Expert Consultation on Adolescents and Substance Use in the Western Pacific Region
23 to 25 March 2011 Manila, Philippines Organ1zat1on ~~§ <- _____;;,__ _ --?
(mf~\. World .Hei!lth Western Pacific Region
(WP)2010/DHP/03-E Report series number: RS/2011/GE/19(PHL)
English only
REPORT ~ERT
CONSULTATION ON ADOLESCENTS AND SUBSTANCE USE 1N THE WESTERN PACIFIC REGION
Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 23-25 March 2011
Not for sale Printed and distributed by: World Health Organization Regional Office for theW estern Pacific Manila, Philippines
September 2011
WHO/WPRO LIURAnV MANILA. PHILIPPlN~-
27 MAR 20l2
NOTE The views expressed in this report are those of the participants of The Expert Consultation on Adolescents and Substance Use in the Western Pacific Region and do not necessarily reflect the policies of the Organization.
This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the Expert Consultation on Adolescents and Substance Use in the Western Pacific Region, which was held in Manila, Philippines from 23 to 25 March 2011 .
CONTENTS
1. 1.1 1.2 1.3 2. 2.1 2.2 2.3 2.4 2.5 2.6
INTRODUCTION ...................... ......... ... .. .................... ....... ............ ................ ....... . 1 Objectives ......................................................................................................... ...... . 1 Opct1i11g re111arks ....................................................... .......... .... ...... .. ..... .............. .. .. .. 1 Appointment of Chairperson, Vice-Chairperson and Rapporteur ........................... 1 PROCEEDINGS .. .... .................. .... .................. .... ....................................... ............. 2 Background and context .......................... ....... .......... .. ............ .... ....... .. ............. ....... 2 Scope of the consultation ....... ...... ....... ..... ........ .... .. .. .. ............ ..... .... ............... .. ........ 3 The review and its recommendations ...... ......... .. .................... ........ .. .. ................... .. 4 Presentations by temporary advisers ............... ........................................................ . 5 Group work ........................................ ....... ...... ............................... .......... .. .... ... ....... 8 Closing session ................................... ............ ......... ...... ........ ............. ...................... 9
3. CONCLUSIONS AND RECOMMENDATIONS ............................ ............ ..... .. .. ..... 9 3.1 3.2 Conclusions .......... ..... .................................... .. .......................... .. .. .. ...................... ... 9 Recommendations ................. ................ ............................ ...... ............... ... ............. 12
ANNEXES: ANNEX 1 LIST OF TEMPORARY ADVISERS, RESOURCEPERSON,OB SERVERS,AND SECRETARIAT PROVISIONAL AGENDA TENTATIVE TIMETABLE OPENING SPEECH
ANNEX2 ANNEX3 ANNEX4
Key words Adolescent I Substance-Related Disorders I Western Pacific
SUMMARY
An Expert Consultation on Adolescents and Substance Use in the Western Pacific Region took place in Manila, Philippines, from 23 to 25 March 2011. The consultation was organized by the World Health Organization (WHO) Regional Office for the Western Pacific. Participants included representatives from eight Member States in the Region, a resource person from a WHO collaborating centre, and WHO staff(Annex 1). The objectives of the consultation were: (1) to discuss the key findings and recommendations of the Review of Adolescent Substance Use and Responses in the WHO Western Pacific Region and to prioritize future actions; (2) to identify good practice models for intervention through the health sector and suggest improvements required in the health sector response; and (3) to suggest actions to support countries in mounting a strengthened response to address the issues and challenges of adolescent substance use.
In the course of the consultation, the resource person who developed the review provided an overview of its findings and recommendations, while WHO Regional Office staff gave brief updates on regional activities related to adolescent health, injury and violence, mental health, alcohol, tobacco and HIV. The experts shared experiences, illustrating evidence-informed policies which underpin a range of strategies to impact on alcohol- and drug use-related harm among young people, the roles of adolescent-friendly health services and school nurses, a range of community-toresidential programmes for young substance users , and grass-roots community actions using, for example, nutrition as a focus for broader strategies. They also noted that health system responses required strengthening, especially in terms of the provision of adolescent-friendly health services and the willingness and capacity of heath care providers to engage with and provide accessible, affordable, accountable and acceptable interventions for adolescents and young people who are most vulnerable and at risk of developing or already experiencing substance use-related difficulties . The need for better data was identified, and for the disaggregation by age of existing data sets. In addition, it was noted that the diversity of adolescents and young people, the range of substances used and the complexity of some presentations require an effective continuum of interventions ranging from information provision, through early and brief interventions for amphetamine, alcohol and cannabis use, to comprehensive and mixed interventions which could include family and residential components. Specific recommendations were made in relation to the scale-up of adolescent-friendly health services, the use of quality assurance frameworks and accreditation as mechanisms to ensure interventions are effective and evidence informed, and the role of WHO in ensuring that policies addressing the use of alcohol in the Region include specific attention to adolescents and young people.
1. INTRODUCTION
An Expert Consultation on Adolescents and Substance Use in the Western Pacific Region took place in Manila, Philippines, from 23 to 25 March 2011 . The purpose of the consultation was to review what is known of the prevalence, patterns and trends in substance use in the Region, to examine current responses by Member States, and to identify possible actions to support building a more competent evidence base and strengthening country responses.
