Working Group on Measures for the Prevention and Control of Drug Dependence, Manila, Philippines, 9-17 December 1974 : final report

REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATION MANILA

#

WORKING GROUP ON MEASURES FOR THE PREVENTIQN AND CONTROL OF DRUG DEPENDENCE

Manila, Philippines 9 - 1'7 December 1974

ICP/lfii/001

ORIGINAL:

ENGLISH

WORKING GROUP ON MEASURES FOR THE PREVENTION AND CONTROL OF DRUG DEPmiDENCE

Convened by the REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATION

Manila, Philippines

9 - 17 December 1974

Not for Sale Distributed by the REGIONAL OFFICE FOR THE WESTERN PACIFIC World Health Organization Manila April 1975

NOTE The views expressed in this report are those of the members of the working group and do not necessarily reflect the policies of the Or~anization.

This report has been prepared by the Western Pacific Regional Office of the World Health Organisation for Governments of Member States in the Region and for those who participated in the Working Group on Measures for the Prevention and Control of Drug Dependence which was held in Manila, Philippines from 9 ~ 17 December 1974.

TABLE OF CONTENTS

!»a§! No. 1. 2. IN'TRODlJC'riOO •••••••••••••••••••••••••••••••••••••••••• USE OF DEPENDENCE- PRODlJCING DRUGS: UNDERLYING FAC'rORS • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • PROBLEMS ASSOCIATED WITH THE USE OF DEPENDENCEPROOO CING DRUGS • • • • • • • • • • • • • • • • .• • • • • .• • • • • • • • • • • • • • • • • • SOCIOCULTURAL RESPONSES •••••••••••••••••••••••••••••••

1

1

3.

:5 5

4.

4.1 4.2 4.3 4.4 4.5 4.6 5·

General ••.••••••••.•.••••.•.••••.•.•••••..••••••• Limiting the availability of drugs ••••••.••••.•.•

5 5 7

Sanctions •••••.••...•.... Treatment including rehabilitation •••••.••••••.•• Information and education ••.••••••.•••••••••••••• Modification of environment o ••••••••••••••••••••••• •••••••• 'II •• 0

9 9 11

••••••••••

Er..mrt.ENTS OF A BALANCED PROORA*E

•

0

••

0

••

0

••••••••• 0

••••

12 12 12

5-1 Opent10Jl&l 5.1.1 IJa.ta 5.1.3 5.2

NStt&rch •••••••• • ••••••• • •

e ••••••• • • • e • • • 0 • 0 •••

base • • • • • • • • •••••••••••••••

5.1.2 M0111 toring ..........••.•...............•.• :BY'alu.a'tiOil •••••••••••• ~ •• " • "' ••••••••••••••

5.1.4 "Feedback" and programme modification •••••• Problem pr-evention ....... " " ., ., .•. o o oil •• " •••

1' 14 14 15 16

l.J lJ

41

.,

•••••••

5.2.1 Measures

limit the availability of drup 5.2.2 Measures directed primarily at individuals and small groups • • . • • • • • . • . . • . • . • . • • . • . • • • 5.2.3 Measures directed primarily at the environment • • • • • • • • • • • • • • • • • • • • • . • • • • • • • • • • • • • • • • to

5.3 Treatment including rehabilitation ••••••••••••••• 6. IMl'LEMENTATION OF PROGRAMMES

17 19 19 21 22

.........................

Conclusions and recommendations.................. Broad regional strategies ••••••.•...••••.•••••••• 6.3 Immediate programme activities •••••••••••••••••••

6.1 6.2

ANMEX 1- LisT ··-

or

~ •* - · · - - · · · ·

MBMeiRS ••••••••••••••••••••••••••••

27

1.

INTRODUCTION

A Working Group on Measures for the Prevention and Control of Drug Dependence met in Manila from 9 to 17 December 1974, under the sponsorship of the WHO Regional Office for the Western Pacific. Dr Francisco J, Dy, Regional Director, opened the meeting and welcomed members of the Group. He noted that, during the previous five years, the WOrld Health Assemblies and several of the Regional Committees, including that in the Western Pacific, had drawn attention to the need for improved regional and national programmes in the field of drug dependence for preventing or alleviating the many health and social problems, both individual and public, that were associated with the use of dependence .. producing drugs, including alcohol. The collection and exchange of information on these problems, the individual and sociocultural factors involved, and the effectiveness of the different approachP.s and mP.thads used far their alleviation needed to be improved. He also observed that the use of psychoactive, dependence .. producing drugs for recreational, medicinal and other purposes probably went back to prehistoric times, and that such use would doubtless continue. As in the past, a certain proportion of the users and those around them would continue to experience a wide variety of problems. As was pointed out in the twentieth report of the WHO Expert Committee on Drug Dependence, 1 the purpose of programmes in that field should be "to prevent or reduce the incidence and severity of problems associated with the nonmedical use of drugs. This is a much broader goal than the prevention or reduction of drug use per~· With respect to the nonmedical use of certain drugs ... , it is also more realistic." In many countries, the problems associated with the use of beverage alcohol far outweighed those associated with the use of less socially accepted substances such as sedatives, stimulants and narcotics. Means to reduce the problems associated with socially accepted as vrell as less tolerated drugs deserved special attention. The Group was, therefore, invited to help the Regional Office formulate strategies that would enable it to assist Member countries to develop effective policies and programmes for reducing the extent and severity of problems associated with the use of ~ dependence-producing drugs.

2,

USE OF DEPENDENCE-PRODUCING DR!JGS: UNDERLYING FACTORS

Drug use may be initiated for many reasons, ranging from conformity to rebellion, from curiosity and experimentation to deliberate. intoxication, from social to antisocial drives. 2 The continued use of dependence-producing drugs3

~ld Hlth Org. techn. Rep. Ser., 1974, No. 551, p. 32 (section 3.2). 2 wld Hlth Org. techn. Rep. Ser., 1973, No. 516, p. 18 (section 3.1). 3For the purpose of this report, the Group adopted the definition of a dependence-producing drug and the other definitions and usages contained in Wld H1th Org. techn. Rep. Ser., 1973, No. 516, p. 8 (section 2.1); and Ibid., No. 526, p. 16 (section 3).

- 2 -

by individuals is similarly the result of many factors, but above all it is a function of the pleasure-giving/discomfort-relieving effects of such drugs. In the case of socially accepted drugs, this function is used wisely and well by the majority of users and is an integral part of the culture of most societies. Alcohol is the most widely used culturally accepted drug, but in those cultures oriented to the use of other drugs, the same principles apply. Not all of the motives for drug use are pathological. Further, most of the adverse family, sociocultural and economic forces thought to affect such use do not necessarily lead to drug-taking behaviour. Indeed, many of the human motives and social pressures apparently involved in fostering the use of dependence-producing drugs by some persons can and do lead others to find satisfactions through activities other than drugtaking. Only some people use drugs in a destructive fashion, presumably because of the relatively greater significance to these individuals of this source of gratification in relation to other sources such as social and family life or work. For some reason, they are unable to gain sufficient pleasure from one or more o:f these life pursuits. Drug use for many drug-dependent, and some other persons, apparently becomes as much an effort to relieve distress and discomfort as it is to seek positive pleaourc. Drug use that creates problems, whether it be through the taking of a socialty accepted or unacceptable drug, is known to be associated with many factors. Of those that af:fect the individual, the commonest are the ones that limit his resources to cope with the ordinary difficulties of life or impose considerable life stress. An example is a disturbed childhood background that leads to personality or other disorders, rendering the individual vulnerable to life stresses. These stresses, including any social condition producing misery, helplessness (for example arising from unemployment), discrimination or degradation, will increase the probability of deviant or destructive behaviour on the part of some persons. The stresses may also be commonplace crises of transition, for example the assumption of a more .demanding adult role in life (to most people a desirable change) or the loss of a person to whom the individual was emotionally attached. These factors are not specific ~ drug dependence. They influence a variety of other problems such as delinquent and other deviant behaviour and, to a considerable extent, a number of psychological disorders. Severely stressed individuals and those who have developed personality disorders constitute "high risk" groups in the community.2 Whether a vulnerable individual under stress becomes drug dependent or his behaviour is disturbed in some other way such as attempting suicide or committing unlawful acts, may well be decided by circumstances and chance. Personal contact between non-users and users of drugs greatly increases the chance that the outcome will be problem-related drug use rather than some other difficulty. Problems associated with the use of alcohol,3 and probably other drugs, increase with the frequency and amount used. Data on problem-related use of 1 2 Wld Hlth Org. techn. Rep. Ser., 1974, No. 551, p. 37 (section 3.4.1). ~

