Harm Reduction in Schools. Why Not?

In this article, Jose López-Guerrero and Claudio Vidal Giné from ABD – Energy Control (Spain) provide their opinions on harm reduction programmes within the school setting. 

It seems like a century ago, but the last Harm Reduction International Conference, held in Porto in April 2019, welcomed the words of Michelle Bachelet, the current United Nations High Commissioner for Human Rights and former President of Chile. In her speech [1], she listed in a convincing way the benefits of drug policies framed within a well-being and health-oriented harm reduction perspective regarding people who use drugs. Opioid substitution treatment, syringe exchange programmes or drug consumption rooms have shown their effectiveness and usefulness where they have been applied and well-funded. However, harm reduction adapted to educational contexts is far from the implementation and recognition shown by previous schemes.

It could be argued at this point that there are already well-evaluated and effective school-based programmes for the prevention of drug use. So why is a harm reduction approach necessary? Some reasons and ideas are outlined below:

  • The initiation of alcohol, tobacco and cannabis occurs mostly when people are in compulsory secondary education (13-16 years old, depending on the country). This means that the primary guide to navigate those first experiences are thanks to what has been learned through peer groups.
  • The older the teenager gets, the higher the percentage of them who start or continue to use. So, the abstinent-oriented prevention probably received in earlier years is no longer useful for them.
  • Harm reduction can offer alternative consumption models with lower risks. And may serve as a parapet for the emergence of more problematic consumption patterns that require more drastic measures.
  • Harm reduction is more sensitive to the causes [2] that lead adolescents and young people to consume alcohol and other drugs, giving greater credibility to the preventive discourse; and allowing a bond of trust to be established with health professionals and adults that will be useful on future occasions. For example, asking for help to a parent [3] when problems arise. 
  • It is also beneficial to non-users because it teaches them how to identify risky situations and keep their friends safe.

The thesis defended in this article is that harm reduction should serve as a complement to more traditional prevention efforts, which it does not intend to replace. Where prevention has been properly implemented, a complementary harm reduction approach could be equally successful. For example, the same skills learned through life-skills training programmes are those that can be put into practice if the person uses drugs eventually. In other words, the life-skills needed to be able to say NO in an ordinary social interaction could be similar to those needed to refuse to smoke a joint without a mouthpiece. 

How does harm reduction education look like?

Several principles guide harm reduction approaches:

  • There are people who will continue to use drugs despite attempts to convince them not to.
  • The person is accepted and welcomed no matter what stage of change he or she is in.
  • Adolescents and young people are recognised as being able to make autonomous and responsible decisions for themselves, without the need for constant parental or police supervision.
  • A pragmatic position prevails, without losing sight of the main objective of any intervention: reducing harm. Therefore, there are times when abstention is recommended, but other times a focus on how to reduce the risks should be encouraged.

From this point on, the methodologies and interventions to be carried out can vary a lot, but always selectively choosing the groups to be intervened and the substances to be worked on. It does not make sense to talk about cocaine with a group of 13-year olds, but it may be necessary to teach skills to manage a case of alcohol intoxication in 17-year olds with majority binge drinking practices.

There are examples of educational programmes imbued with the spirit of harm reduction in different countries: Australia [4], UK [5], Canada [6], USA [7] and Spain [8]. There are also examples of evidence-based intervention models and strategies implemented through such programmes: screenings [9] and personalised feedback [10], brief motivational interventions [11], peer education [12], teaching of protective behavioural strategies [13] etc.

Barriers and boundaries

Adapting harm reduction to school-based prevention is not without its obstacles and difficulties. Some of the challenges for its implementation are: 1) the widespread misconception that harm reduction promotes or facilitates drug use; 2) reluctance among parents and teachers; 3) the belief that it is not morally acceptable to teach certain content to minors. However, when explained and understood, harm reduction is accepted by all the different actors in education6, including parents [14]. In addition, for students, harm reduction is seen as a realistic [15] approach that does not stigmatise the user because it does not make moral judgments about consumption and is tailored to specific risk factors.

Finally, efforts must be redoubled to properly evaluate this approach and analyse which components show effectiveness. In other words, and despite the difficulties and lack of resources, obtaining evidence through methodologies such as randomised controlled trials and less from satisfaction surveys. Moreover, it should be necessary to establish substantial evaluation indicators of impact that go beyond the generic and insufficient ‘decrease in the number of people who use drugs’. For example, exploring the variation after the intervention of acute problems related to drug use, risk practices, or protective behavioural strategies learned and implemented.

Conclusions

If the most restrictive approaches teach [16] us anything [17], it is that they are not only ineffective, but also violate the fundamental right to health. Is there anyone who currently advocates sex education in which abstinence is promoted as the only valid objective and condom use is not encouraged? So, why deprive our adolescents and young people of learning how to use a ‘seatbelt’ in their relationship with alcohol and other drugs? Let us provide protection strategies and motivate to include them in the repertoire of behaviours with which the youth will face the world.

We are at a moment in our history when it seems that innovation and digitalisation will be the mainstays of preventive strategies. If we add to this the new regulations on the recreational use of cannabis that are on the horizon, harm reduction approaches in the educational context have much to contribute.