The burden of ill-health from substance use by adolescents is substantial. Some effects include road traffic accidents and other accidents, risky sexual behaviour resulting in HIV and other sexually transmitted infections (STI), and stigma, discrimination, social marginalization and exclusion. The burden of disease falls heavily on highly vulnerable adolescents. 1.1
Objectives (1) To discuss the key findings and recommendations of the Review ofAdolescent Substance Use and Responses in the WHO Western Pacific Region and to prioritize future actions. (2) To identify good practice models for intervention through the health sector and suggest improvements required in the health sector response. (3) To suggest actions to support countries in mounting a strengthened response to address the issues and challenges of adolescent substance use .
1.2
Opening remarks
Dr Susan Mercado, Team Leader, Tobacco Free Initiative, WHO Regional Office for the Western Pacific, welcomed participants to the consultation on behalf of the WHO Regional Director. She stressed that substance use was a public health issue that required a public health approach, in collaboration with other key stakeholders. Dr Mercado referred to available data that linked morbidity and mortality to substance use, and highlighted that many of the actions required to address substance use by adolescents and young people lay outside the responsibilities of WHO, in areas such as education and employment, but could be supported by WHO if ethical, evidence-informed and effective interventions were used. The opening remarks were followed by self-introductions and an orientation to the consultation by Mrs Nina Rehn-Mendoza, Technical Officer, Substance Abuse, who emphasized that WHO had a key role in strengthening national responses. Participants included representatives of eight Member States in the Region, a resource person from a WHO collaborating centre, and WHO staff from the Regional Office (Annex 1). 1.3 Appointment of Chairpersons and Rapporteurs
Dr Regina Lee of Hong Kong (China) was appointed Chairperson for the first day, Dr Gochoo Soyolgerel of Mongolia for the second day and Dr Emma Alesna-Llanto of the Philippines for last day of the consultation. Dr Tran Tuan of VietNam was appointed as Rapporteur for the first day and Associate Professor Yvonne Bonomo of Australia for the second day of the consultation.
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2. PROCEEDINGS
2.1
Background and context
The Western Pacific Region is home to a very youthful population. Within the Region, drug production and trafficking routes have been well established. Member States have become increasingly concerned about the increase in alcohol and other substance use among young people, but a clear picture of the extent and patterns of substance use is not readily available. Member States are well aware of links between substance use and: • • • • e
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death and injury, especially when driving or riding vehicles while intoxicated; violence, in the form of assaults and sexual violence; unintended pregnancies; family disruption; mental health, especially depression, psychoses and suicide; HIV and other bloodborne and sexually transmissible infections; cnme; early school leaving; and social exclusion, marginalization and loss of productivity.
To provide an overview of relevant health concerns and responses within WHO's Western Pacific Region, WHO Regional Office staff made brief presentations on current priorities and activities in relevant areas. 2.1.1 Adolescent health
Dr Patanjali Nayar stressed that while adolescents are diverse as a group, many behaviours ... SO, what's so special abo:.~ t adolescents (10-19 yrs)? that impact on the burden of disease, including • A pt:riod of rapid deveiopment anc! cflange: substance use, begin during adolescence. - Physical •; lh.:-ir n;,c; He highlighted that adolescent developmental needs • u and their emerging cognitive development are often ~~t~:::~~~~~~~~ , ignored in the shaping of interventions. He reviewed - Sod.AI IDMI' r.,.:.• J...,_. what is known about risk and resilience approaches, mv,;om.s and the particular needs of especially vulnerable young people, including those also designated as most-at-risk adolescents and most-at-risk young people (MARA/MARYP). He also reviewed the components of the WHO Child and Adolescent Health (CAH) 4 S strategic framework: strategic information, supportive evidence-informed policies, services and supplies, and support to and synergies with other sectors. ~1 .
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2.1.2
Alcohol
Mrs Nina Rehn-Mendoza's presentation focused on alcohol use and related morbidity and mortality, especially injury, impainnent, and sexual and reproductive health concerns. She noted that, as a neurotoxin, alcohol had specific impacts on the brain and its functioning. She also highlighted the situation for young women, that being, more harm can accrue faster and at lower levels of consumption. 2.1.3 HIV and other STI
Dr Pengfei Zhao provided regional data on HIV and associated concerns, and highlighted the importance of attention to hepatitis C virus, the need for a strengthened harm reduction response in the Region, and the negative impacts of incarceration. 2.1.4 Tobacco
Dr Susan Mercado stressed that tobacco use is a "paediatric disease", and therefore, it is important to increase attention to the use of tobacco by adolescents and young people. She stressed that the tobacco industry was targeting young people, especially young women, via packaging and product development, and that 80%-90% of smokers began smoking before the age of 18 and 25% starting before the age of 10. 2.1.5 Injury and violence
Dr Krishnan Raj am noted that young people could be both victims and perpetrators of violence. He stressed that interventions need to take into account country-specific contexts. Dr Raj am also noted some activities focusing on alcohol use and road trauma to reduce related injury and death among young people. 2.1.6 Mental health
Dr Wang Xiangdong stressed the importance of including young people in decisionmaking and shaping of mental health strategies. He also announced the slogan: "Nothing about us without us". 2.2 Scope of the consultation
The Review ofAdolescent Substance Use and Responses in the WHO Western Pacific Region, which was distributed to participants prior to the meeting, assisted in guiding the work carried out during the consultation. This desk review explored the context of adolescent substance use; the prevalence of substance use in all countries in the Western Pacific Region, as best known from available data; and prevention and treatment interventions. The review made a number of recommendations, including improving data quality and quantity, setting up a monitoring system to identify trends, adopting a collaborative approach among United Nations agencies and organizations, creating a facilitative and supportive policy environment, building capacity among primary health care workers, trialling evidence-informed preventive and
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treatment interventions, and paying greater attention to the high morbidity among MARA and MARYP. The Secretariat proposed structuring the discussions during the expert consultation around three main areas: (1) (2) (3) 2.3 research, monitoring and analysis to fill gaps in information; issues related to health systems; and settings for interventions, especially for those most at risk.
