Canadian Research Initiative in Substance Misuse Prevention Cameron Wild, Julie Bruneau, Benedikt Fischer, Evan Wood Canadian Drugs and Substances Strategy Prevention and Treatment Sub-Working Group Meeting February 7, 2017

Prevention – (Very!) Brief State of the Science

Prevention strategies Access specialty services Diagnosed Seen in health services Indicated (tertiary) prevention Users who meet clinical screening criteria for problematic use Selective (secondary) prevention ‘At risk’ subpopulations Universal (primary) prevention Healthy population: includes substance users and non-users

Approaches Universal prevention (default approach in Canada and elsewhere) Selective and indicated prevention (much less common) Goals Promote abstinence Selective: Reduce use Indicated: Reduce use, seek care Target population All youth and young adults Selective: Subpopulations at higher risk of substance misuse/already using Indicated: Individuals exhibiting early warning signs/behaviours of misuse Settings Schools, communities Selective: schools and communities Indicated: schools, communities, primary and emergency health services Providers Mass media, classroom teachers, peer leaders, law enforcement Health providers located in school s and health services Tactics Public service announcements; social (drug) resistance skills, normative education; personal and social skills training Selective: screening and intervention Indicated: case finding and referral to specialty care

Universal prevention – review of reviews Focus Parameters Included studies Conclusions Community-based interventions Ferri (2013) Effectiveness of mass media campaigns aimed at reducing illicit drug use Earliest - 2013 23 studies reported in 28 articles No evidence of effectiveness or iatrogenic impacts on drug use. Werb et al. (2011) Effectiveness of public service announcements aimed at reducing illicit drug use Earliest - 2010 7 RCTs, 4 observational studies No evidence of effectiveness on substance use. Thomas et al. (2011) Effectiveness of mentoring on substance use among deprived youth Earliest - 2011 4 cluster RCTs No evidence of effectiveness on drug use, substance use; mixed evidence of effectiveness on alcohol use. Gates et al. (2006) Drug use prevention in non-school settings Earliest - 2004 17 cluster RCTs Positive effect of brief interventions and motivational interviewing; no evidence of effectiveness for educational and skills training.

Universal prevention – review of reviews Focus Parameters Included studies Conclusions School-based interventions Teeson et al. (2012) Alcohol and other drug use prevention Earliest - 2011 8 RCTs of 7 Australian programs Positive impact for alcohol programs; no evidence of effectiveness for other drug programs Lemstra et al. (2010) Cannabis and alcohol use prevention 1980 - 2007 6 RCT and cohort studies Positive impact of comprehensive interventions; no evidence of effectiveness of ‘knowledge only’ interventions on alcohol and of longer program duration Porath-Waller et al. (2010) Cannabis use prevention 1999 - 2007 15 experimental and quasi-experimental studies (NB: no assessment of study quality) Overall positive impact on cannabis use. Interactive interventions more successful than didactic approaches.. Poorer outcomes for teacher-led interventions; better outcomes with increasing number of sessions. Foxcroft (2011) Universal alcohol use prevention Earliest – 2010 53 RCTs Inconclusive evidence of positive impact for alcohol-specific and generic substance use programs. No evidence of effectiveness of generic education. Faggiano et al. (2008) Illicit drug use prevention Earliest – 2004 32 (29 RCTs, 3 controlled prospective studies) No evidence of effectiveness for knowledge-based interventions. Positive impact for skills-based interventions.