About the authors:

Jose López-Guerrero is a Psychologist, Master of Science in Social Intervention Psychology and a health promotion technician in ABDEnergy Control (Spain). He has been involved in several projects regarding harm reduction interventions in party and educational settings at national and international level. His research focuses on behaviour change in nightlife contexts and drug use in a recreative way. His research interests are the use of new technologies for prevention, the goal of changing behaviours in drug education, developing new harm reduction approaches for drug prevention in academic settings, and analysis of new trends and future scenarios in drug use and prevention. You can contact him at talleresandalucia[at]energycontrol.org .

Claudio Vidal Giné is a Graduate in Psychology and University Expert in Research Methodologies in Drug Addiction by the University of Malaga. Since 2000 he has been professionally involved in different risk and harm reduction programmes for young people. Since 2004 he coordinates ABDEnergy Control in Andalusia (Spain). His main interest is the definition of risk and harm reduction strategies, as well as the evaluation of drug checking services. His research interest includes the study of specific populations of recreational drug users (especially ketamine and GHB), and the harm reduction behaviours that they employ for reducing drug-related risks, and the study of drug markets using datasets from drug checking services. You can contact him at claudiovidal[at]energycontrol.org .

References

[1] Harm Reduction International Conference 2019. Statement by UN High Commissioner for Human Rights Michelle Bachelet. Available from: https://www.ohchr.org/en/NewsEvents/Pages/DisplayNews.aspx?NewsID=24529&LangID=E

[2] Szmigin, I., Griffin, C., Mistral, W., Bengry-Howell, A., Weale, L., & Hackley, C. (2008). Re-framing ‘binge drinking’as calculated hedonism: Empirical evidence from the UK. International journal of drug policy, 19(5), 359-366.

[3] Slemon, A., Jenkins, E. K., Haines-Saah, R. J., Daly, Z., & Jiao, S. (2019). “You can’t chain a dog to a porch”: a multisite qualitative analysis of youth narratives of parental approaches to substance use. Harm Reduction Journal, 16(1), 26.

[4] McBride, N., Farringdon, F., Midford, R., Meuleners, L., & Phillips, M. (2004). Harm minimization in school drug education: final results of the School Health and Alcohol Harm Reduction Project (SHAHRP). Addiction, 99(3), 278-291.

[5] McKay, M., Sumnall, H., McBride, N., & Harvey, S. (2014). The differential impact of a classroom-based, alcohol harm reduction intervention, on adolescents with different alcohol use experiences: a multi-level growth modelling analysis. Journal of adolescence, 37(7), 1057-1067.

[6] Poulin, C., & Nicholson, J. (2005). Should harm minimization as an approach to adolescent substance use be embraced by junior and senior high schools?: Empirical evidence from an integrated school-and community-based demonstration intervention addressing drug use among adolescents. International Journal of Drug Policy, 16(6), 403-414.

[7] Drug Policy Alliance. Safety First: Real Drug Education for Teens. Available from: https://www.drugpolicy.org/resource/safety-first-real-drug-education-teens

[8] López-Guerrero, J. (2019). Do you know how you drink? Intervention in educational settings for risk reduction of binge drinking. In: Ibero-American Network of NGOs working on Drugs and Addictions (RIOD), ed., Prevention and risk reduction associated with the use of drugs and addictions among the youth, 1st ed. Madrid: RIOD, pp.138-146.

[9] Donoghue, K., Patton, R., Phillips, T., Deluca, P., & Drummond, C. (2014). The effectiveness of electronic screening and brief intervention for reducing levels of alcohol consumption: a systematic review and meta-analysis. Journal of medical Internet research, 16(6), e142.

[10] Riper, H., van Straten, A., Keuken, M., Smit, F., Schippers, G., & Cuijpers, P. (2009). Curbing problem drinking with personalized-feedback interventions: a meta-analysis. American journal of preventive medicine, 36(3), 247-255.

[11] Jensen, C. D., Cushing, C. C., Aylward, B. S., Craig, J. T., Sorell, D. M., & Steele, R. G. (2011). Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: a meta-analytic review. Journal of consulting and clinical psychology, 79(4), 433.

[12] Medley, A., Kennedy, C., O’Reilly, K., & Sweat, M. (2009). Effectiveness of Peer Education Interventions for HIV Prevention in Developing Countries: A Systematic Review and Meta-Analysis. AIDS Education and Prevention, 21(3), 181-206.

[13] Pearson, M. R. (2013). Use of alcohol protective behavioral strategies among college students: A critical review. Clinical psychology review, 33(8), 1025-1040.

[14] Midford, R., McBride, N., & Munro, G. (1998). Harm reduction in school drug education: Developing an Australian approach. Drug and Alcohol Review, 17(3), 319-327.

[15] Marlatt, G. A., & Witkiewitz, K. (2002). Harm reduction approaches to alcohol use: Health promotion, prevention, and treatment. Addictive behaviors, 27(6), 867-886.

[16] Santelli, J., Ott, M. A., Lyon, M., Rogers, J., Summers, D., & Schleifer, R. (2006). Abstinence and abstinence-only education: A review of US policies and programs. Journal of Adolescent health, 38(1), 72-81.

[17] Santelli, J. S., Kantor, L. M., Grilo, S. A., Speizer, I. S., Lindberg, L. D., Heitel, J., … & Heck, C. J. (2017). Abstinence-only-until-marriage: An updated review of US policies and programs and their impact. Journal of Adolescent Health, 61(3), 273-280.


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