The review and its recommendations
Dr John Howard, a WHO resource person from the National Drug and Alcohol Research Centre, Faculty ofMedicine, University ofNew South Wales, Australia, a WHO Collaborating Centre for the Prevention and Control of Alcohol and Drug Abuse, presented an overview of the purpose, findings and recommendations of the Review ofAdolescent Substance Use and Responses in the WHO Western Pacific Region. He recommended taking caution when considering the review due to the paucity of data. He noted the following: " Data availability was poor and data quality was inconsistent and problematic . Within countries, surveys used over time varied considerably, as did populations sampled. Most data were out of date and did not allow for the identification of trends or of emerging drugs of concern.
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It was extremely difficult to convey a meaningful picture of current, or even recent, prevalence of adolescent substance use across the Region, let alone identify details of preventive and treatment interventions.
Dr Howard then briefly reviewed what is known about the aetiology of substance use among adolescents and young people, some regional risk factors, and the findings regarding prevalence and trends in use of substances by adolescents and young people in the Western Pacific Region. He then commented on current prevention and treatment responses, both effective and ineffective, and how available evidence could shape more effective responses. What do ""-'e know about what does NOT wo1k well or ot oil for nto~t yo1mg pf'op lei' Ci:il -----···--l!lt"drve>11ior:.> thct wrg~::>l both ri1h em=! !}rtli~tlive fc::lor>
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The review recommended the following: • • conduct routine monitoring of in- and out-of-school young people; explore the specific "contexts" and "cultures" within which young people initiate and maintain substance use; improve collaboration among the United Nations family; create a supportive and facilitative policy environment; trial more targeted and evidence-informed prevention interventions for in- and out-of-school young people; trial brief interventions - especially for cannabis, alcohol and amphetamine-type stimulants (ATS) use; diversify sites for preventive and treatment interventions, e.g. schools, dormitories, work places, marine colleges; and engage with the compulsory treatment system where it exists.
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Presentations by temporary advisers New Zealand
Ms Sally Liggins presented on the Community Action Youth and Drugs (CAY AD) project (http://cayad.org.nz), which was informed by evidence and supported by effective collaboration and communication. Building local capacity has been key, with activities supported by local sporting clubs, councils, community rallies, community empowerment and advocacy. Outcomes have included increased cross-sector/community collaboration, strengthened parental support, improved local policy, reduced substance use-related suspensions from school, and increased educational participation. 2.4.2 Malaysia
CAYAD national outcomes • Increased informed community discussion and debate about issues related to illicit drugs • Effective policies and practices to reduce harm are adopted • Increased local capacity to support young people .in education. employment and recreation • Reduced supply of drugs to young people
Professor Mahmood Nazar Mohamed outlined current activities in Malaysia, such as a student intervention programme that promotes early drug use screening and identification of students at risk, with multiple agency collaboration. Random urinalysis is used at some schools, and students who test positive are enrolled in an early intervention programme that consists of spiritual, physical, counselling, life skills and information, education and communication components. Rakan Antidadah (RADA) is a voluntary peer-based group that provides peer
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counselling -youth-to-youth interaction, sporting activities, meetings between recovering drug users and their families, and community-based youth volunteer activities such as community clean-ups. Other community activities include a parenting programme for mothers and their children and a community watch. 2.4.3 Hong Kong (China) Model of A School-based Adolescent Health Programme in Hong Kong
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Dr Regina Lee outlined the roles of health facilitators and school nurses in the school-based adolescent health programme. The drug control policy in Hong Kong (China) is based on preventive education legislation, early identification (including urine testing), intervention, treatment and rehabilitation, law enforcement and external (China and beyond) cooperation and research. 2.4.4 Mongolia
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Dr Gochoo Soyolgerel outlined the development of the country's adolescent-friendly health services project. The project is based on a quality improvement approach that offers training in assessment and the WHO Adolescent Job Aid for primary health care workers. Alcohol use among adolescents is a major concern, as is accessibility to services for those in rural and peripheral areas. 2.4.5 Philippines
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Dr Emma Alesna-Llanto outlined the involvement and activities of professional bodies such as paediatric associations. She noted that while "substance use is a paediatric problem," the evidence of difficulties such as impact of alcohol use is often missed or ignored. A review indicated variability in the willingness of health providers to engage with substance-using adolescents, and a lack of focus on substance use among many professional bodies and organizations. The Home, Education, Activity, Drugs, Sexuality, Suicide, Safety (HEADSSS) assessment approach was highlighted, as was e-learning.