Wld Hlth Org. techn. Rep. Ser., 1974, No. 551, p. 25 (section 2.1~).

Wld Hlth Or~. techn. Rep. Ser., 1974, No. 551, p. 60 (section 3.6).

- 3-

alcohol in a number of countries show that the large majority of users drink relatively little and have few problems. Only a small proportion drink "excessively", but these users have many more problems than do the "lighter" drinkers. Further, such data show that there is no sharp transition from 11 light 11 to 11 heavy11 drinking, nor from 11 few 11 to "many" associated problems. It follows that programmes designed to reduce alcohol-related problems may well need to focus on the patterns of use and attitudes of the whole population of users as well as on those already involved in the destructive use of alcohol. It also follows that the greater the proportion of a total population that users alcohol, the greater will be the number of persons at risk of becoming involved with alcohol-related problems. Consequently, factors such as increased availability, licit or illicit, or the forceful promotion of a drug, will probably increase the incidence and prevalence of drug-related problems. These same principles probably apply to the use of other dependenceproducing drugs as well. Most controls on the use of alcohol, including those which increase the price, affect all users. The effectiveness of these controls on problemrelated use has been limited by the understandable resistance of the population to restrictions on social use. The ideal for the management of the problems associated with the use of alcohol would be measures designed to reduce them without affecting unduly the non-problem use.

3.

PROBLEMS ASSOCIATED WITH THE USE OF DEPENDEN~PRODUCiijG DRUGS

These problems may be seen from the objective, detached point of view presented in previous reports, l 2 or from the subjective standpoint of the drug user, his family and other se'ctions of society. Each approach is concerned with the effects of intoxication and the medical, psychological and social complications of use. From the objective point of view, intoxication may give rise to seriously disordered behaviour or have potentially lethal effects such as respiratory depression. Medical complications may be the acute consequences of the intoxication such as injuries incurred in falls, fights or accidents, or the delayed consequences of malnutrition and other toxic effects on organs such as the brain, nerves or liver. The intravenous use of drugs has its own added serious risks such as septicaemia, thrombosis and hepatitis. Drug withdrawal brings suffering for those who use drugs that produce physical dependence. The best known of these syndromes is that produced by the narcotics, but more common and potentially much more threatening to life is the withdrawal syndrome produced by withdrawal of alcohol and many other commonly used sedatives (for example some minor tranqu_illizers, the barbiturates and methaqualone) .3 4 Psychological_ .complications range fr;om acute anxiety reactions 1

Wld Hlth Org. techn. Rep. Ser., 1970, No. 460, p. 17 (section 3.2.3). Wld Hlth Org. techn. Rep. Ser., 1974, No. 551, p. 32 (section 3.2).

2

3

4

Wld m.th Org. techn. Rep. Ser., 1970, No. 437, p. 13 (section 4.4).

Eddy, N.B. et al. (1965) Bull. Wld Hlth Org., 32, p. 725.

- 4 ... to the more prolonged psychoses seen after the heavy use of stimulants or cannabis preparationsol Social complications arise from the effects on and reactions of peers, family, employers. law enforcers, health services and social agencieso The drug dependent person may injure others, not only directly but also through impaired efficiency as in road traffic and industrial accidents; his productivity is impaired or lost; he may turn to crime to procure drugs or the wherewithal to purchase them; and society in turn has to expend considerable effort and resources on law enforcement and treatment and assistance for users and victims alike. The drug dependent person has an impact on his family often as disturbing as any impact the family may have had on him. With the subjective approach the problem has an entirely different aspect. The person regularly injecting heroin in an environment where such use is proscribed may not be at all concerned about the behavioural effects of intoxication, but is concerned about the medical complications. He turns to peers who have similar attitudes about drugs. He is faced with a variety of difficulties as a result of the reactions of his family and other social groups, for example in obtaining his drugs on the black market, expending most or all of his efforts on procuring the drug (including stealing), avoiding enforcement authorities, finding a place where he can take drugs without interference, cleaning or sterilizing his injection paraphernalia and making allowance for the uncertain dose and the possibility of toxic adulterants in "street" drugs. By this time he has probably known at least one person who died of an overdose. When intoxicated with alcohol, numb with sedatives, high on a stimulant or dazed by a narcotic, he must be able to function and try to appear normal in the presence of others such as relatives, friends or police, his boss and even treatment personnel. The subjective views of relatives, employers, law enforcers, health services and social agencies correspond to those of the drug dependent person only in respect of the medical complications. All agree that these are undesirable and all are prepared to treat the disorders. Perhaps this is why, in most countries, this is the only area in which facilities and care have been provided by society and patronized by the users. Otherwise the differences are marked. Almost all except the user disapprove of the behavioural effects of intoxication and the nature of the new circle of peers he collects, and they are frustrated and hurt in their roles as family members, employers, law enforcers and workers in health care and social welfare. Their initial reaction may be fear and helplessness which may lead to. intensely punitive responses such as proposing to send the user to prison. These subjective views differ in one important respect for socially accepted drugs such as alcohol. Social use is often encouraged and the ability to remain within the limits qf intoxication set by society is seen as personal strength, but once the individual is recognized as obviously dependent on the drug he is often rejected by peers, family, employers, law enforcers and even the health care and social agencies. At this stage his dilemma is somewhat similar to that of the heroin user described above. 1

Wld Hlth Org. techn. ReE· Ser., and 4. 3).

1971, No. 478, p. 22 (sections 4.2

- 5 -

Whether or not a person's initial drug-use was socially acceptable, if his continued use is associated with family and/or public disturbance, unlawful behaviour and an inability or unwillingness to support himself and his dependents, there are social complications that ~o beyond himself and his immediate family and associates. These include {1) increased costs to society of drug-related correctional enforcement, health and welfare services, (2) loss of property and other loss through crime and (3) the loss to society of potential artistic, intellectual, economic and other contributions that the drug-taker might have made were it not for his destructive use of dependence-producing drugs.

