and it's everyone else who is out ofstep.

Xenophobia, and in particular Americophobia, is a frequent facet of criticism of prevention, sometimes matching the hysteria it seeks to condemn (011are, 1988). The American political and media rhetoric does of course set itself up for pillory but it is no more representative of the main body of serious drugs work than is the case in this country. Likewise some American drugs workers corne across with alt-nost missionary zcal, but to discount the message because of some of the messengers is either a mistake or a deliberate misconstruction.

DOING THE HOMEWORK BETTER

If prevention is to sway the sceptics and justify a firm future then several specific actions are indicated:

1. More money now into longitudinal studies. The British Government's new Central Drugs Prevention Unit could usefully involve itself in this.

2. Better collation of existing research world wide, published as The Case for Prevention, in plain words.

3.  Critical assessment of which schemes work, which don't.

4. Collation of ancillary research justifying prevention: work by those such as Dr Robert Gilkeson on the harm caused by even moderate use of cannabis; Dr Harith Swadi's (1988) work on peer influence and family factors; Stoker and Swadi's (1990) on the same topic; Botvin's (1983) research on smoking prevention work and the use of lifeskills training.

5. Recognition that harm reduction has a place, but put it in its place, and in proportion to prevention. Educators, youth workers etc. need to retain the 'I personally don't recommend you using because' message alongside harm reduction; staying silent on prevention would be taken by even more youth as a tacit message that it's okay to do drugs so long as you use the least risky method.

6. Drop the rhetoric about 'War on Drugs' which backfires all too often. Apart from the inflammatory effect, if one talks of war people expect a victory in a finite period, and that isn't going to happen. What, we have with drugs is more like the contest between the Dutch and the sea. The sea continually seeks to ~ erode the land, whilst the Dutch continually prevent erosion and sometimes even achieve substantial reclamation, but they will never be able to let up.

Much more concentrated prevention work: it must he recognised that a little here and there is at best ~ useless. To succeed, prevention has to be substantial and sustained

Prevention is riot alone in needing evaluation evidence to support its case. Any measurement of changing, behaviours around harm reduction is fraught with all the same difficulties. The struggle to change behaviour is just as tough. Review of British syringe exchange schemes by Goldsmiths showed that despite all the efforts overa third of clients using the exchanges were still sharing (Stimson et at., 1988). Behaviour among those not patronising the exchanges is unlikely to he more careful. Such statistics are of course of no comfort to anyone, but they strengthen the resolve of prevention workers to continue to strive to reduce the number of people reaching such straits.

A note of caution here: the majority of critiques of drug education programmes have themselves been criticised as being inadequately rigourous (Goodstadt ' i 1980). Scrutinise everything, including the scrutineers! Prevention workers may not realise it but they owe harm reductionistsand other sceptics a debt of gratitude. In forcing a more rigorous assessment of prevention programmes (what works and what doesn't) a much more potent bran(] of prevention should be developed.

Above all there is a need to be clear that prevention is being chosen not merely to salve some moral conscience but because it is a rational, proven and effectiveprocess.

This article is based on a paper presented to the PRIDE International Conference at Atlanta, Georgia. Peter Stokes is a project worker with a west London drug/alcohol agency. Address any correspondence to: 3 Radnor Way, Slough, Berks SL3 7LA.

REFERENCES
Adams, R. D. (1989). From the computer: Bowling Green yields marijuana findings in five-year case study of PRIDE community plan. PRIDE Quarterty, Summer.
Botvin, G. J. (1983). Prevention of adolescent substance abuse through the development of personal and social competence. In: Glynn, T, J., Leukefeld, C. G. and Ludford, J. P. (Eds). Preventing Adolescent Drug Abuse: Intervention Stategies, pp. 115-140. Department of Health and Human Services, Maryland, USA.
Dorn, N. (1987). Minimisation of harm: a U-curve theory. Druglink, March/April.
Edwards, G. (1984). Addiction: a challen;e to society. New Society, 25th October.
Ellickson and Bell (1990). Prevention programmes effective in school setting. PRIDE Quarterly, Summer.
Goodstadt, M. S. (1980). Drug education - a turn-on or a turn-off? Journal of Drug Education, 10.
Nilson-Giebel, M. (1980). Peer groups help prevent dependence among youth in Federal Republic of Germany. International Journal of Health Education, 23,20-24.
O'Hare, P. A. (1988). Drug Education: the American way. Mersey Drugs Journal, May/June.
O'Hare, P.A, Clements, 1. and Cohen, J. (1988). Drug Education: A Basis for Reforra. International Conference on Drug Policy Reform, Maryland, USA.
Parry, A. (1988). Unpublished presentation to NW Thames Regional Health Authority Drug Workers Seminar, 15th September.
Parsons, C. et al. ( 1988). Food for thought. (Evaluation Unit, Christchurch College, Canturbury). Monitor (TACADE) No. 78, Autumn.
Stimson, G. Donoghoe, M., Alldrit, L. and Dolan, K. (1988). Syringe exchange 2 - the clients. Druglink, July/August, 8-9.
Stoker, A. and Swadi, H. (1990). Perceived family rela- ~ tionships in drug-using adolescents. Drug and Alcohol Dependence, 25, 293-297.
Swadi, H. and Zeitlin, H. (1988). Peer influence and adolescent substance abuse: a promising si( Journal of Addiction, 15 3-15 7.