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2.4.6
Australia: Risk and protective factor approach
Associate Professor Yvonne Bonomo outlined the risk and protective factor approach, including protecting and intervening early, with a focus on connection with family, school and mental health literacy, and stepped care models. The contentious issue of abstinence as a goal
Why so important? "Identification and treatment of anxiety disorders may· be another strategy to decreas~ the public · tieaith burderi"cit"ctiifd and adolescent depression" • 75% of adults diagnosed with mE>ntal health problems had symptom onset before age 24 years · (t:o;>:;IIr.t £:! ,,I, /\r(.IJ GP.n P~y~h;iJt'V 1005; til; S~3·if.lZI
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was discussed, as was what is needed to provide young people with healthy alternatives to meet the needs that drugs previously met. The Gunja (Yarndi) Brain Story (cam1abis) flip chart was used to illustrate a resource available (http://www.healthinfonet.ecu.edu.au/keyresources/promotion-resources?lid= 17941 ). 2.4.7 Guam
Mr Don Sabang stressed the importance of evidenced-informed interventions and highlighted websites of organizations that have collections of such interventions, e.g. Substance Abuse and Mental Health Services Administration (SAMHSA). Approaches that are based on effective screening and that meet current stage of change via appropriate levels of care in Guam were emphasized, and the Teen MATRIX model was outlined. He also illustrated Guam's substance use treatment continuum of care, where people who use substances are screened, assessed and allocated to the most appropriate level, composition and intensity of treatment. In addition, he outlined the accreditation process for people working in substance use treatment to ensure quality standards are met. Guam's Substance Treatment Continuum of Care Lt~vel 0 J Early lntr.rv~ntion l_£:vr.t 0 7 /\fh:rca1 i!IC:Jrllin~u:d Coif(·
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2.4.8
VietNam
Intervention model design (cont.)
Dr Tran Tuan outlined an approach to nutrition and exercise that starts at the community level and moves upwards. While initially focusing on a general issue such as nutrition, the approach can be expanded to cover mental health, substance use, HIV and other health issues.
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Solomon Islands
Mr William Same outlined the national alcohol policy, "Hands on the Site", which is an area-focused intervention aimed at community empowerment. The model enables the development of partnerships between health promotion and healthy village settings and among key stakeholders. 2.4.1 0 Australia: Cannabis intervention
Dr John Howard gave a presentation on a brief motivational enhancement intervention for cannabis use, with a video demonstration of the approach. 2.4.11 United Nations Children's Fund (UNICEF)
Ms Margaret Sheehan briefly outlined some current UNICEF activities that focus on increasing understanding of MARA and MARYP- now also known as key affected populations, the need for community-based interventions, and building on successes. 2.4.12 United Nations Office on Drugs and Crime (UNODC)
Dr Juana Tomas-Rossell6 briefly outlined some current UNODC activities that relate to young people, such as family interventions, improved data collection (e.g. on ATS), livelihood projects, and the publication of a range of useful material and manuals. Questions and answers followed each of the presentations. 2.5 Group work
Participants were divided into three smaller groups for the group work sessions. The first session identified problems, issues and challenges of working in the area of adolescents and substance use. Each group discussed one of the following topics: (1) (2) issues related to health systems; research, monitoring and analysis to fill gaps in information; and
(3) settings for prevention for adolescents most at risk and with highest morbidity and mortality.
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The work from the first group work session was carried into the second session. Each group reviewed the presentations, identified effective and promising strategies, and gave them priority rankings. This work was used to inform development of recommendations and priority interventions. During the third group work session, participants were asked to provide !iUidance on strategic actions for WHO in the Western Pacific Region. 2.6 Closing session
In the closing session, the three groups presented their final recommendations and Dr Wang Xiangdong, Team Leader, Mental Health and Injury Prevention, closed the consultation by expressing his sincere thanks for the hard work and active participation of all participants.
3. CONCLUSIONS AND RECOMMENDATIONS
The experts shared experiences, illustrating evidence-informed policies which underpin a range of strategies to impact on alcohol- and drug use-related hann among young people, the roles of adolescent-friendly health services and school nurses, a range of community-toresidential programmes for young substance users, and grass-roots community actions using, for example, nutrition as a focus for broader strategies. The following are the conclusions and recmmnendations of the expert group. 3.1 Conclusions
It was noted that health system responses required strengthening, especially in terms of the provision of adolescent-friendly health services and the willingness and capacity of health care providers to engage with and provide accessible, affordable, accountable and acceptable interventions for adolescents and young people who are most vulnerable and at risk of developing or already experiencing substance use-related difficulties. The need for better data was identified, and for the disaggregation by age of existing data sets. In addition, it was noted that the diversity of adolescents and young people, the range of substances used and the complexity of some presentations require an effective continuum of interventions ranging from information provision, through early and brief interventions for amphetamine, alcohol and cannabis use, to comprehensive and mixed interventions which could include the family and residential components. 3.1.1 Better epidemiology - appropriate data
While many data gaps exist and the quality of available data is variable, there is evidence to indicate some priorities and future directions. However, overall, data are lacking, and if available, are often of poor quality, outdated and/or not disaggregated by age. Thus, some settings require further development in research capacity and ·output - to better inform policy, surveillance, and type, range, level, monitoring and efficacy of interventions. There may be a need to map the data being collected, and to determine if mapping assists in ascertaining regional patterns and trends, and to ensure that data on young people down to at least age 14 is included, especially in all data collections of United Nations agencies and organizations. There is also a need to ensure that the data collected are representative of target
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populations, for example, for all young people in an area, district or country, and not just young people in school who completed a survey. Likewise, there may be a need to over-sample or specifically target sub-groups of young people with greater morbidity and mortality associated with substance use, for example, MARA and MARYP. WHO and partner agencies can play a role by advocating for and supporting countries to improve strategic information for informing evidence-based policy and programmes, particularly addressing emerging HIV/STI coverage among adolescents who use substances. 3 .1.2 Building workforce capacity
The uptake and usage of available training and practice guides is variable across the Region. The provision of adolescent- and youth-friendly services and interventions that are accessible, affordable, accountable and acceptable needs to be promoted, and barriers to accessing training, capacity-building and implementation identified and overcome. It is also evident that many clinicians do not know how to treat substance use among young clients, or see it as too specialized, too difficult, too messy and too demanding. 3.1.3 Supportive policy environment
Policies relevant to substance use among adolescents and young people often do not promote, protect and support safe environments for young people, or if they do address such issues, are not implemented as extensively as possible. There is a capacity-building issue in relation to the development of appropriate evidence-informed policies for adolescents and young people. Policies also need to be consistent with WHO guidelines. Policies and legislation should be informed by evidence, and such evidence should be indicated in their promulgation. There is an urgent need to review legislation and policies that discriminate against adolescents and young people on the basis of age in relation to service or intervention eligibility and access (for example, age restrictions for opioid substitution treatment, needle and syringe programme access). 3 .1.4 A continuum of care
Given the diverse patterns of substance use by adolescents and young people (for example, in terms of age, complexity, substances used, social dislocation), there is a need for a range of interventions - from screening, through early and brief, to comprehensive and complex. This will enable the provision of an appropriate level and intensity of treatment and care necessary to meet assessed current need. The model presented by Guam is useful in this regard, and allows for investment where risk/morbidity is greatest, and for "stepped care", whereby level and intensity can be adjusted upon review of current functioning and intervention effectiveness. In addition, there is a need for a range of preventive interventions- universal, selected and indicated. The latter intervention attempts to limit transitioning to more harmful routes of substance administration. These approaches include the current Population Services International (PSI) "Break the Cycle" strategy to limit transitioning to injecting drug use. Approaches that strengthen protective factors and reduce or ameliorate the impact of risk factors in a variety of settings are essential. The development of an effective, youth-friendly continuum of care requires collaboration between the primary health care systems, adolescent-friendly health services, and nongovernmental organizations.