4. 4.1 General

SOCIOCULTURAL RESPONSES

Problems in the broad field of drug dependence are particularly liable to prompt responses by individuals and society when such problems are seen as involving new groups of users, especially middle and upper class youth, or when they result from the use of drugs with which a particular society is unfamiliar (e.g. new pharmaceuticals or drugs traditional to certain geographic areas appearing in another). Long standing, but familiar problems, such as those associated with the use of beverage alcohol, often tend to be ignored or minimized. The responses of individuals and societies to a particular drug-related problem are often quite varied, even within a given community, social institution or country. They are influenced by prevailing attitudes and beliefs about the causes ~ consequences of drug use and the broad value systems of those responding. Individuals and social groups often modify their responses as time passes, particularly when an earlier response is perceived to be ineffectual or even counter-productive. A variety of helping agencies, including law enforcement agencies, become involved and may develop their own vested interests. The profit motive intrudes into this field in many ways, helping to perpetuate and magnify the incidence and prevalence of drug-related problems and to influence individual and social responses. Indeed, making profits can be seen as one response to these problems and not solely as a complication. The sale of drugs provides income to, manufacturers and distributors 1 both licit and illicit, and, of course, to government. The major responses to a perceived threat associated with the use of drugs can be broadly classified under the following headings: (1) curtailment of the availability of drugs, (2) application of social sanctions for use and/or closely related activities, (3) treatment including rehabilitation, (4) information and education, and (5) modification of the environment. dependenc~-producing

4.2

Limiting the availabilitl of drugs

The problems associated with the use of dependence-producing drugs cannot exist unless the drug is available. This simple obvious fact tends 1 2

Wld Hlth Org. techn. Rep. Ser., 1973, No. 516, p. 27 (section 5.1). Wld Hlth Org. techn. Rep. Ser., 1973, No. 516, p. 30 (section 5.3).

- 6 -

to prompt the simple social response - banish the drug altogether. The experience of this response is that once a drug is incorporated in established patterns of use in a community and society has developed a demand and a culture around its use, total prohibition of use is very difficult or even impossible to achieve. 1 In these circumstances availability can be restricted only to a limited degree and certain controls such as excise, taxation and restricted outlets inevitably affect all users. They fall mainly on the social user and only decrease, never abolish, the proportion of users who experience drug-related problems. In contrast, when there is not an established significant demand for use of a drug in a community, strict controls and even prohibition may be feasible, particularly when these controls are part of a co-ordinated campaign or balanced programme utilizing other methods, such as education and treatment, in addition to controls on availability. The problems do not necessarily commence when a dependence-producing drug first becomes available, but once the attention of a "high risk" group in a population is directed to the "pleasure-giving" effects, an outbreak of problem-related use is likely, especially among the young. ~o often the social response has been to limit the availability of drugs only after significant problems have developed and become obvious and this is usually a matter of years after the outbreak actually began. The prohibition of use in the face of a heavy demand for a drug has predictable consequences. A black market commences 8 the prices on this market rise steeply and criminals take over the distribution of the drugo The quality of the drug deteriorates and the dose becomes unpredictable because of adulteration and toxic impurities. The users of a drug to which tolerance2 develops need increasing amounts and in time may be forced to turn to crime in order to steal the drug or get the money to purchase it. Law enforcement requires more resources and is undermined by attempts at corruption. And should the efforts of prohibition effectively curtail availability of one drug, many users shift their attention to other dependence-producing drugs- the use of which may be associated with the development of even more serious problems. The converse is also true; the use of substitute drugs may be associated with less serious problems. The partial restriction of availability may have only limited effectiveness, but also may be associated with correspondingly fewer problems, unless the restrictions are so severe that the illicit market becomes an attractive alternative to the user. The fact is that the prohibition of use in the case of socially accepted drugs, such as alcohol, also in practical effect only partially restricts social use and has an even lesser effect on dependent use. In these circumstances. the undesirable consequences of total prohibition, for example crime, are so disrUptive that this social response has been rejected as impractical in most countries. Pharmaceutical preparations give rise to a considerable part of the problems associated with the use of dependence-producing drugs in developing countries of this region as well as those that are more developed. Restricting distribution by requiring the use of ordinary prescriptions seems to have been

Lwld Hlth Org. techno Rep. Ser., 1973, Noo 516, Po31 (sec. 5•3o3).

~ddy, N.B. et al., 1965, Bull. Wld Hlth Org., Noo 32,

Po

723 o

- 7insufficient to curtail these problems. There are diffieulties associated both with medical prescribing and control of retail sales. Even in countries ivhere such restrictions have operated w1 th relative efficiency, the extensive use of some minor tranquilizers such as chlorpiazepoxide, diazepam and meprobamate appears to have increased as rapidly as in other countries where the controls are less rigorous and more likely to be ignored. Availability only on limited medical prescriptionsl and improved control of retail outlets may well be in order. '!he considerable demand for such drugs may stem in part from attitudes generated by the undoubted success of many pharmaceuticals in recent decades.

4.3

Sanctions

Sanctions may result from the laws and regulations of the community or may stem from its less formally expressed social customs, mores and attitudes.2 Legal sanctions may be imposed as a result of either criminal or civil proceedings. Those stemming from criminal proceedings may be designed to EUnish transgressors, deter others from similar actions, quarantine users, or correct their behaviour. Sanctions stemming from civil proceedings are usually intended to bring users into contact with treatment-oriented programmes. Punishment is often an early social response to a developing problem, and it is also a common response to the socially unacceptable use of the widely used drugs, such as alcohol. In some extreme situations, illegal acts associated with drug use have been punished by whipping or the imposition of the death sentence.) NOt surprisingly, voluntary entrance into available treatment programmes has been limited when users were faced with the possibility of such punishments. Compulsory de~ntion alone has not been shown to be beneficial to drug-dependent users. Punishment as a deterrent is thought to have little effect on drugdependent ~rsons, either those who are punished, or on those who only iVitness it.5 Its deterrent effect on non~dependent users requires further study. Compulsory detention may sometimes be undertaken to quarantine drug· users, that is to prevent contact with others and the spread of what is essentially a communicable disorder, and to prevent their involvement in unlawful activities such as theft. In some countries, drug users are subject to compulsory detention in institutions intended to correct their behaviour, but all too frequently no correctional or other therapeutic programme is provided. Such incareeration must be seen as punishment and/or quarantine. This is so, whether the 1 Wld ID.th Org. techn. Rep. Ser., 1970, NO. 437, p •. 19 (section 4. 5). 2

Wld Hlth Org. techn. Rep. Ser., 1973, No. 516, p. 33 (section 5.3.4); No. 55, p. 52.

3 4

The latter has usually been reserved for large-scale traffickers.

Wld ID.th Org. techn. Rep. Ser., 1970, NO. 460, p. 28 ~ection 3. 3. 5). 5 Wld Hlth Ors. techn. Rep. Ser., 1973, No. 516, p. 33 (section 5.3.4).

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institution is called a "correctional" or "treatment" centre or a prison, or whether the compulsory detention came about as a result of criminal or civil proceedings. Civil proceedings may be utilized to compel drug users to come into contact with treatment-oriented programmes. Only the contact can be successfUlly compelled, not "treatment" or "correction 11 • Compulsion, whether deriving from civil or criminal proceedings, may involve full deprivation of liberty or only a requirement that the drug user meet his probation officer or therapist at stated intervals. The active participation of the drug user is required if he is to benefit from contact with helping personnel. Compulsory as well as voluntary contact can initiate the necessary therapeutic process. The skills and interests of the helping personnel have an important bearing on the development of this process. A user who is sincerely seeking help and may be seen as "well motivated", can be "turned off" by a disinterested unskiltul "helper". Of course, not all drug users who seek, or are offered, help are well motivated. The existence of le!al and other social sanctions has effects beyond t:he compulsory treatment-oriented programmes. Many who turn to voluntary treatment programmes, ranging from self-help therapeutic committees to methadone maintenance programmes, do so to avoid such sanctions. Many "voluntA,ry" treatment programmes will accept only those 1.1.sers who are subject to some possible legal sanction. Legal sanctions may be so severe that they harm the user more than the problems that brought him to the attention of the authorities. Additionally, the inappropriate use of legal sanctions, for example, with the recidivist alcoholic committed night after night to police cells or prison for short periods, is wasteful of sometimes limited and expensive resources apart from any considerE>' ion of the unnecessary suffering it involves. Legal sanctions may create a ,;eries of undesirable consequences for the user such as the loss of employment opportunity, the association with hardened criminals and a sense of worthlessness. The availability of legal sanctions may create a sense that provision has been made for effective programmes and thus impede the development of other necessary programmes. This has been particularly true in connexion with the failure in some countries to provide other means of helping problem drinkers. Like the legal sanctions that develop as an initial response to drug-related problems, other social sanctions tend to be punitive in many instances. Peers may summarily break off their relationship with the user, the family may propose compulsory confinement with or without treatment and the employer may dismiss or deny job opportunities to those who have had this disorder. Subtle social sanctions are built into the cultural attitudes of a society towards drug use. Social sanctions may be applied deliberately to encourage entrance into treatment and rehabilitation programmes. This avenue, an application of what might be called "benign coercion", is used in industrial programmes for alcoholics developed in cooperation by employers and trade unions. A fundamental principle is that.the worker keeps his job as long as he "voluntarily" submits himself to treatment.

