Demand Reduction Section

Technical Services Division

12 March 1993

Introduction

The fight against drug abuse has traditionally been divided between suppression of illicit supply and reduction of demand for drugs - that is, between the suppliers and traffickers in illicit drugs and the consumers of those drugs. This mirrors a model from economics but the distinction has led many people and countries to delineate the problem in terms of the supply and trafficking countries and the consuming countries, so that those who were the suppliers were the developing countries, while the consuming countries were largely in the economically developed areas of the world.

This stereotyping no longer remains accurate, if it ever was. Clear-cut boundaries between developing producer countries and developed consumer countries no longer exist. There are many developed nations which export large quantities of drugs, particularly benzodiazepines and sedatives, to the developing countries, and there are many developing countries which either because they are on a trafficking route or because they are producers, find their own populations becoming increasingly dependent on drugs produced or transported locally. Further, the means of taking drugs are often being changed to a more harmful means - as in many countries in Asia, where opium smoking has given way to intravenous heroin and even intravenous opium use. Thus, developed countries may manufacture illicit drugs for use in both the developed and developing world, while developing countries produce illicit drugs which are consumed not only in the developed world end user countries, but also in the countries through which

the drugs are trafficked and those in which they were grown and processed.

Nevertheless, a distinction between demand reduction and supply reduction activities remains, in which the former concentrates on the individual who is abusing drugs while the latter is concerned with stopping illicit production and trafficking of these drugs.

However, we must not forget the strong relationship between demand and supply. In the economic model demand fuels supply, and the effective marketing of goods can generate demand. To reduce the size of the total market, both supply and demand must be lowered simultaneously. Most international and national efforts, in terms of funds spent, have been concentrating on the supply side of the equation. There has been a belief that poppy, coca and cannabis cultivation could be eradicated. Just as it has now been acknowledged that malaria cannot be eradicated because the main carrier, the mosquito cannot be wiped out, and that containment efforts should continue, but with emphasis now given to the protection of individuals and the treatment of the disease, so it is with drug abuse.

Much more attention should be paid to the demand side of the drug equation, because once a demand has been created or is being satisfied, then it is self sustaining because of the nature of addiction. The demand will continue to fuel a supply which can only be contained.

The Role of the UNDCP in Demand Reduction

UNDCP was given the lead role in drug abuse control by the General Assembly when it was set up in 1991. The resolution which led to the creation of UNDCP (GA 45/179, 1990) did so with "the objective of enhancing the effectiveness and efficiency of the United Nations structure for drug abuse control" and "with the exclusive responsibility for co-ordinating and providing effective leadership for all the United Nations drug control activities, in order to ensure coherence of actions within the Programme as well as co-ordination, complementarity and non-duplication of such activities across the United Nations system."

Developing a Demand Reduction Strategy

Just as it is now realized that in an effort to contain the supply of illicit drugs the fundamental reasons for production must be addressed, so the fundamental reasons for the demand for drugs must also be confronted. This was recognized by the United Nations General Assembly in 1990 when adopting the Global Programme of Action. This states "The causes generating illicit demand for narcotic drugs and psychotropic substances, including its recent increase, shall be analyzed and the necessary measures shall be identified in order to combat drug abuse at the root of the problem. In this regard, special attention shall be given to the social causes underlying the drug problem, which should be adequately reflected in national social policies" (Para 10)

Thus demand reduction strategy must move away from the piecemeal, "sticking plaster" approaches, and deal with the social problems associated with illicit drug use, and integrate the efforts so that they reinforce each other rather than remain isolated and vulnerable islands of activity.

1. The Nature of Demand Reduction

Demand reduction is concerned not only with the individual drug abuser or potential abuser, but also with the people upon whom illicit drug use has an impact, such as the family of the drug user. Although concern is focussed on individuals, it is within specific socio-cultural and economic contexts. People are social animals and cannot be seen as separate individuals divorced from the socio-cultural milieu. It follows, therefore, that any strategy for the reduction of the demand for drugs must be adapted to the specific society and even different subcultures within that society.

