Rights, respect and recovery: alcohol and drug treatment strategy

Chapter 4: Prevention and Early Intervention

Outcome: Fewer people develop problem drug use

Commitments to achieve the outcome
Identify and implement actions to reduce inequalities and improve Scotland’s health.	P1
Work with key experts, including those with lived and living experience to address stigma as a way to prevent and reduce related harm.	P2
Develop a comprehensive approach to early intervention amongst those who are at risk of developing problem drug use alongside those services who are already working with this group.	P3
Revise and improve the programme of alcohol and drug use education in schools to ensure it is good quality, impactful and in line with best practice.	P4
Develop education-based, person-centred approaches that are delivered in line with evidence-based practice to aim to reach all of our children and young people including those not present in traditional settings, such as Youth Groups, Community Learning and Development, looked after and accommodated children, excluded children and those in touch with services.	P5
Develop our current online resources to ensure they provide accurate, evidence-based, relevant and up to date information and advice around alcohol and drug use; and how to access help.	P6

Introduction

1. The more we can do on prevention and early intervention, the less harm will be caused by alcohol and drugs. This chapter sets out commitments that cover both alcohol and drugs, but additional, alcohol-specific actions have been set out separately in our Alcohol Framework 2018^[38]. As alcohol is legally available for those 18 and over there is a range of additional measures set out in that framework which do not apply to drugs.

2. Similarly, there are many issues associated with problematic drug use which require specific commitments which apply only to drugs. Much of this chapter focuses particularly on the prevention and early interventions which apply to drug use.

3. Our approach to drug prevention is aligned to the European Monitoring Centre for Drug Dependence and Addiction (EMCDDA)^[39] definition and covers:

• Environmental prevention - Addressing the cultural, social, physical and economic environments in which people make choices about drug use.
• Selected prevention and indicated prevention – Interventions with specific individuals, groups, families or communities who are more likely to develop drug use or dependence.
• Universal prevention – Improving drug education and awareness.

Delivering the Outcome

Environmental prevention

Reducing inequalities

4. We understand the clear links between problem drug use, health and other inequalities. Our approach to prevention is framed within the wider context of tackling these broader inequalities, including improving people’s quality of life, access to housing and employment. This will have the most significant impact on reducing problematic drug use in the longer term.

5. Many national and local strategies make key contributions to reducing inequalities, including this strategy. We need to work together – joining up policy at a national and local level – to ensure that we can help to reduce inequalities, particularly in those areas most affected by problem drug use.

6. Significantly, The Fairer Scotland Action Plan (2016)^[40] sets out a 50 point plan to deliver a fairer and more prosperous Scotland by 2030. This includes the Fairer Scotland Duty which ensures that public bodies take account of poverty and disadvantage whenever key policy decisions are made. The Scottish Government is committed to ending child poverty. Every Child, Every Chance^[41] – the Scottish Government’s Tackling Child Poverty Delivery Plan for 2018-22 – outlines the next, crucial steps to delivering on this ambition and its basis is in the Child Poverty (Scotland) Act 2017^[42]. The plan, backed by a range of investments, including a £50 million Tackling Child Poverty Fund, sets out a range of actions to increase household incomes, reduce costs, and support children and families to have a better quality of life.

The Scottish Government, NHS Boards and Local Authorities will work with Public Health Scotland (once established) to identify and implement actions to reduce inequalities and improve Scotland’s health. (P1)

Improving community connections

7. Improving connections within communities and reducing loneliness and social isolation will have a significant impact on reducing drug problems. Our approach to addressing these issues is set out in a number of national and local strategies and frameworks. Scotland is launching a national strategy to improve community connections.

8. For people with lived and living experience of alcohol and drug problems, stigma and discrimination can be a significant barrier to engaging in community services and activities. We will build on the work done by our expert advisory group to address drug related stigma. This group has identified three levels of stigma which need to be addressed concurrently:

• stigma by association;
• self-stigma; and
• institutional stigma^[43].

9. Future work will include addressing these points and raising awareness with the workforce across a range of services and organisations to improve services in a way which will reduce stigma. With actions including the developing of a stigma training course in partnership with Police Scotland.

10. Evidence shows that people who participate in culture are more likely to report good health and life satisfaction than those who do not. The Scottish Government is developing a Culture Strategy for Scotland^[44] which will seek to build on initiatives and promote lifelong health and wellbeing in Scotland’s most deprived communities. We need to consider and perhaps challenge the place of alcohol and drugs as well as recovery within the context of Scotland’s culture.