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4.4

Treatment including rehabilitation

The perceived failure of drug controls and punishment to overcome the problems associated with the use of dependence-producing drugs may provoke, as an additional or alternative response, the provision of correctional, medical and/or social treatment resources. The initial move is usually to provide for withdrawall with little or nothing else. The medical complications of drug use are treated, if at all, in existing conventional health facilities, usually with an approach focussed narrowly on the physical disorder alone and ignoring the underlying drug use and other problems of the affected individual. Where there has been further development of facilities for treatment and rehabilitation, a great variety of approaches have been used. 2 Various programmes may emphasize c~mplete abstinence or use maintenance3 for some narcotic-dependent person. They may be run on conventional hospital lines or as therapeutic communities and they may or may not use p~fessional staff, Religious and other voluntary organisations using spiritual as well as other approaches have been active in this field. The

a

Many of these approaches have certain features in common. Help is offered with firm conditions and limits and predictable sanctions. Rehabilitated users are prime movers in the treatment process in many localities, especially in self-help organisations and self-regulating communities.5 Some of these programmes offer extended after-care, a feature that has been neglected all too often in the past. Acupuncture, an ancient treatment technique, is now being studied in Hong KOng to determine its usefulness in the field of drug dependence. It may have potential for drug free withdrawal from opiates and perhaps for use during the post-withdrawal phase. 4.5 Information and education

The initial response to a new drug problem has almost invariably included a simple information-giving programme, apparently based on the ~istaken assumption that no person would use a drug that is potentially 1 Wld Hlth Org. techn. Rep. Ser., 1970, No. 460, p. 19 {section 3.3.1). 2

Wld Hlth Org. techn. Rep. Ser., 1973, No. 516, p. 35 {section 5.3.5). 3

4

Wld Hlth Ors. techn. Rep. Ser., 1970, No. 460, p. 20 {section 3.3.2).

Many different religious faiths have been involved. Wld Hlth Or~. techn. Rep. Ser., 1973, No. 516, p. 37 {section 5.3.5); 1970, No. 46o, p. 2 (section 3.3.4).

5

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harmful once he knows of the danger. "Scare'! techniques to instill fear of the consequences seemed to be the "logical" course of action. '!he failure of these programmes to be effective and the suspicion that they may, at times, have had directly the opposite of their intended effects, have been discus~eci').l As tar as the "high risk" individual is concerned, the elements of risk and danger emphasized in some "scare" programmes may provide an irresistible attraction, rather than dissuade him from drug use. Information programmes frequently convey covert, unintended messages which may have the opposite of the desired effect. Another problem is that information given is often perceived differently by different persons. Most information-giving programmes, particularly those utilizing such media as the general press, radio and television, do not provide the opportunity for clarification of misunderstandings or resolution of unintended anxieties that might be generated. Information about drug use has been demanded quite rightly by people, but it is now obvious that different groups need different tYP!s of infonnation, which must be seecially prepared for each target group.2 Past efforts to persuade people to stop smoking have, in general, not been conspicuous by their success, and the results of advertising campaigns against drunk driving in countries with a high rate of alcoholism have yet to show results where they have not been associated with sanctions. Nevertheless, further experience and refinement of techniques may in time provide a tool for developing attitudes in the community that will provide improved cultural controls for some of the problems associated with the use of dependence-producing drugs. Education in schools has focussed, for the main part, on courses and subjects rather than on individuals. Where measures have been taken in schools to deal with the problems associated with the use of dependenceproducing drugs, they have usually consisted of lectures and other didactic information-giving techniques not integrated into a programme of education for living. And yet the school is in a position to achieve much more. than these doubtful measures. ~achers are in a position to detect the early signs of developmental problems in pupils and the "high risk" individuals of the community.3 The school may also educate students with respect to the use of socially accepted drugs as part of the process of making decisions and solving life problems. '!he school, in collaboration with other agencies, may even be able to provide remedial influences for disturbed children. A pilot programme has been in progress for the past two years in one country of the Region (the Philippines), re-orienting and training teachers to undertake these new functions. Children from the earliest grade to fourth year 1

2

Wld Hlth Org. techn. Rep. Ser., 19701 No. 460, p. 33 (section 3.4.2). Wld Hlth Org. techn. Rep. Ser., 1974, No. 551 1 p. 44 (section 3.4.3).

3

Wld Hlth Org. techn. Rep. Ser., 1974, No. 551, p. 41 {section 3.4.1).

- 11-

high school, that is from age 6 to 16 years, are involved in disoussions that begin before and continue during the stage of lite at which they become exposed to drug use and experimentation. Evaluation procedures have been developed as part of the programme, fbr both teachers and students. Parents are involved in the programme and the teaohers are trained to recognize the family-related problems of the children. In the evolution of a multitude of education programmes,· many mistakes have been made and some traditional concepts have been rudely shaken. Education has been widely but inaccurately equated with information .1 The fact is that education has to be "a two-way process in which facilitation of ~l.~_arning and maturation is more important '!it}an t.~ .E!-cquisition of f~cts".l1 4.6 Modification of the environment

There has been considerable speculation about the influence of adverse environmental factors and as a result measures for modifying the environment have been proposed for preventing or lessening the problems associated with the use of dependence-producing drugs. Poverty is thought to be a factor, but now it is evident that certain drug-related problems also grow with increasing ~uence. The proposals for mo4ification of the environment are mostly non-specific, ~ing designed to improve living conditions and alleviate environmental stress. In many Asian countries, secret societies like the Triads are known to be involved in rackets supporting or sponsoring syndicates for drug trafficking, gambling, prostitution and other vices. i'he belief is widely held that drugs are SOMtimes used to recruit and control the "rank and file" of such societies and, street gangs of delinquent or alienated youth. Such a sub-culture may exert a strong influence on young persons who lack the opportunity to participate in constructive recreational and sporting activities. Whenever ~ traf· ficking syndicate is broken in a big city, black market prices of narcotics usually rise sharply and a temporary "panic" among drug-dependent persons may occur. The irony is that higher prices mean ii~g.-:.- pret1ts which tempt unorganized small-time smugglers or ordinary travellers to take a chance and join in the trade. Another approach is to provide meaningful altetbat1ves3 to drug use, mainly for youth. Particular attention has been paid to districts with more than the usual share of drug-related problems and to potential problem districts such as ghettos, slums and new ·~ousing- areas. Youth may be given opportunities to take part in community action progra:rmnes designed, for example, to belp reduce environmental pollution or provide services to handicapped and other disadvantaged persons. Youth may also be encouraged to patronize community or youth centres, and to take part in recreational ana

W1d Blth Org. techn. Re2. Ser., 1974, No. 551, p. 48 (section 3.4.3(h)). 2

Wld Blth Org. techn. Rep. Ser., 1974, No. 551, p. 59 (section 3.5.4). 3 Wld Blth Org. techn. Rep. Ser., 1974, Nb. 551, p. 57 {section 3. 5. 3).