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3.1.5
Quality assurance and evidenced-informed interventions
A quality assurance framework can be useful in relation to professional and service development, for example, in accrediting courses and programmes and continuing education, and in reviewing programme development and delivery. Funding can be tied to provision of evidence-infonned interventions by accredited agencies and organizations. For ~xRmph~, A review in Mongolia of "life skills" activities could ensure that life skills related to alcohol and other substance use are linked to behaviour change and not just knowledge. 3.1.6 Closedsettings
There is no evidence to support the use of closed settings (for example, compulsory drug treatment or imprisonment) to effect positive change among adolescents and young people who use substances. ln fact, the evidence is to the contrary- high relapse rates (in excess of 80%), high levels of abuse and denial of rights, and violation of international treaty and convention obligations. The negative impact is particularly acute when adolescents and young people are placed in adult-oriented settings with no attention paid to age-specific developmental needs. Some countries are dismantling such systems and developing community alternatives. For example, clinics in Malaysia that offer open access to treatment for drug users have proven to be successful in attracting individuals who come forward voluntarily for drug treatment and rehabilitation . 3.1. 7 Participation
There remain opportunities to increase and strengthen the participation of adolescents and young people in all aspects of interventions - data collection, policy-making, strategy and intervention development, delivery of interventions, and monitoring and evaluation. 3.1.8 Coordination and collaboration
It is crucial to continue efforts to strengthen coordination and collaboration with stakeholders in other sectors, especially education and the media, to provide comprehensive initiatives to address substance use by adolescents and young people. Given the evidence for the role of community action and ownership in supporting and bringing about change, it is essential to strengthen links between the health sector and civil society to effectively address the issues associated with substance use and related difficulties of adolescents and young people. Such efforts need to be evidence-based, grass roots driven, culturally sensitive and appropriately built on consensus.
3.1.9
Urine testing in schools
There is no evidence base for random urine testing in schools, especially where there is an absence of evidence-informed, effective and appropriate interventions to assist those identified as having used substances. Issues of rights violations, increasing stigma and discrimination, and early departure from the usually protective role of participation in education and training tend to outweigh any putative benefits. It appears to be more appropriate to use available screening tools in a sensitive and youth-friendly manner to screen for substance use and related difficulties for those identified via their behaviour or other concerns. Voluntary participation in any urine testing process may assist in monitoring intervention effectiveness.
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3 .1.1 0
Mental health and substance use
The links between substance use by adolescents and young people and the onset and/or exacerbation of mental health concerns is increasingly recognized in the Region. There may be opportunities to explore the development of projects that attempt to build capacity to address this comorbidity, especially via developing interventions focusing on substance use and depression and anxiety. 3.2 Recommendations
The experts made specific recommendations in relation to the scale-up of adolescentfriendly health services, the use of quality assurance frameworks and accreditation as mechanisms to ensure interventions are effective and evidence informed, and the role of WHO in ensuring that policies addressing the use of alcohol in the Region are evidence-based and include strategies that are effective in reducing alcohol- and other drug-related harm to adolescents and young people. 3.2.1 Better epidemiology- appropriate data
WHO, in collaboration with UNODC, UNICEF and the Joint United Nations Programme on HIVI AIDS (UNAIDS), should strengthen advocacy for disaggregation of data by age to include those under 18 as a specific category, and promote routine surveillance of key indicators, such as substance use and risk behaviours. In addition, these United Nations agencies should collaborate with research institutes to identify the most useful instruments to yield data required for meaningful local, district and regional comparisons, identification of trends, and early warning of risk for negative health and social outcomes via changing behaviour or emergence of new substances of concern. 3.2.2 Building workforce capacity
WHO should increase its support for building the capacity of Member States to provide adolescent-friendly health services, and to use available tools and guides (such as HEADSS, Adolescent Job Aid). This may require identifying and overcoming barriers that could be associated with access to technology, roles and attitudes. It is also recommended that strategies should be developed to ensure that preventive and rehabilitative initiatives related to substance use are on the menu of services offered by adolescent-friendly health services. WHO should explore regional development and use of e-courses, such as the recent WHO/CAH e-courses on sexual and reproductive health. WHO should embrace the capacity, reach and influence of professional associations, institutions, universities and networks to advocate for, build capacities for and support provision of evidence-informed prevention and rehabilitative efforts related to substance use and related difficulties of adolescents and young people. The target groups include general and family medicine practitioners, paediatricians and adolescent physicians, generalist and school nurses, psychologists and social workers, primary care workers, health promoters and community health workers, substance use counsellors and workers. School nurses, where they exist, are ideally suited to provide evidence-informed substance use screening, brief interventions and support for adolescents and young people in educational settings. There is an urgent need to broadly disseminate research that demonstrates which strategies and interventions do not work and which are effective to prevent alcohol-related harm and treat
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adolescent and young people's substance use-related difficulties. It is recommended that WHO support the development of knowledge hubs that could assist with such dissemination, or ensure its inclusion into existing and effective knowledge hubs. 3.2.3 Supportive policy environment
WHU should rmtrate a process tor countnes to review legislation and policies to reduce alcohol- and other drug-related harm to ensure the adoption of evidence-based, cost-effective prevention strategies that will reduce harm to young people.