Nevertheless, broad principles can be laid down which characterize successful approaches. These would indicate that all stages and all types of demand reduction activity must be tackled simultaneously, and that to concentrate on only one stage or one type of activity will inevitably lead to a worsening situation. For example, concentrating all resources into preventing people from becoming illicit drug users while ignoring the pool of existing drug abusers will lead to an actual increase in the number of drug abusers. This arises because however successful these prevention efforts are, they can never be one hundred per cent successful. There will always be a small number of people to augment the number of drug abusers, partly because there will be a supply of drugs fuelled by those already using. Similarly, if there is a concentration of efforts only upon the illicit drug user, particularly when the problem is well established, then there will be a constant addition of new abusers to those in need

of help and treatment and rehabilitation. This is not to suggest that equal weight in terms of financial resources be given to each activity, for this must be determined by the nature of the problem in each country, but that a full range of demand reduction activities should be undertaken in the development of any programme.

i). Stages of Demand Reduction Activity

Primary Prevention: preventing and deterring the use of illicit drugs. This is achieved through efforts to control the illicit supply and by educating the potential users of the risks and potential problems associated with illicit drug use, and in particular the dangers of intravenous drug use.

Secondary Prevention: helping the people who are using illicit drugs to stop doing so, with particular emphasis on those who are using drugs intravenously. This may be achieved in a very wide variety of ways from pamphlets on how to cope with detoxification in private, drug free counselling to a very wide variety of treatment regimes, followed in some cases by rehabilitation programmes.

Tertiary Prevention: limiting or minimizing some of the worst effects of disease, or in this case, harmful behaviour. The purpose of this may be to limit the extent of physical illnesses but also criminal behaviour, by providing information and education, substitute drugs, care and counselling, syringes or bleach. Just as with the legal drug, nicotine, it has been accepted for many years that smoking low tar cigarettes is preferable to high tar cigarettes, but that the ultimate goal is not to smoke cigarettes at all.

ii). Types of Demand Reduction Activity

Education

Specifically, support may be given to mass media campaigns not only to raise awareness concerning the dangers of drug abuse, but of injecting drugs and sharing syringes. Campaigns may be also directed at the general public both for information purposes, and in order to facilitate the acceptance of treatment or other programmes for drug abusers. Treatment and rehabilitation services themselves provide important means of educating the user, as well as helping them to become drug free. However, perhaps the target group for education programmes are young people in school. Special curricula have been developed in most countries, incorporating a drug prevention element within a wider healthy life styles programme. Specific anti-illicit drug programmes and campaigns have not been found effective as isolated activities, but need to be embedded in a wider perspective on drug use and abuse.

Treatment and Rehabilitation

There exists a wide variety of programmes for the treatment and rehabilitation of drug misusers. No particular programme has been found effective for all drug misusers even within one culture, and the transference of one treatment regime from one culture to another has not, in some cases, been found constructive. A wide variety of treatment regimes and modalities, some different to, and outside conventional western medical practice, are needed. Within a single country and culture, a variety of approaches may be necessary in order to reach drug misusers at different stages in their drug careers.

Separate rehabilitation programmes are often not available. The concept of rehabilitation is frequently included in that of treatment. Rehabilitation however, involves the idea of some form of training for the reintegration of the ex-illicit drug abuser into society. A fundamental problem, such as literacy, might well be addressed with a skills training programme in this subject.

Community Empowerment

The idea of community empowerment in relation to drug abuse is that it should be identified and mobilized, often as the key link between education and treatment services. However, this can only be done if the community feels that it has some control over decision-making which directly affects them. It must be recognized that, in many areas where drug use is rife and almost endemic, in effect, no community exists. One of the reasons for drug misuse in the first place may be the virtual absence of social controls which are typically exerted within communities. Therefore one important task would be to try to rebuild communities, but this would involve a far wider programme of activity in co-operation with other agencies whose concern focusses on issues of urban deprivation and decay. Just as crop substitution programmes go beyond the simple provision of substitute crops, so urban drug programmes could go beyond narrow education or treatment programmes to address some of the fundamental issues underlying dr

ug abuse.

Needs Assessment - the basis for a demand reduction strategy

Problems of assessment

In order to assess the needs of countries in both these spheres, various measures are required. The acreage under illicit drug cultivation can now, to a certain extent, be assessed through the use of satellite reconnaissance pictures, and the amount of drugs leaving, transmitting and arriving in consumer countries can often be inferred from the statistics for police and customs seizures. The former figures, of acreage under cultivation, can be used to assess the need for crop substitution or other eradication programmes, while the latter figures are often used to justify the training, help and support given to enforcement authorities in combatting illicit drug traffic.