- 12extra-mural educational activities 1 arts and crafts. ~ be meaningful, such programmes must help participants satisfy a number of basic human needs- the same needs that are involved in initial and continued drug use. 1 The contact between persons with problems and helping agencies has been facilitated by innovations such as community based health care centres, drop-in centres, "hot lines" and the apeoial training of teaohera._ .. The mass media have been involved extensively in disseminating information about drug use and related problems. Because of the intense public interest in the subJ~ct, the media, i~cluding television stations, have volunteered facilities and solicited drug-related materials for dissemination. Unfortunately, many of the resultant publications and broadcasts have suffered in the past from the shortcomings noted above with respect to informationgiving programmes.

5.

ELOO:N'l'B OF A BALANCED PROGRJU.ME

5.1 5.1.1

Qperational research Data base

Some data about the nature and extent of the use of dependenceproducing drugs and associated problems exist at the stage where the need for initial or expanded action is accepted. The task is to assess these and any other existing relevant data. "Guidelines for reporting available information on the non~medical use of dependence-producing drugs"2 are being developed by WHO Headquarters fOr use· by a limited number of designated reviewing centres. They may also be of use to operational research personnel in other locations. Almost inevitably the existing data will be inadequate in some respects for the planning of a balanced programme. The Group emphasized that this should not necessarily delay the initiation of a programme 1 especially the development of treatment including rehabilitation services 1 if there is an apparent substantial need. lbwever, steps should be taken as soon as possible to gather further data about the extent and characteristics of dru,-related problems 1 tbe associated environmental factors, and the nature ot relevant existing services and programmes. This should be done, using a variety ot techniques including tield studies, case finding surveys, sampling ot population groups and studies of selected localities. Since the establishment of a central case register is otten considered, the Group wished to draw particular attention to a ~iscussion of this matter contained in the report ot a WHO Expert Committee. . 1 2

Wld 11th Org. tecbn. Rep. Ser., 1974 1 No. 551, p. 57 (section 3.5.3).

WHO n,cument CMB/74. 7· 3 Wld Blth Org. techn. Hep. Ser., 1973, No. 526, p. 25 {section 4.2.2).

- 13 -

5.1.2

Monitoring

The problems associated with the use of dependence-producing drugs are subject to continual change, which may be the result of changes in the supply or nature of the drugs, the population of users or the effects of the social responses. The situation needs to be monitored continuously to recognize change when it begins, that is,to provide an "early warning system", and follow significant trends as they develop. Monitoring may be carried out using the same techniques employed to determine the data base, such as field work, case finding, population sampling and studies of selected localities; but one or more of these need to be conducted on a continual or regularly and frequently recurring basis. Monitoring may detect unforseen as well as follow the trends of known problems. Monitoring may employ specific techniques for more narrowly defined purposes, such as the laboratory testing of street drugs to determine their quality and toxic impurities. Timely warning concerning the presence of contaminated and even unusually potent drugs may prevent serious infections and deaths due to overdose. 5.1.3 Evaluation

In such a complex field, influenced by so many factors, the results of any intervention, no matter how simple, cannot be fully anticipated and often have some unforeseen consequences. Also because of this complexity, programmes dealing with the problems associated with the use of dependence-producing drugs are almost always costly in personnel and resources. The costs are not only to be reckoned in terms of the programme itself, but also need to take into account the direct and indirect effects and sometimes the unintended complications. For these reasons, the collection of data needed in connexion with evaluation must be undertaken at the time that policies and programmes are initiated. Evaluation helps avoid wastage of effort, resources and personnel on ineffective methods. Evaluation will guide the further development of measures that prove beneficial and not too costly and will help to modify ineffectual and/or harmful undertakings. The evaluation must be an integral part of the total elanning. It is an essential part of trial studies, which, in general should be undertaken before any definitive programme is begun. Self-evaluation of a programme by the team involved is a necessary part of the on-going process, but it is also necessary that definitive evaluation be carried out by knowledgeable outside personnel who have no direct involvement with the programme or methods used. The planning of the programme, the goals 1 the methods and the criteria for evaluation should, in general, be a joint effort of the evaluation team, including outside experts, and the key personnel in the programme. The criteria for evaluation of an individual's response would include data on the amount and method of drug-taking, the periods of drug abstinence (checked if possible with laboratory testing of random urine samples), occupation (school, gainful employment), involvement with crime, and changes in the family and peer relationships.

5.1.4 "Feedback" and programme modification The information gathered for general purposes, monitoring or evaluation must be relayed back as soon as possible to the various groups that collaborated

- 14 -

in its collection and be communicated to those concerned with its implications. Where the information provides the basis for some evaluation of a method or action and indicates the possible need to modify some element of the programme, the need for prompt feedback is obvious. If possible, the information should be made widely available rather than restricted to a few chosen recipients; the unforeseen consequences of a measure may not be immediately obvious to those directly involved in its evaluation, but could be recognized by others in peripheral fields who have at their disposal information which was gathered for quite different purposes. Feedback also has a significance for the information gathering process itself. Information for the data base gathered·. by governmental and other agencies is derived from many sources, including official, quasi-official and voluntary organisations. Delay in communicating the results of the information gathering, or indeed the failure to do so, is discouraging and reduces the extent of subsequent cooperation.

5.2

Problem prevention availabilit~

5.2.1 Measures to limit the

of drugs

Each society is faced with its own unique patterns of drug use and associated problems and its own requirements for curtailing the problemrelated use of licit and illicit drugs. Clearly it is preferable to anticipate problems rather than allow them to become established. Where a problem has not yet arisen, but can be predicted from the experience of others, controls on availabilit~ of drugs are best undertaken before the Eatterns of use can become established. Tbo often legislation has to be prepared and enacted with haste and insufficient consideration in the face of a rapidly escalating problem that could have been anticipated. Some considerations should be kept in mind when planning legislation. Controls to limit the availability of dependence-producing drugs often have more effect on persons not involved in their destructive use than on those who are. The inherent resistance in the community to such control of socially accepted drugs will limit the effectiveness of this approach for management of the problems associated with their use. Where there is a large and insistent demand for illicit drugs, there will be comparable problems in imposing effective controls on drug availability. On the other hand, where there is little demand for the drug this type of control, to the extreme of total prohibition, may be effective. Such controls should not be introduced unless it is possible to implement them and allowance has been made for the predictable consequences, direct and indirect. The use of dependence-producing pharmaceutical preparations is associated with considerable problems in the Region and it is likely that the situation 1vill become more serious. The medical profession has a potential for considerable impact on the use of these drugs, either by (1) increasing such use because of uncritical acceptance and unnecessary prescribing or (2) encouraging restricted and cautious use for clearly defined therapeutic purposes. An educational programme directed at physicians seems to be desirable. The Group emphasized the importance of controls on prescribing, recommending that the prescription for any dependence-producing drug should be restricted to a specific amount, time within which it is valid and