WHO, UNICEF, UNODC and UNAIDS should ensure the dissemination of available guidelines and documents that could assist in the development of evidence-informed legislation, policies, strategies and guidelines that are culturally applicable and will reduce alcohol- and other drug-related harm to young adolescents and people. 3.2.4 Interventions- a continuum of care
WHO should promote the identification and dissemination of effective and emerging evidence-infonned, good-practice, youth-friendly continuum of care models. In addition, WHO should support the piloting of evidence-informed early and brief interventions for problematic use of alcohol, cannabis and ATS by adolescents and young people, to assist in providing a wider range of treatment intervention options. Furthermore, WHO and UNICEF should identify and promote innovative initiatives that meet the needs ofMARA and MARYP and can be delivered in diverse settings, such as workplaces, non-traditional youth settings, and via outreach. 3.2.5 Quality assurance and evidenced-informed interventions
WHO, in conjunction with relevant professional bodies, should support a review of available intervention services and accreditation approaches, and identify and promote those that have evidence of success in effecting clinical and organizational change, to ensure the needs of adolescents and young people who use substances are identified and met via an evidence-informed approach. Quality audits would ensure that adolescents and young people who seek substance use services are not discriminated against in gaining access to services and interventions essential to their health and well-being. These include youth-friendly harm reduction and mental health services . 3.2.6 Closed settings
The United Nations family should strengthen advocacy for the discontinuation of closed settings for adolescents and young people, and for the promotion of evidence-informed alternatives.
ANNEX I
LIST OF TEMPORARY ADVISERS, RESOURCE PERSON, OBSERVERS, AND SECRETARIAT
1. TEMPORARY ADVISERS
Associate Professor Yvonne Bonomo, Physician in Adolescent Medicine and Addiction Medicine, St. Vincent's Health and the University of Melbourne, Melbourne, Australia. Tel. No.: (61) 03 92882627. Fax: (61) 03 92882642. E-mail: yvonne.bonomo@svhm.org.au Dr Gochoo Soyolgerel, OIC, Child and Adolescent Health, Department of Medical Service Policy Coordination, Ministry of Health, Government Building-8, Olympic Street-2, Ulaanbaatar, Mongolia. Tel. No.: (976) 51 263652 (office). Mobile: (976) 91910655. Fax: (976) 11 320916. E-mail: gsoyolgerel@yahoo.com Dr Regina Lee, Assistant Professor, School of Nursing, Hong Kong Polytechnic University (PolyU), WHO CC for Community Health Services, Hung Hom, Kowloon, Hong Kong. Tel. No.: (852) 96578671. Fax: (852) 23341124. E-mail: hsrlee@inet.polyu.edu.hk Ms Sally Liggins, Team Leader, National Community Action Youth and Drug (CAYAD) Coordination, SHORE (Social and Health Outcomes, Research and Evaluation), SHORE & Whariki Research Centre, School of Public Health, Massey University, P.O. Box 6136, Auckland, New Zealand. Tel. No.: (649) 3666 136. Fax: (649) 3665 149. Mobile: 027 688 3311. E-mail: s.a.liggins@massey.ac.nz Dr Emma Alesna-Llanto, Clinical Associate Professor, University of the Philippines, College of Medicine, Department of Paediatrics, Section on Adolescent Medicine, Manila, Philippines. Tel. No.: (632) 521 8450 local2100. Fax: (632) 524 0892. Mobile: 0917 5611505. E-mail: teendoc99@yahoo.com Professor Dr Mahmood bin Nazar Mohamed, Deputy Director-General (Operations), National Anti-Drug Agency (NADA), Ministry of Home Affairs, Jalan Maktab Perguruan Islam, Sg. Merab, 43000 Kajang, Selangor, Malaysia. Tel. No.: (603) 8911 2200. Fax: (603) 8926 2089. Mobile: (6019) 3149202. E-mail: mahmoodnazar@yahoo.com; mahmoodnazar@gmail.com Mr Don P. Sabang, CSAC II, ICADC, Substance Abuse Program Supervisor, Drug and Alcohol Branch, Clinical Services Division, Department of Mental Health and Substance Abuse, Government of Guam, 790 Governor Oirlos G. Camacho Road, Tamuning, Guam 96913. Tel. No.: (671) 475 5439. Fax: (671) 477 7782. E-mail: don.sabang@mail.dmhsa.guam.gov; dcsabang@guam.net Mr William Same, Director, Integrated Mental Health Services, Ministry of Health and Medical Services, P.O. Box 349, Honiara, Solomon Islands, Tel. No.: (677) 20688/20830. Fax: (677)20085. Email: wsame@moh.gov.sb; samewl.same@gmail.com Dr Tran Tuan, Research and Training Center for Community Development (RTCCD), No. 39, Lane 255, Vong Street, HBT, HaNoi, VietNam. Tel. No.: (844) 3628 0350. Fax: (844) 3628 0200. Mobile: 0912 309597. E-mail: trantuanrtccd@gmail.com
Annex 1 2. RESOURCE PERSON
Dr John Howard, Senior Lecturer, National Cannabis Prevention and Intervention Centre, National Drug and Alcohol Research Centre, Faculty of Medicine, University of New South Wales, Sydney NSW 2052, Australia. Tel. No.: (612) 9385 0303. Fax: (612) 9385 0221. E-mail: john.howard@unsw.edu.au