We will continue to work with key experts, including those with lived and living experience to develop plans to address stigma as a way to improve, prevent and reduce harm. (P2)

Selected prevention and indicated prevention

11. Our approach to prevention is placed within the overall approach to meeting the needs of children and their families. In this context effective prevention aims to reduce the circumstances and situations which place children, young people and adults at greater risk of developing problem drug use and its associated harms.

Addressing adverse childhood experiences

12. There are clear links between Adverse Childhood Experiences (ACE) and problematic alcohol and drug use. Adults who experienced four or more adversities in their childhood, were two times more likely to binge drink, and eleven times more likely to have used crack cocaine or heroin^[45]. In many instances children and young people who experience adversity will not experience this harm due to a range of protective factors in their lives. However, we need to work to prevent ACEs as far as possible and ensure children, young people and adults affected have the support to overcome adversity. This is covered in detail in Chapter 6 on Getting it Right for Every Child, Young People and Families.

Early intervention to address drug related harm

13. We know from the stories and experiences of those who are in recovery that their alcohol and drug use started at a young age, in many instances under the age of 16.

14. Tackling needs early and joined up working between services is central to the values and principles of Getting it Right for Every Child (GIRFEC). Our approach to workforce development needs to ensure that professionals and volunteers working in services which support young people have the necessary skills to respond to drug use. This will include approaches to reduce harm, as well as support to reduce or stop their use.

15. We know that young people under the age of 25 make up a decreasing proportion of those accessing drug services accounting for just 14% all new clients in 2016/17^[46]. In addition, those young people who do access services are presenting with a different range of drug problems and are less likely than before to state heroin as their main drug^[47]. We cannot be complacent that problem drug use is decreasing amongst young people and we need to use and develop our public health surveillance data to better understand drug trends amongst young people. This will enable us to develop effective approaches to meeting their needs at the earliest possible stage.

We will develop a comprehensive approach to early intervention amongst those who are at risk of developing problem drug use alongside those services who are already working with this group. (P3)

Identified Actions

• Our workforce development framework will set out levels of skills, competencies and understanding for those working with children and young people experiencing drug related harm.
• Our public health surveillance data will enable us to understand the risks and harm linked to problem drug use by young people.
• Local areas will develop and improve specialist services in response to local evidence of need.

Universal prevention

Education in schools

16. Our approach to providing substance use education is the same for both alcohol and drugs. We must give the next generation the tools they need to make healthy choices about substances. Through the Health and Wellbeing component of Curriculum for Excellence, Scottish schools aim to provide helpful, engaging information about substances that, crucially, empower children and young people to make positive decisions about their health. It is also really important that education includes the impact of alcohol and other drugs on sexual risk taking, and focuses on the need to be confident that consent has been given for any sexual activity^[48].

17. Health and wellbeing indicators have an important place within the National Improvement Framework for Scottish Education^[49], and we will continue to look at how we can best emphasise their importance going forwards. Following work with stakeholders, Education Scotland published health and wellbeing benchmarks for schools, including substance use^[50] in 2017. These benchmarks set out clear statements about what learners need to know and be able to do to achieve a particular level of learning. More recently, Education Scotland has published a thematic report which includes a review of Personal and Social Education (PSE) in schools^[51]. This indicates improvements that could be made in providing PSE within Curriculum for Excellence.

18. Around 70% of 15 year olds say they have received lessons or discussions in class on drugs^[52]. While this is encouraging, there is still room for improvements to increase the number of 15 year olds that have access to a learning experience which is based on best practice, and education that is universal across Scotland.

19. The Scottish Government is committed to taking steps to ensure that Initial Teacher Education (ITE) prepares students to enter the profession with consistently well-developed skills to teach areas such as literacy, numeracy and health and wellbeing. The initial phase of this work is being taken forward through the development of a new self-evaluation framework to support universities to evaluate their ITE. The General Teaching Council for Scotland is also reviewing its Professional Standards for Registration to work as a teacher in Scotland, which includes reference to the requirement for teachers to understand and apply the curriculum as it applies to health and wellbeing.