- 15 -

number of refills. In the case of drugs such as methadone and certain rescri tion mi ht well be restricted central nervous s stem stimulants to those with a s ecial license and or anel of a roved h sicians. The availability of socially established drugs such as alcohol is curtailed conventionally by restrictions in the hours of sale, licensed outlets and the minimum age for purchasing and use in public. The suggestion that consumption may be reduced by increasing the price through excise and taxation was considered by the Group, which emphasized that this measure, as well as the other controls on availability of acceptable drugs, can have only a limited effect on problems and may create even more serious problems if they encourage users to turn to illicit manufacturers and distributors. The manufacturers and suppliers of pharmaceutical drugs and socially accepted drugs such as alcohol have the legitimate aspiration of making a prof~t and use mass media advertising and other means of promotion for this purpose. Unfortunately this promotion has the secondary effect of fostering attitudes that lead to the creation of the drug-oriented society and may increase the readiness with which some persons will try drugs. The Group recommended that the advertising of deeendence-producing drugs, including alcohol 2 to the public should be restricted or banned in the mass media. 5.2.2 Measures directed primarill at individuals and small groups

The users who are at risk of developing problems, and, of course, those who have done so, need to be identified. The available and usually limited, preventive and therapeutic resources may then be focussed on these persons at the earliest possible time. Attention should be given to the recognition of 11 high risk11 individuals when they seek help for other conditions such as the medical complications of drug use. Efforts may be needed to seek them out in the community, for example, with field work techniques including case finding and "outreach" programmes. HOwever, resources and personnel for assisting these individuals must exist before such measures are initiated. Certain characteristics help to identify the individuals in the community at risk of problem-related drug use. Those characteristics which identify the non-user also indicate the risk of involvement in a variety of other possible problems, such as deviant behaviour and mental disorder, and are of significance to all programmes within the field of mental health. These individuals need to be identified as early as possible. The school is particularly well suited to this task. Teachers are brought into daily contact with the children having behaviour problems and developmental retardation.l Drop-outs from school are at special risk of becoming involved in problem-related use of drugs. Health and social welfare agencies, religious bodies and law enforcement officers have repeated contact with these individuals and their families. Each may deal with the individual from the point of view of a narrow function, whereas each should initiate, at first contact, supportive and rehabilitative measures or ensure that the person at risk gets this help. Preventive measures include the provision of meaningful alternatives to drug use. Some of these facilities fulfil the goals of broadly aimed 1

Wld Hlth Org. techn. Rep. Ser., 1974, No. 551, p. 38 (section 3.4.1).

- 16 -

mental health programmes, for example, youth centres, recreational, occupational and extra-mural educational facilities. However, individuals at risk often do not join conventional youth groups and need to be attracted to organisations that make allowance for their problems in relating to others or which can take advantage of their desire to help others with difficultie similar to their own. The role of the school in identifying individuals at risk has been mentioned. The school may also be used to provide guidance and counseling for such persons which may help to prevent the development of problems later in life. The Group emphasized the importance of promoting this function of the school. Education about the problem-related use of drugs, both within and outside of educational institutions, should have as its aim development of the capacity to make rational decisions about drug use and the prevention of harm to the individual and society. Educational efforts must be ta:i.lorcd to the needs of specific target groups, that is the potential users, existing users, interveners (e.g. parents, teachers, counselors, clergy, physicians, pharmacists, manufacturers and distributors), and decision makers (e.g. community leaders, legislators, potential leaders). The needs, knowledge, attitudes and motivation of each group must be borne in mind when planning programme approaches, methods and content. Fbr specific target groups, comprehensive, well planned and systematic educational efforts aimed at enlisting community support and involvement should be considered from the very beginning of a programme.

5.2.3 Measures directed Erimarill at the environment Legislation provides a potent means for modifying the social milie: and habi·: >. The effectiveness and limitations of legislation to curtail availability have been discussed. Legislation may provide compulsion for corrective and treatment measures. The Group emphasized that any legislation for compulsory treatment and rehabilitation should be designed to encourage voluntary participation in programmes for treatment including rehabili tatj on. The Group also emphasized that legislation for punishment or correction will be ineffective in managing the problems associated with the use of dependence-producing drugs unless combined with adequate treatment measures and after-care services. Compulsory supervision, such as probation, may be particularly useful.l Specific legislation is necessary for particular problems such as drunk driving. This type of legislation will be ineffective unless the offender knows there is a reasonable certainty he will be detected and that., if detected, there is certainty he will be punished and/or treated. Programmes for the management of drug-related problems require a suitable statutory base. Financial support may be derived from both offici., 1 and voluntary sources. Legislative acts are often used to foster support for programmes carried out in the public interest. Such programmes should include measures to influence the attitudes, customs and mores of society with regard to drug use in general and to specific problem-related behaviouc', l

Vaillant, G.E. (1973) Arch. gen. Psychiat., 29, 237-241.

- 17-

such as drunk driving, in particular. The Group emphasized that the attitude of the drug-oriented culture, the belief that there is a pill for every problem and a drug for every discomfort, should be given special attention. The mass media provide the most widely and extensively used source of information about drugs and drug-related problems for the community. They should be used to deal with broad subjects such as social attitudes, information about treatment and other facilities or community problems such as drunk driving. Extreme care should be exercised in the use of mass media to transmit information intended for specific target groups. A person's home and community environment may be modified through urban renewal, resettlement or rehousing, and community reorganization projects. The human environment may be modified by measures to eliminate the negative influences, for example, of certain secret societies and restrictions on job opportunities. The Group emphasized that programmes designed to relieve such environmental stresses should be undertaken regardless of whether or not a drug-related problem already exists. Such programmes are worth pursuing in their own right.

5.3

Treatment including rehabilitation

Unlike the conventional situation in medical treatment where patients will, in general, seek treatment, persons with problems associated with the use of dependence-producing drugs are likely to be reluctant to attract attention. Usually this is because of reluctance to abandon drug use, and the anticipation of possible legal or other social consequences if they admit to their use. The first requirement of a treatment programme is to facilitate contact between individuals who need help and helping personnel. This may require changes in laws and regulations, removing or modifying some measures that discourage people from seeking treatment,l the provision of drop-in centres, "hot lines" and special clinics in hospitals. In time, case finding in the community or in specially selected areas may be undertaken if the necessary facilities are available for the treatment of persons located by these methods. The assessment of the needs of the individual with problem-related drug-use also presents unusual difficulties. The motivation of the user may be to avoid compulsion or other consequences of the law. Even in the presence of direct or indirect compulsion, treatment and rehabilitation can proceed provided the individual has resources that can be tapped by the treatment process, particularly if he can be supported by his family, peers, social agencies and legal measures. Initially, attention may have to be paid to detoxification and drug withdrawal for-the individual; and the assessment of other needs may have to wait until he is well enough. The assessment should be an on-going

1

Fbr example, civil service regulations requiring that all drug users be dismissed and statutes that impose sanctions for being drug dependent.