Assessing needs for demand reduction is often more complicated. Whereas illicit trafficking can be seen as a threat to more than the producer and trafficking countries, demand reduction is often characterized as a uniquely national problem, to be dealt with using national responses. This is a misleading portrayal.

Firstly, many countries do not have the knowledge, training, staff, infrastructure or resources to cope with a newly developed and/or worsening drug situation. It would be an abrogation of the UN ideals to abandon such countries to their fate without offering some help, expertise and training developed perhaps elsewhere in the world in trying to combat similar problems.

Secondly, as already pointed out, the distinction between supplier countries and consumer countries is becoming increasingly blurred. Therefore, to give attention to only one side of the equation in a country while ignoring the other seems irrational.

Thirdly, using the economics analogy again, once a market has been established, it is no longer the case that the supply creates the demand: additionally, demand sucks in the supply. The illicit drug market becomes both supply-driven and demand-driven. So far, in spite of valiant efforts and hundreds of millions of dollars, both total acreage under illicit cultivation and tonnage of illicit drugs produced have grown.

While not abandoning the fight against supply of illicit drugs and their trafficking, it is necessary to address more vigorously the problem of reducing the demand for drugs, and therefore to better understand the underlying reasons people turn to drugs.

Assessing the needs of countries in the realm of demand reduction means assessing the extent of illicit drug misuse, the pattern of that misuse (which groups of people are consuming which drugs and by what means) and trends in drug misuse in the countries concerned. Obviously, since by definition illicit drug use is an illegal activity, assessing the extent of illegal activity which has no direct victim There is a well established concept in criminology called "victimless crimes". These categories of crimes really relate to the problems of recording the extensiveness of certain behaviours where there is no obvious victim to be discovered. The contrast is with, say, the case of murder where, usually, a body is discovered, or where there is a victim to report an offence has occurred, as in the case of theft. Where the victim is a willing partner to the crime, as in the buying of any illegal services which the "victim" desires, then the victim will not report the crime. is extremely hazardous, just as i

t is in any other sphere of criminological statistics. In countries where the penalties for drug abuse and possession of illicit drugs are harsh, the drug abuser has every incentive to keep their activities secret.

Furthermore, the definition of what constitutes a drug problem or an abuser might differ between countries. Endemic and widespread culturally accepted use of particular drugs, although they may be under international control, might not be viewed by one country as a problem, whereas in another country, with no cultural support or cultural control over the same drug's consumption, less absolute consumption might be seen as a serious problem.

Techniques of assessment

Many techniques have been developed to assess these "hidden populations." The techniques include using a triangulation of indirect indicators, such as seizures, arrest figures for drug offences, an increase in the amount of specific types of crime such as shoplifting, the number of callers to an anonymous hotline, the number of people seeking treatment or the number of deaths resulting from drug use, as well as observation and direct data collection.

The problems associated with indirect methods are that they are all heavily reliant upon the activities of those generating the statistics. For example, if two countries both estimated the extent of their drug problem for cannabis on the basis of police arrest figures, but one country had a policy of bringing a charge for every person found with even the smallest amount of cannabis in their possession, whilst the other had a policy or law which only led to the arrest and prosecution of those in possession of an amount which was deemed to be for dealing or trafficking, then the same situation in each country could yield vastly different estimates, while apparently the same estimates would reflect very different situations in reality.

It is therefore often misleading to attempt to compare situations in different countries even when the same bases are apparently being used. When different bases for the estimates are used, such as police figures or treatment figures, then cross-culturally the comparison becomes nonsense.

A few countries try to estimate the extent of serious drug abuse by using a multiplier of the number of deaths recorded as the result of drug misuse. However, there is an extremely long list of research papers and reports on the difficulties of estimating at all the number of deaths directly or indirectly resulting from drug abuse. Suffice it to say that these are perhaps the least reliable of all the figures available and, leaving the question of HIV aside, the number of deaths directly due to drug misuse is particularly small when compared with those from alcohol and tobacco use, and also with most of the world's other endemic diseases.

