Evidence-based principles for effective drug demand reduction: applying theory to practice

Introduction

Between December 8 and 10, 2021, ISSUP’s International (virtual) Conference took place to address the issues surrounding translating the theory and research with respect to an evidence-based approach to prevention, treatment and recovery support. The conference tackled its application to international practice of drug demand reduction.

The Conference was very well received, we had a total of 2372 attendees from 123 different countries across 4 sessions. ISSUP were also privileged to have leading international figures to provide the theoretical perspective including a thought-provoking overview to launch the event from Professor Harry Sumnall. This was followed by inputs on Treatment, Prevention and Recovery Support from Annette Dale-Perrera, Giovanna Campello and Dr. Hendree Jones. The inputs on practice and the challenges of implementing the evidence-base were provided from the experience and expertise of those working within or in collaboration with ISSUP’s National Chapters. Examples of work were provided from practitioners from India, Kazakhstan, Kenya, Lebanon, Mexico, Pakistan, Peru, and Ukraine. ISSUP’s National Chapters in Chile, Indonesia, Nigeria and United Arab Emirates also provided the Session Moderators.

Discussion

Rather than try to summarise the inputs from the stimulating sessions which are all available on the ISSUP website, I offer my own comments on the discussed issues. I personally and professionally feel that these topics deserve further thought and further action in the future. I should add these are my own perspectives and cannot be seen as necessarily representing the views of ISSUP.

It is important when organising a conference that we avoid such events becoming merely “shop windows” for awareness raising without a follow up process for action. This should be a result of the very important issues that are often addressed. I am sure that this ISSUP Conference did offer a very interesting shop window of issues. Having seen what is “on offer” there will be those who want to ask more about what is presented. They also seek more detail of its value and potential application. I hope the “shop window” can become a starting point for development and action to address the shared objective of the Conference. This is mainly through identifying the evidence-base for drug demand reduction and how we can encourage, develop, and support the transfer of the theory into practice. The follow up on the ISSUP website listing the resources referenced by speakers and uploading presentations and recordings will assist in part here.

Among the many items in the shop window following the Conference there are three topics that I would like to highlight. These require further attention and that I hope will result in further discussion, development and, most importantly, action:

Evidence

First of all, I do hope that how we define “evidence”, raised by Professor Sumnall and endorsed by other speakers, is given further attention. This can impact how we can obtain important feedback and information from a variety of sources as to what constitutes the evidence-base. It can then be used to better inform and build the evidence-base. Professor Sumnall referred to the “gold star” evidence that can be obtained from the pure and rigorous scientific work of a randomized control trial. However, even with such a “pure” approach to finding evidence there is a need for caution. Transferring what can “work” in greenhouse conditions of a well-funded and implemented evaluation to the realities of being undertaken within the conditions that exist in communities where it might be applied, poses significant challenges. The main challenges are maintaining the quality and fidelity in provision of an evidence-based approach. There are other types of evidence, and ways of obtaining it, that need to be recognised and utilised.  They can come from practice that need to be applied and taken seriously as we seek to build an evidence-base. Evidence, and its application, needs to be seen in the context of the different realities that the practitioners face in trying to implement an evidence-based approach. This points to the need for research identifying evidence to include those involved with practice as well as the pure scientist. The multi-disciplinary nature of how we go about tackling drug demand reduction in practice needs to be considered alongside how we accumulate the evidence-base. Perhaps too often the “us and them” between “scientist” and “practitioner” has contributed to the less than acceptable transfer from research to practice and then from practice to policy. Practitioners can contribute significantly and be regarded as scientists themselves. They have a significant contribution in identifying the evidence-base. The challenge now is how we tackle this issue, promote collaboration and encourage understanding and sharing between the academic and practice communities.

Language and culture

The second item in the “shop window” that took my attention was that of language and culture. How our “evidence-base” – often developed in higher-income countries and communicated in English – can be easily and readily applied to those cultures which are significantly different? Additionally, a serious challenge to consider is the communication and language barrier. The latter issue appears to be relatively straightforward to address: ensure accessible and good translations of the information with respect to the evidence-base. But is it as simple as this? If so, surely this would have been addressed? Somehow the solution to this remains a problem. Perhaps it is the vast number of languages that would need to be considered? Perhaps no one takes responsibility for this other than for the “official languages”? Even that does not always happen. The big challenge this epitomises is the need for developing more effective communication and sharing of our learning to allow for it to be understood and therefore, addressed by all. The development of our response to this challenge should be led by the countries who are being isolated by the English / high income imbalance.

The issue of culture also needs shared understanding of the similarities and differences within different cultures. It can often appear that what “works” in one culture can be anticipated to work elsewhere. An additional question might be to consider whether common principles for an evidence-based approach can be identified that are common across different cultures. As well as to identify those which might apply in one culture but not another?

The culture – and additionally the context – for implementing an evidence-based approach has to be considered in an adaptation process. Providing “the research” will not have any impact unless the context and cultural issues are considered and addressed. Appropriate practical plans need to be made as to how to help such a community and its leadership and stakeholders consider alternatives and to engage with the joint effort of moving towards an evidence-based approach.

Identify immediate actions

My third and final concern and challenge for further action on viewing the shop window of the ISSUP Conference is that with so many items or issues on view it is extremely difficult to prioritise those requiring immediate attention. I offer a perspective of how we might need to focus and address issues that came through most if not all the presentations made during the Conference. The all-encompassing question is how do we address the challenges of communicating and implementing evidence-based approaches to our drug demand reduction work in the “real world” with all its differences, complexities, and agendas? If we are to make a real difference from implementing an evidence-based approach at the practice level, we need to move to this being identified and implemented not only at the practice level but also at the policy level and for it to be given appropriate support politically and financially. There lies the major challenge.

Conclusion

Within our work in drug demand reduction, we have identified prevention, treatment and recovery support as the three key elements of work. Each of these areas has different needs, a different evidence-base and different considerations for transfer of evidence to practice. I refer you again to the Conference recording which identifies many of these issues which were presented in a most valuable, eloquent, and interesting way.  And yet the three dimensions of drug demand reduction share the same objectives. They are united in the need to identify the evidence-base, apply it to practice, consider and respond to the challenges – some of which I have tried to identify above. In addition, it is important to aim for their efforts and recommendations to be addressed and implemented at the policy level if they are to have a much better chance for success.

I could add more and there are many reading this who have many more pertinent questions and experience of the issues shared in this reflection. What poses a challenge is how the scientific community, and the voice of those working in the field of drug demand reduction, can be better heard, understood, and valued by governments and policy makers. Only then will its advice be better supported and implemented.

I think we should remain positive about working towards this end. However, it will mean we now need to review what was shared at the Conference and identify our recommendations and action plan. If we can improve on the statement from Professor Sumnall that the impact of research takes 17 years for 14% of it to be acted upon we will know we are on the right track!  It is a long-term effort but one we need to address together to ensure the shop window has a different look next time round!