- 18-

process, because the needs of each person treated change throughout the lengthy process of treatment, including rehabilitation, and subsequent after-care. Detoxification for most drug-dependent persons needs to be carried out in drui·free institutional environment (though not necessarily a hospital), which should have a close relationship with other treatment and rehabilitation facilities so that the process of continued treatment may commence as soon as possible fDd continuity of services at this stage of treatment may be facilitated. Detoxification for some drugs, such as alcohol and sedatives, may be complicated by serious physical disorder and the situation can be particularly d1fticult when the individual has been using a variety of drugs simultaneously. Many view these measures for bringing the patient into treatment as the decisive step and assume that rehabilitation will proceed as a matter of course in well defined ways. In fact, the methods used in treatment and rehabilitation and the types of personnel vary widely, partly because much of this work is still experimental and partly because of the varied requirements of the Mny tY"PGS of individuals involved. '!be type of treatment to be used may be chosen because of other problems the individual may have, for example, personality or other psychiatric disorder, and the outlook may be more a function of this background than of the immediate drug-related problem. In general, the aim of treatment and rehabilitation is behaviour modification and the methods are those used for a variety of related disorders, in particular for deviant and antisocial behaviour. Where the personnel and resources are available, individual, group or family psychotherapy may be used. Therapeutic communities and, in particular, some self-regulating communities have been accepted enthusiastically by some drug users. Behaviour therapy techniques are being developed in this field, particularly for alcohol-related problems. Supportive discussion and counseling have been used extensively and are probably the significant therapeutic factors in the success attributed to the use of compulsory supervision in the community (probation). Self-help organizations for exusers in the community have been used particularly to support individuals in maintaining a drug-tree life. Occupational or work therapy may be used as part of the treatment process and those living in the community should be encouraged to maintain gainful employment. Fbr some individuals with serious problems of adjustment to life, the treatment process may be more one of habilitation than of rehabilitation. During after-care, the individual may need vocational training or a range of social services for himself or his dependents and sometimes material assistance. Many drug users are sentenced to penal and correctional institutions. These should provide treatment and rehabilitation services. After-care services should be available upon release.

1

It is taportant that provision be made for continuity of service during the entire treatment and after-care process.

- 19 After-care in the community may require some form of prolonged contact with helping personnel. The Group emphasized the value of approaches that encourage the individual to re-establish himself in the community. The Committee accepted that for some individuals there may have to be a compromise and, in this case, the individual may have to remain within the care of a self-help organization, on maintenance therapy, or in a half-way house for a prolonged period. The Group emphasized the significant part that can be played by persons who themselves have experienced drug-related problems in the treatment, rehabilitation and after-care process.

6.

IMPLEMENTATION OF PROGRAMMES

It is recognized that: {1) the use of some dependence-producing drugs is socially acceptable while the use of others is not, {2) the seriousness and extent of problems related to the use of such drugs in countries of the Western Pacific Region vary widely, and (3) the human, technical and economic resources available for ap'plication to these problems also vary from country to country, and the existence of other major health and social problems results in competing demands. A wide variety of dependenceproducing drugs is involved and a given user may use several simultaneously or in sequence. There is an element of communicablllty involved in taking such drugs, the initial and continuing use of which often occurs in peer groups. Keeping these factors in mind, the Group proposes the following conclusions, recommendations and strategies for consideration of the WHO Regional Office for the Western Pacific in the further development of its programme in this field. 6.1 Conclusions and recommendations

{l) The broad purpose of programmes in this field should be to prevent or reduce the incidence and severity of problems associated with the use of dependence-eroducing druss. This goal can be broken down into specific objectives directed at the many different problems involved. As a goal, it is more realistic and provides better direction to a variety of operational approaches than the commonly stated aim of preventing or reducing drug use or drug "abuse" alone. (2) Because of the complex and disparate problems involved, the skills of a number of disciplines and organizations are necessary in the planning, as well as the operation of programmes in this field.

(3) "Realistic planning requires the cooperation and participation of (a) persons fully acquainted with the attitudes, customs, and resources of the country or locality in which the programme is to be implemented, {b) persons familiar ytth the special health and social problems associated with the use of drugs and the various means used for their prevention, 1

Including, if possible, persons who themselves have experienced drug-related problems.

- 20-

treatment, and control, and (c) persons ivho have or are to have major responsibility for the operation of the programme." 1

(4) Specific objectives, as well as broad goals, should be stated in as quantifiable terms as possible; priorities and short and longer term plans with ~arget dates should be established in connexion with these objectives. (5) In planning a programme, attention must be given to the following broad approaches and objectives: (a) operational research to provide for (i) on-going assessment of problems and resources, (ii) the establishment of criteria and means to evaluate the usefulness of the various approaches and methods utilized, and (iii) the modification of programme policies and activities as indicated; {b) treatment including rehabilitation of persons involved in the problem-related use of drugs, utilizing correctional, medical, and social approaches; and (c) problem prevention~ utilizing educational, legislative, sociocultural and other environmental approaches designed to (i) curtail the availability of dependence-producing-drugs, (ii) reduce interest in the demand for such drugs and the social acceptance of problem-related use, {iii) reduce the incidence and severity of complications, and (iv) improve understanding of the causes of the problems involved and their management. Countries should be encouraged to develop balanced programmes that provide services in all these areas.

(6) Services for the treatment, including rehabilitation, of persons experiencing drug-related problems should provide for (a) continuity of assistance as the person receiving help moves from one type of service to another, and (b) the provision of long-term supportive and "after-care" services. While voluntary participation in such programmes is to be encouraged, it is recognized that compulsion has been found to be useful in some cases, especially in connexion with necessary "after-care services". 3 Compulsory detent~on alone, in the absence of treatment has not been shown to be beneficial. (7) Large-scale programmes should be based on scientifically demonstrated premises. Where such knowledge is lacking, a proposed approach or method should first be tested on a trial basis and applied on a larger scale only after its worth has been demonstrated. If such a trial is not feasible 1

Wld Hlth Org. techn. Rep. Ser., 1974, No. 551, p. 74 (section 3.7.1

no. 2). 2

Wld Hlth Org. techn. Rep. Ser., 1974, No. 551, p. 74 (section 3.7.1). 3 Vaillant, G.E. (1973) Arch. sen. Psychiatry, ~' 237. 4 Wld Hlth Org. techn. Rep. Ser., 1970, No. 460, p. 28 (section 3.3.5).

- 21-

(e.g. because of time limitations or difficulty of establishing suitable controls), a large-scale programme should be undertaken only if it is based on operating assumptions widely accepted by knowledgeable persons of the types listed in paragraph 3 above, representing at least 3 or 4 different professional disciplines.l

(8) Provision· should be made for developing activities in the proper sequence, for example, with respect to {a) the scope of the programme {moving from limited to broader or additional target groups, geographic areas or drug types), (b) training (preparation of necessary personnel before beginning additional activities) and (c) the availability of counseling, trea~­ ment or other helping services before case-finding procedures are undertaken.

(9)

par~professional

Pre- and in.service training is essential for professional and personnel involved in programmes designed to serve the

broad purpose set out under (1) above. (10) Persons who themselves have experienced drug-related problems and who have achieved a substantial degree of rehabilitation have been usefully employed in many programmes in this field. Because of the special contribution they may be able to make,3 and the shortage of personnel who are prepared to work in such programmes, the recruitment and training of selected "ex-users" should be given particular consideration in the Western Pacific Region. 6.2 Broad regional strategies

With respect to programme development in countries of the Region, the Group identified areas, activities and approaches to which priority might well be given. HOwever, these may need to be modified to take account of practical field experience as well as the views and particular strengths of the intercountry consultant due to be assigned. It was strongly emphasized that the priority areas and activities listed in this and the following section were to be understood as suggestions and guidelines subject to revision. Substantial flexibility is essential in implementing programmes in the broad field of drug dependence. The :f'ollowins _~~tegies were __recommende~:

(1) The provision of consultation on programme development and assistance for training in countries with existing or potential drug-related problems. (2) The development, where it is not feasible to implement a fully balanced programme from the outset, of demonstration projects beginning with

1 no. 5). 2

Wld Hlth Org. techn. Rep. Ser., 1974, No. 551, p. 74 (section 3.7.1, Wld Hlth Org. techn. Rep. Ser., 1974, No. 551, p.