3. OBSERVERS THE MEDICAL CITY
Dr Cornelio G. Banaag Jr., Professor Emeritus, Child and Adolescent Psychiatry, Room 312 MATI Building, The Medical City, Ortigas Avenue, Pasig City, Metro Manila, Philippines. Tel. No.: (632) 6356789loc. 5012; 6347714 (DL). Fax: (632) 7062278. E-mail: cgbanaag@yahoo.com Dr Rosalia Buzon, MD, Immediate Past President, SAMPI, Professor, Department of Pediatrics, Faculty of Medicine and Surgery, University of Sto. To.mas, Espana, Manila, Philippines. Tel. No.: (632) 749 9771. Fax: (632) 731 2834. E-mail: rose_buzon@yahoo.com Dr Nerissa M. Dando, MD, Secretary, SAMPI, Faculty, UP College of Medicine, Clinical Toxicology Consultant, National Poison Management and Control Center (NPMCC), College of Medicine-Philippine General Hospital, University· of the Philippines-Manila, Taft Avenue, Manila, Philippines. Tel. No.: (632) 554 8400 local2311; 5241078. Fax: (632) 526 0062. E-mail: docirisd@yahoo.com
SOCIETY OF ADOLESCENT MEDICINE OF THE PHILIPPINES INCORPORATED (SAMPI)
UNITED NATIONS CHILDREN'S FUND (UNICEF)
Ms Margaret Sheehan, Regional Youth and Adolescent Development Specialist, Asia-Pacific Shared Services Centre (APSSC), United Nations Children's Fund, Bangkok 10200, Thailand. Tel. No.: (662) 3569417. Fax: (662) 2 2805941. Mobile: (66) 88601 0008. E-mail: msheehan@unicef.org Dr Juana Tomas-Rossell6, TREATNET Coordinator, Southeast Asia, United Nations Office on Drugs and Crime, Regional Centre for East Asia and the Pacific, UN Secretariat Building, Bangkok 10200, Thailand. Tel. No.: (662) 2881777. Fax: (662) 2812129. Mobile: (66) 81732 6471. E-mail: juana.tomas@unodc.org Mr Zimmbodilion Y. Mosende, M&E Adviser, UNAIDS Philippines, 31 51 Floor, Yuchengco Tower, RCBC Plaza, 6819 Ayala Avenue, Makati City, Philippines. Tel. No.: (632) 9010413. Fax: (632) 9010415. E-mail: mosendez@unaids.org
UNITED NATIONS OFFICE ON DRUGS AND CRIME (UNO DC)
UNITED NATIONS PROGRAMME ON HIV/AIDS (UNAIDS)
Annex 1
4. SECRETARIAT
Dr Wang Xiangdong, Team Leader, Mental Health and Injury Prevention Team, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 528 9858. Fax: (632) 521 1036. E-mail: wangx@wpro.who.int Mrs Nina Rehn-Mendoza (Responsihle Offi~er), Te~hni~Al Offir.er, S11hstAnr.e Abuse, Mental Health and Injury Prevention Team, WHO Regional Office for the Western Pacific, United Nations A venue 1000 Manila, Philippines. Tel. No.: (632) 528 9856. Fax: (632) 521 1036. E-mail: rehnmendozan@wpro.who.int Dr Patanjali Dev Nayar (Co-responsible Officer), Technical Officer, Maternal, Child Health, and Nutrition Team, WHO Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel. No.: (632) 528 9083. Fax: (632) 521 1036. E-mail: nayarp@wpro.who.int Dr Krishnan Raj am, Technical Officer, Injury and Violence Prevention, WHO Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines. Tel. No.: (632) 528 9874. Fax: (632) 521 1036. E-mail: rajamk@wpro.who.int Dr Susan Mercado, Team Leader, Tobacco Free Initiative, WHO Regional Office for the Western Pacific, P.O. -Box 2932, 1000 Manila, Philippines. Tel. No.: (632) 528 9854. Fax: (632) 521 1036. E-mail: mercados@wpro.who.int Dr Emma Mafialac, Medical Officer, Maternal, Child Health, and Nutrition Team, WHO Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines. Tel. No.: (632) 528 9871. Fax: (632) 521 1036. E-mail: manalace@wpro.who.int Dr Pengfei Zhao, Technical Officer (Prevention), HIV/AIDS and STI, WHO Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines. Tel. No.: (632) 528 9718. Fax: (632) 521 1036. E-mail: zhaop@wpro.who.int
ANNEX2
PROVISIONAL AGENDA (I)
Opening Introduction (background and objectives of the consultation) Examination of key findings and recommendations of the "Review of Adolescents and Substance Use in the Western Pacific Region" Working in the area of adolescents and substance use -identifying problems, issues and challenges Showcasing regional- and country-level resources Experiences and good practice models for interventions Health sector response to substance use and adolescents - what needs to be done in the Western Pacific Region Priority interventions for the health sector response to adolescents and substance use Strategic actions for WHO in the Western Pacific Region
(2) (3) (4)
(5) (6) (7) (8) (9)
(I 0) Finalization and presentation of consultation recommendations
( 11) Closing
Expert Consultation on Adolescents and Substance Use in the Western Pacific Region Manila, Philippines, 23-25 March 2011 TENTATIVE TIMET ABLE Time 08:30-09:00 09:00-09:30 Registration (1) Opening ceremony Welcome address - Self-introductions - Nomination of the Officers of the consultation -
7 March 2011 ENGLISH ONLY
Wednesday, 23 March
Time
Thursday, 24 March
Time
Friday, 25 March
09:00-10:00
(6)
Experiences and good practice models for interventions (1 0-minute presentations followed by discussion)- Moderated session
09:00-10:00
(9)
Strategic actions for WHO in the Western Pacific Region
(2) 09:30-10:00 10:00-12:00