Taking stock of universal prevention Most commonly-used approach (DARE and offshoots [Take Charge of Your Life]) shown conclusively to have no or iatrogenic effects (Foxcroft et al., 2011; Sloboda et al., 2009) Yet infrastructure for/interest in this program lives on Community-based settings: No evidence of effectiveness for mass media campaigns as currently implemented Out of school youth: brief interventions/motivational interviewing show positive effects; no evidence for general knowledge and skills training School settings: No evidence for effectiveness of passive, knowledge-based informational approaches Interactive and skills-based approaches show positive effects

Time to re-think universal prevention Most common factors that reduce program effectiveness: Implementation failure Low fidelity to program elements known via research to improve odds of success. Contracting development of ‘creative materials’ used in programs to marketing and PR firms that are poorly informed by or responsive to scientific evidence. Overemphasis on abstinence as the outcome of interest. Not allowing for a distinction between safer/appropriate use and problematic use BC research with street-entrenched youth suggests that they are eager to access factual information about drug use, resources and support for getting care, counseling, harm reduction (Ti et al., 2017)

CRISM: Overview and work on Prevention

CRISM: Objectives Identify and develop the most appropriate clinical and community-based prevention or treatment interventions for substance misuse Provide evidence to support the enhancement of prevention or treatment services regarding substance misuse to decision makers and service providers Support improvements in the quality of care and quality of life for Canadians living with substance misuse

CRISM: Aim Enhance uptake of interventions and programs that are proven to be efficacious; tailored to individuals in both their needs and psychosocial context; feasible and applicable in clinical and community intervention settings; more easily accepted by health care, service providers, communities.

CRISM – National network Provides access to the expertise of over 200 members, including: 104 researchers located in 29 institutions Addiction medicine, biomedical, health services, epidemiology, health policy, statistics, infectious disease, health economics, behavioural science 101 knowledge users located in 86 organizations Provincial policy makers, service managers, people/advocates with lived experience

A blend of National and regional projects National level Regional level Substance/issue Projects Opioids: treatment OPTIMA: multi-site CRISM trial CRISM National opioid treatment guideline Cannabis – public health CRISM Lower-risk cannabis use guideline Interventions to address addictions and related comorbidities for high risk populations, including corrections Improving client retention and engagement in speciality addiction treatment Interventions to reduce polysubstance use among patients in opioid treatment programs Building working relationships with drug user and recovery communities of people with lived experience CRISM Node development support for new teams

CRISM-affiliated National-level prevention trial proposals Investigator (Node affiliation) Title Target population and setting Substance(s) Approach Delivery Design Patricia Conrod (University of Montreal; Quebec- Maritimes Node) Scaling up access to personality-targeted interventions Adolescents in Canadian and US schools Cannabis, prescription drugs Selective prevention: personality-matched skills training Train-the-trainer model with and without implementation facilitation RCT Amanda Newton (University of Alberta; Prairie Node) Check your drinking Adolescents 14-17 years presenting to 9 EDs across Canada Alcohol Selective/ indicated prevention: brief intervention for youth attending EDs with alcohol involvement Usual care with and without web-based personalized alcohol assessment feedback Cluster-randomized RCT

CRISM – Regional prevention projects ongoing or proposed CRISM Node Overdose prevention and harm reduction School populations Online substance education, SBIRT Special populations Quebec/Maritimes OD prevention + naloxone delivery (2 projects) Selective prevention: Scaling up personality-targeted interventions - MSM - Concurrent substance use among OST patients Prairies OD prevention + naloxone delivery Universal prevention: Online substance use information, SBIRT tools BC Street-involved youth - Treatment interventions - Barriers to treatment

Take home points

Time to reconsider universal prevention Disinvest in approaches with no demonstrated effectiveness Acknowledge a continuum of substance use and the need to adopt more sophisticated prevention targets than just abstinence. Requires embracing harm reduction objectives Capitalize on youth interest in accessing trustworthy facts about substances, warning signs of problems, and behaviour change options, including self-care and structured interventions/treatment Computer and web-based prevention programs have untapped potential and are more cost efficient (Champion et al., 2013). View prevention as a system of stepped interventions that connect universal, selective, and indicated approaches Invest in promising selective and indicated prevention approaches Personality targeted interventions Brief, personalized assessment-feedback interventions Safer prescribing interventions (e.g., standards) OD prevention and prevention of concurrent drug use among opioid users