This is not to say that it is impossible to reliably estimate the number of illegal drug users in each country, but rather that the various estimates must be assessed for each country in the light of both enforcement and treatment policy. There may also be some need for direct data collection using anthropological/sociological techniques.

Targeting services

The emphasis given to the need for information within a demand reduction strategy is predicated on the need to deliver the appropriate service to the right target group. This means properly identifying target groups as those people in need of a service, tailoring that service to their needs, and designing and implementing it in such a way that it does in fact reach them.

It is only necessary to know the approximate size of the problem, for if the services are over-used they can be expanded. However, it is particularly important to know what drugs are being taken by whom, in what manner, and why. Is the nature of the problem heroin misuse, amphetamine misuse, solvent abuse? Are the drugs eaten, sniffed, smoked or injected? Why are they being taken - for lorry drivers to stay awake on long journeys; as self-medication; for recreation; because it is culturally acceptable; or because with no home, income or little to eat, taking drugs seems to ease a miserable plight?

In many countries in Africa, intravenous drug use is not a problem. It could be envisaged that an inappropriate mass media campaign on the dangers of this practice might actually encourage it, whilst in some countries in Asia, such a campaign would be apposite. There can be no demand reduction programme which can simply be exported from one country to another. Each must be adapted to the needs and cultural context in which it is to be implemented.

Nevertheless, there are certain principles underlying the diverse approaches which can be articulated, and which can be used to structure various programmes.

Implementation Assessment

The key link between the identification of a need, and the suggestion as to how that need might be met, is the implementation mechanism. The efficient delivery of services to the targeted population is a crucial, if not pivotal point of concern in the deployment of responses to a defined need. Therefore, it is vital to know who or which organization, can deliver what, and to whom. An NGO might be more appropriate than a Ministry of Health to set up and operate out-reach programmes, whereas not to involve the Ministry of Education when developing curricula for drug education in schools would at best be foolish and at worst counter-productive.

It may therefore be the case that desirable partners in the implementation process and necessary partners in the process are not always identical. This is a difficulty which can be overcome either by instituting training courses for administrators as well as for professionals and/or by fostering partnerships in the implementing process so that one group may learn from the other.

This suggests, therefore, that much more attention needs to be paid to the building up of successful implementation mechanisms. One option here would be training courses in project management, another would be to have seminars devoted not so much to the substance of a project but the difficulties that the managers have encountered, how they have overcome problems and how they have responded to changed circumstances.

Evaluation

Following a model put forward by French and Kaufman, evaluation can be seen as comprising three parts, process, outcome and impact. "Process evaluation refers to an assessment of a (prevention) programme that includes identification of the target population, a description of the services delivered, the utilisation of the resources for programmes, and the qualifications and experiences of the personnel participating in them.

Outcome evaluation is concerned with measuring the effect of a project on the people participating in it. In essence, outcome evaluation tries to determine if a (prevention) project has met its own objectives.

Impact evaluation explores the aggregate effect of prevention programmes on the community as a whole. ...The purpose of impact evaluation is to gauge the effects of numerous drug abuse prevention programmes operating within a geographic boundary, or of an individual ...programme operating over an extended period of time."

The difficulties encountered whenever there is a call for more efforts to be directed at the prevention of drug abuse inevitably revolve around the measurability of supposed outcomes, that is how can the programmes be evaluated. Most of the difficulties are essentially conceptual, and secondarily financial. Investment in school drug education prevention programmes might not yield positive results in the short term because of the difficulty of establishing that there would have been more drug abusers had it not been for specific programmes. The political need for short term observable outcomes is in direct conflict with the nature of prevention programmes, which may serve not to stop young people from taking drugs, but would, for example, delay the age of experimentation, and prevent more experimenters from becoming habitual abusers. Thus a programme may be judged successful or not according to the criteria for success which are adopted, and the type of evaluation undertaken. For many programmes, imp

act evaluation would not be realistic because to do it properly it might cost as much as the programme itself, and the impact might be cumulative over time and dependent on other programmes which are being undertaken simultaneously.