Introduction - Background and objectives of the consultation 10:00-10:30 Adolescent health issues Alcohol HIV andSTI Tobacco Injury and violence Mental health, including suicide and depression 10:30-12:00
Coffee break Coffee break Experiences and good practice models for interventions (Cont'd} Feedback and discussion 10:00-10:30 10:30-12:00 Coffee break (10) Finalization and preo;entation of consultation recommendations (11} Closing
(3)
Examination of key findings and recommendations of the "Review of Adolescents and Substance Use in the Western Pacific Region"
12:00-13:00 13:00-13:30
LUNCH BREAK Working with MARA Working with adolescents
12:00-13:00 13:00-14:00
LUNCH 8/lE;!li' (7} Health sector response to substance use and
12:00-13:00
LUNCH
adolescents- what needs to be done in the Western Pacific Region 14:00-14:30 Coffee break
13:30-14:30
(4)
Working in the area of adolescents and substance use- identifying problems, issues and challenges (group work) - Issues related to health systems - Research, monitoring and analysis to fill gaps in infonnation - Setting for prevention for those most at risk and with highest morbidity/mortality- MARA
14:30-15:00 15:00-16:00
Coffee break Working in the area of adolescents and substance useidentifying problems, issues and challenges (groupwork)- Cont'd Feedback to plenary
14:30-16:00
(8)
Priority interventions for the health sector response to adolescents and substance use (groupwork)
16:00-16:30
(5}
Showcasing regional- and country-level resources (tools and materials) available on substance use and adolescents
16:00-16:30
Feedback to plenary
ANNEX4
OPENING REMARKS BY DR SHIN YOUNG-SOO WHO REGIONAL DIRECTOR FOR THE WESTERN PACIFIC AT THE EXPERT CONSULTATION ON ADOLESCENTS AND SUBS'l'ANCb USE IN THE WESTERN PACIFIC REGION 23-25 MARCH 2011, MANILA, PHILIPPINES (delivered by Dr Susan Mercado, Team Leader in Tobacco Free Initiative) DISTINGUISHED EXPERTS, COLLEAGUES, LADIES AND GENTLEMEN. Good morning, and welcome to the Expert Consultation on Adolescents and Substance Use in the Western Pacific Region. I would like to thank you, experts, who have travelled from near and far to help us in addressing this issue, which so far has not received due attention. Drug and alcohol use among adolescents is an important public health issue and a growing concern in marty countries of the Region. Rapid increases in the use of alcohol, tobacco and other psychoactive substances by adolescents are contributing significantly to the global burden of disease. Furthermore, the onset of such use is occurring at younger ages in many countries and the range of substances is increasing. Risky sexual behaviour while intoxicated increases the risk of unplanned pregnancies and sexually transmitted infections. Road traffic and other accidents, often associated with alcohol use, are a major cause of mortality and injury among children and young people. Injecting drug use contributes to the spread ofHIV, hepatitis and other infections. And the troubling increase in violence and suicide among young people is often seen to be associated with drug and alcohol use. The burden of disease and morbidity associated with adolescent substance use tends not to be evenly distributed, but falls specifically on vulnerable adolescents, often referred to as "most-at-risk adolescents" or MARA. These vulnerable young people have great exposure to risk and little access to preventive services. Substance use among adolescents is clearly an issue of public health importance that WHO should play an active role in. But what can and what should WHO do? We know that much of what makes many young people vulnerable to alcohol and drug use is outside of the health sector responsibility, such as education, social environment, employment and family life. From the viewpoint of public health, we need to support these other sectors to work with young people, using ethical, evidence-based and practical interventions. WHO commissioned a review of substance use and adolescents in the Region, which became the basis of this expert consultation. You will be discussing the key findings and the recommendations stemming from this review later this morning. We are expecting that with your varied experiences and expertise you will give us further guidance on a plausible way forward. For effective programme development and support, it is important that we understand the situation and determinants, so the health sector, including school health or adolescent friendly
Annex4
health services, can respond adequately to the problems. During the meeting we will examine a number of different approaches and interventions and discuss possible strategic actions for WHO to support countries. We have a fair bit of work ahead of us these next three days, but with your valuable input ami shatiug I am swe we will ue successful. I wish you a fruitful consultation and pleasant stay in Manila. Thank you
'-'.tl Organization ~
(tr!~) World Health Western Pacific Region
www.wpro.who.int