74

{section 3.7.1,

no. 6). Fbr example, as role models to other users and as persons specially skilled in contacting and empathizing with them.

3

- 22 -

treatment (including rehabilitation) for drug dependent personal in those countries already experiencing substantial problems. At the same time, attention should be given to the development of measures for limitins the availability of dependence~producins drugs to existing and potential users and also education ofthe public to bring about desired attitudinal ch~es and build a supportive social climate. All three are important first steps n fostering further improvements in sociocultural control.

(3) The implementation of policies and procedures that will foster and facilitate contact between persons involved with the destructive use of drugs and "helping" personnel. (4) through: (a) emphasis on the importance of skills in human relations and community organization as well as the technical field involved; (b) the use of consultants to assist with pre- and in-service trainins of local personnel in the country where they will be workins; and (c) the use, when indicated, of fellowships to train local personnel in foreign settings, preferably only after they have had local experience in a drug-dependence programme. The strengthening of personnel resources in Member countries

6.3

Immediate prosramme activities

The Group was pleased to learn that the WHO Regional Office plans to employ an intercountry consultant to work in the broad field of drug dependence and that it is giving attention to the qualifications suggested under 4(a) in the preceding section. (1) In response to staff queries about activities to which the intercountry consultant might give major attention during the next two to three years, the Group identified the following: {a) acquiring knowledge about the problem-related use of drugs, the prevailing social attitudes and responses, and the available resources for meeting these problems in all the countries of the Region; making personal visits2 to selected countries (commencing with those that have a major interest in the field) 1

Such demonstrations (1) are helpful in improving the understanding of community leaders about problems associated with the use of drugs, (2) are susceptible to early and continuing evaluation, and (3) can be used as a base for training needed personnel, monitoring needs and further programme development. 2 Initial visits might be of one to three weeks duration. Shorter visits may result in limited perceptions while longer visits may encourage unnecessary involvement in details.

- 23 -

entering into and correspondence with official and other operational, research and training personnel, identifying persons and institutions, voluntary as well as official, that are carrying out, or could foster, action~oriented research and training activities; (b) analysing available data to determine needs and identify gaps in services, and to establish priorities for action; (c) promoting information interchange (i) informally by personal contact or by introducing people to each other and to ideas, and (ii) formally through means such as a newsletter and the development of a directory of people and services in the Region; (d) stimulating further activities such as data collection and provision of the missing elements of a balanced programme; (e) fostering concerted actionl and the associated task of defining measures and targets precisely by promoting (i) the formation of active boards or committees at different levels to assist in fact finding, planning and implementation of programmes, (ii) joint observation and training activities at both interorga.nizational and interdisciplinary levehl, and (iii) conferences, discussion groups and seminars both for those directly involved in the action and for others such as the general public; (f) identifying are representative of able to serve the WHO consultants for short to come; experts, especially within the Region, who a variety of disciplines and might be availRegional Office as temporary advisers and/or or longer term assignments for several years

(g) providing consultatien services, on request to Member countries; (h) planning and implementing intercountry working groups, seminars, consultations; and (i) assisting on request in the development of similar intercountry activities. (2) The Group noted the provisions and proposals made for group educational activities in 1975, 1976 and 1977 and expressed the following opinions: (a)_ The WHO Regional Office should proceed with its plans to convene, in 1975, a working group on health education programmes for yotmg people concerning the problem.. related use of drugs. Such a meeting might well concentrate on an exchange of views between persons actually working with youth involved in the destructive 1

Wld Hlth Org. techn. Rep. Ser., 1974, No. 551, p. 72 {section 3.7).

- 24 ..

use of drugs, school counselors, youth leaders, consultants skilled in the field of health education and those involved in the of balanced programmes, both community the broad field of drug dependence. (b) Corwideration should be given to the possibility of conducting the following intra-regional group activities as rapidly as personnel and financial resources will permit. '!bey are listed in rough order of priority, taking account of need and time required for preparation: (i) A working group on the development of a co-ordinated programme in selected high drug-use local! ties of the Region .1 (ii) Consultations between the persons noted under l(e) above, to provide support in the continuing formulation of Regional Offjce concepts and strategies, and further their understanding of the Organization's emphasis on a balanced p1~gramme, and strategies. (iii) .A travelling seminar for key personne12 from Member countries who are or will be responsible for policy formulation, programme planning and/or operation at national or community levels. The purpose would be to review significant programme features in the host and participant countries and discuss the involved in programme formulation and implementation. {iv) Intra-country programmes of the types noted under {i) and ) above. It is understood that such activities might well be carried out with little, if any, WHO expenditure being involved. 1

Participants would be individuals involved in providing services in high drug-use areas, who are well accepted by the local drug-using subcultures. They might be invited to describe briefly their programme activities and indicate somewhat more fully the nature of their record-keeping system, the minimum data they would like to record and the recording rubrics they would like to use if they had the necessary staff resources. It is hoped that the participants could agree on the latter and formulate the outlines of a joint monitoring programme. Funds might be sought from extra-budgetary sources to finance the recommended record-keeping and data analysis aspects of their projects. Consideration should be given to coordinating such a programme with related activities being initiated by WHO Headquarters. 2

Fbr example, health, enforcement, correctional, welfare or educaf'rf''"

tional personnP1

~'f'i ri

Rl Rnr'l 1J('I111n+Rry Rgenci "'"

See Moser, Joy, 1974, Problems and programmes related to alcohol and drug dependence in 33 countries, (WHO Offset Publication. NO. 6)

3

- 25/26 -

(3) In view of the importance given in this report to problem reduction, the Group suggested that, instead of using terms such as preventing "drug-use", "drug abuse" and "drug dependence" to express broad programme aims or purposes in this field, in the future these purposes be stated as the prevention and control of "problems associated with the use of dependence-producing drugs".

- 27 ... ANNIX 1

WORKnm GROUP ON MEASURES FOR THE PREVENTION AND CONTROL OF DRUG DEPENDENCE 9 - 17 December 1974 Members Dr David Bell

...

The Hale Clinic 6 Hale Road Mosman, N.s.w. 2088 Australia Society for Aid and Rehabilitation of Drug Addicts 290-B Hannessy Road Hong Kong Klyvarvagen 10 130 10 Ektorp Sweden President Drug A~se Research Foundatian 8 Inc. No. 8 Hillcrest St. Cubao, Quezon City, Philippines National Institute of Mental Health 1~7~3 Koonodai 8 Ichikawa Chiba ...ken Japan

Mr J. Ch'ien

-

Dr Richard M,. Esser

Fath•r Boo Garon

Dr M. Kat.o

Dr

~ong

Hon Koon

..

Department of Social Medicine and Public Health University of Singapore Singapore Project Manager Treatment and Rehabilitation Project UN/Thai Programme for Drug Abuse Control Ruam Rudee Building (Fifth Floor) 566 Ploenchi t Road Bangkok Dean, College of Education University of the Philippines Diliman, Quezon City Philippines

*Dr Mogens Nimb

..

Dr Paz G. Ramos

*Attended only for two days.

- 28 Annex 1

Secretariat Dr H.J.L. Burgess Regional Adviser on Nutrition WHO Regional Office for~the Western Manil :.t (Co-operational Offioer) 5300 Fremont Avenue Minneapolis, Minn. 55419 United States of America (Consultant) ~)outh Paoifi~

Dr D.C. Cameron

Mr H. S. Dhillon

Regional Adviser on Health Eduoatian WHO Regional Office for the Western Pacific Manila (Operational Officer)

Dr S.T. Han

...

Assistant Director of Health Services WHO Regional Office for the Western Paoific Manila