1. 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

2. Prevention – (Very!) Brief State of the Science

3. 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

4. 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

5. 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
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
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
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
17 cluster RCTs
Positive effect of brief interventions and motivational interviewing; no evidence of effectiveness for educational and skills training.

6. Universal prevention – review of reviews
Focus
Parameters
Included studies
Conclusions
School-based interventions
Teeson et al. (2012)
Alcohol and other drug use prevention
Earliest
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
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
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.

7. 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

8. 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)

9. CRISM: Overview and work on Prevention

10. 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

11. 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.

12. 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

13. 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

14. 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 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

15. 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

16. Take home points

17. 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

18. 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

19. 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

20. 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, 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, 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.: CD DOI: / CD pub2. Foxcroft, D. R., & Tsertsvadze, A. (2011). Universal school-based prevention programs for alcohol misuse in young people. Cochrane Database Systematic Reviews, 5, CD 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, CD 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 Addiction Research and Theory, 18, 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, , 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, 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: /j x Thomas, R.E., Lorenzetti, D., & Spragins, W. (2011). Mentoring adolescents to prevent alcohol and drug use. Cochrane Database of Systematic Reviews, 11, CD 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 /s 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,