20. We have also continued to take forward substance use education work in Scottish schools through the Choices for Life^[53] programme. In these, children and young people learn about a variety of substances including alcohol, medicines, tobacco, solvents and other drugs, and explore the impact risk-taking behaviour has on life choices and health. Choices for Life is primarily a schools-based education programme on alcohol, drugs and tobacco, funded by the Scottish Government and delivered in partnership with Police Scotland and Young Scot. The programme includes an information website for young people and their parents, teachers and carers.

21. In December 2016, the Scottish Government published a literature review on ‘What works’ in drug education and prevention^[54]. The key findings are consistent with other reviews of the evidence of effectiveness of substance use prevention programmes. The publication acknowledged that some popular and well-meaning approaches, for example using lived experience testimonials, are associated with no, or negative preventative outcomes. Stand-alone, mass media campaigns are also considered ineffective. The literature review found that children and young people benefit from prevention models that are delivered in a supportive environment, which use non-fear arousal techniques, and which provide the freedom to learn about alcohol and drug use within a broader conversation about choice and risk, rather than standalone input.

22. In addition, for those most at risk from harm, targeted prevention interventions are most effective, alongside a whole school approach. These are most effective in interactive structured sessions, with booster sessions over several years, and should be of sufficient intensity and duration to influence change. Approaches that combine social and personal development and resistance skills with normative education techniques have also been shown to be effective.

23. The research highlighted increasing interest in peer led models and the use of social influence methodology. This is supported by research conducted in partnership with the Scottish Youth Parliament, and has also shown that the tone of substance use education should be neutral, based on fact and that young people should be involved in the design, development, and dissemination of the information as young people are more likely to respond better to advice and information from their peers^[55]. This has provided an informed basis for our overall approach to prevention activity both in and outwith schools.

24. Following the What Works report a rapid review mapping exercise^[56], conducted in 2017, concluded that the quality of substance use education and local practice in education had to be made more consistent throughout Scotland. To help achieve better consistency the Scottish Government has produced a guidance summary of key findings^[57] to support commissioners and practitioners in developing education and prevention strategies in line with the evidence.

25. Also following the What Works report, the Scottish Government commissioned a review of Choices for Life and found that although the programme engaged with large numbers of young people, there were variations across Scotland and inconsistencies in both the delivery, setting and frequency of sessions. It was observed that there was some evidence of good practice, although ineffective approaches remained, alongside a lack of structured delivery guidance or lesson plans.

26. Taking all of this into account, the Scottish Government considers a new approach is required to universal substance use education for young people in schools.

We will revise and improve the programme of alcohol and drug education in schools to ensure it is good quality, impactful and in line with best practice. (P4)

Broadening our universal approach

27. Our education system provides a window of opportunity to equip our children and young people with the life skills to make informed choices relating to their health and wellbeing. However we recognise that for some, traditional education methods are not working or not appropriate, and these children and young people can be more at risk. We need to go beyond classroom based interventions to ensure we provide a universal approach to alcohol and drug education that is delivered in different and innovative ways. This includes, but is not limited to, considering Youth Groups, Community Learning and Development, looked after and accommodated children, excluded children, and those in touch with services.

We will develop education-based, person-centred approaches that are delivered in line with evidence-based practice to aim to reach all of our children and young people including those not present in traditional settings, such as Youth Groups, Community Learning and Development, looked after and accommodated children, excluded children and those in touch with services. (P5)

Online and outreach education and information

28. The dynamic growth in digital platforms used by young people present new challenges and opportunities in substance use education and prevention. They are increasingly the route through which young people obtain information and misinformation, about alcohol and drugs, as well as a growing and constantly evolving supply route.

29. We have a responsibility to our young people to provide accurate and reliable information about the risks of substance use, as well as providing them with the skills and knowledge to question the information they find online and the resilience to challenge and resist misinformation and pressure through social media.

30. The Choices for Life programme includes an information website (https://young.scot/choices-for-life/) for young people and their parents, teachers and communities which in 2016-17 received over 36,529 page views on the website; 103,411 videos watched on YouTube; and 69,605 and 10,532 views of Snapchat and Instagram stories respectively.

31. The Scottish Government Know the Score website (https://knowthescore.info/) also provides advice on drugs and their risks. It is updated in partnership with Crew, a third sector drug service based in Edinburgh. The Drinkline website provides advice on alcohol and its risks. It is operated under contract with the Scottish Government.

We will develop our current online resources to ensure they provide accurate, evidence-based, relevant and up to date information and advice, around alcohol and drug use; and how to access help. (P6)