Stepped care for prevention Access specialty services Diagnosed STEP 3 Seen in health services Community and health service-based OD prevention Brief interventions, motivational interviewing STEP 3 Users who meet clinical screening criteria for problematic use Personality-targeted interventions STEP 2 ‘At risk’ subpopulations STEP 1 Healthy population: includes substance users and non-users Factual drug information, self-help resources, lower risk use guidelines, safer prescribing

Thank you! British Columbia Node Ontario node Prairie Node NPI: Evan Wood NPI: Benedikt Fisher Node manager: Nirupa Goel Node manager: Sarah Miles Prairie Node Quebec-Maritime Node NPI: Cameron Wild NPI: Julie Bruneau Node manager: Denise Adams Node manager: Aïssata Sako

References Champion, K.E., Newton, N.C., Barrett, E.L., & Teeson, M. (2013). A systematic review of school-based alcohol and other drug prevention programs facilitated by computers or the internet. Drug and Alcohol Review, 32, 115-123. Emmers, E., Bekkering, G.E., & Hannes, K. (2015). Prevention of alcohol and drug misuse in adolescents: An overview of systematic reviews. Nordic Studies on Alcohol and Drugs, 32, 183-198. Faggiano, F., Vigna-Taglianti, F. D., Versino, E., Zambon, A., Borraccino, A., & Lemma, P. (2008). School-based prevention for illicit drugs use: A systematic review. Preventive Medicine, 46, 385–396. Ferri M, Allara E, Bo A, Gasparrini A, Faggiano F (2013). Media campaigns for the prevention of illicit drug use in young people. Cochrane Database of Systematic Reviews, Issue 6. Art. No.: CD009287. DOI: 10.1002/14651858.CD009287.pub2. Foxcroft, D. R., & Tsertsvadze, A. (2011). Universal school-based prevention programs for alcohol misuse in young people. Cochrane Database Systematic Reviews, 5, CD009113. Gates, S., McCambridge, J., Smith, L. A., & Foxcroft, D. R. (2006). Interventions for prevention of drug use by young people delivered in non-school settings. Cochrane Database Systematic Reviews, 1, CD005030. Lemstra, M., Bennett, N., Nannapaneni, U., Neudorf, C., Warren, L., Kershaw, T., & Scott, C. (2010). A systematic review of school-based marijuana and alcohol prevention programs targeting adolescents aged 10-15. Addiction Research and Theory, 18, 84-96. Porath-Waller, A.J., Beasley, E., & Bierness, D.J. (2010). A meta-analytic review of school-based prevention for cannabis use. Health Education Research, 22, 177-191, Sloboda, Z., Stephens, R.C., Stephens, P.C., Grey, S.F., Teasdale, B., Hawthorne, R.D., Williams, J., & Marquette, J.F. (2009). The adolescent substance abuse prevention study: A randomized field trial of a universal substance abuse prevention program. Drug and Alcohol Dependence, 102, 1-10. Teeson, M., Newton, N.C., & Barrett, E.L. (2012). Australian school-based prevention programs for alcohol and other drugs: A systematic review. Drug and Alcohol Review, doi:10.1111/j.14653362.2012.00420.x Thomas, R.E., Lorenzetti, D., & Spragins, W. (2011). Mentoring adolescents to prevent alcohol and drug use. Cochrane Database of Systematic Reviews, 11, CD007381. Ti, L., Fast, D., Small, W., & Kerr, T. (2017). Perceptions of a drug prevention public service announcement campaign among street-involved youth in Vancouver, Canada: A qualitative study. Harm Reduction Journal, 14:3 DOI 10.1186/s12954-017-0132-7 Werb, D., Mills, E.J., Debeck, K., Kerr, T., Montaner, J.S., & Wood, E. (2011). The effectiveness of anti-illicit-drug public service announcements: A systematic review and meta-analysis. Journal of Epidemiology and Community Health, 65, 834-840.