Too often the unrealistic expectations of many people concerning treatment and rehabilitation programmes lead to too few resources being channelled in this direction. Many countries have not put resources in this area, and some have even cut down their commitment here. Drug addiction has long been acknowledged to be a chronic relapsing condition which is at odds with expectations of treatment outcome of immediate and continued cessation of drug abuse. Education campaigns on the nature of addiction among professionals and decision makers would not be amiss in many States. Many Member States adopt only one treatment model and do not show due regard for the diverse needs of individual drug addicts as called for in the GPA. There is a need for more resources to be devoted to treatment but this cannot be the case unless the nature of drug dependence is more widely understood. Only then can the needed diversity of forms of treatment be put into place.

The Way Forward

There is a clear need to develop an overall framework for demand reduction programmes and to develop regional plans within that network. However, it is not a matter of tackling the problem solely with a "top-down" approach, but also from a "bottom-up" one as well, so that the problem is attacked from multiple perspectives.

When new activities are being undertaken, these must be located within a broad framework. This framework may be based upon the local community but not exclusively, particularly for those areas of countries where the community seems to have broken down almost completely.

What can be envisaged in the field of demand reduction is a matrix development. There is a need to integrate at a national level all the various components of demand reduction activities, perhaps under a master-plan framework, not only so that an overview of often disparate activities can be undertaken, but also that the activities can begin to reinforce one another, rather than remain as isolated, stand-alone endeavors.

There is also a need to develop sub-regional plans, leading perhaps to regional plans, across each of the levels or activities in demand reduction. Thus, for example, there could be a pooling of knowledge concerning the development, use and implementation of various education programmes, mass media campaigns or treatment approaches, so that in each country a demand reduction subprogramme, be it in education or rehabilitation, would link up, or be implemented together with similar subprogrammes in other countries. A series of demand reduction seminars for subregions have already been planned to start in 1993.

Either in the absence of "top down" policy planning, or as a powerful adjunct to it, a "bottom up" approach can be instituted by insisting that each project put forward for funding provide a detailed account of where it fits into which particular sector of demand reduction activities, and how it will tie in and benefit, as well as benefit from, other on-going programmes. It would be more efficacious if both approaches were applied simultaneously, but must be accepted that usually, at government level, progress may be slow.

To put these principles into practice. preferably before but hopefully soon after Master Plan exercises have taken place, there will be a need to assess the nature and the extent of the drug problem. The most appropriate way of doing this is by a rapid assessment which, according to circumstances may take between one and six months to complete. The methodology and guidelines for carrying out such an assessment are explained in a Technical Information Paper. This paper is intended as a general guide, but the approach needs to be modified and adapted according to circumstances. The basis will be the same for all assessments, that is what is the nature of the problem, which groups are taking which drugs and by what means, together with a rough assessment of the extensiveness of the problem. The assessment will also address the capacity of existing institutions to deliver demand reduction programmes and the ability of local NGOs to develop or expand on demand reduction activities. This study will the

n form the basis for the development of a range of closely targeted intervention strategies.

To implement both a top down and bottom up approach two strategies will be advocated. Firstly, where possible and where appropriate the need for a wide range of interventions will be emphasised. Within this certain programmes will be developed as model programmes. These will be programmes which will be well resourced and very closely monitored and evaluated. The monitoring and evaluation will be costly, but will provide a guide to the difficulties encountered, how they were overcome, and what worked, and why it worked as well as what did not and why it did not. Thus the knowledge and experience gained in one programme will not be confined to that programme but will be made available to anyone setting up a similar programme in similar circumstances. These programmes will also serve as working practical examples which can be studied by others wanting to set up something similar.

At the same time it must be recognised that demand reduction activities are mainly labour intensive ones and not capital intensive. Also that if the community is to be involved this must happened at the grass roots level and cannot be designed from a distance. Particularly in relation to NGOs, a little money goes a long way, and many initiatives deserve to be supported. However, the formulation of a project document and headquarters involvement in very small projects is not cost effective. It is therefore proposed to devolve to the field responsibility for support for small projects. The person in the field is far more likely to come across these small projects which would benefit from a grant, and be in a better position to not only to asses the effectiveness of what is being done, but to monitor the outcome. This is not to turn the field advisors into executing agencies, but it would give them the necessary discretion to be able to support local initiatives which seem to be working. Therefore i

t is suggested that either in almost every demand reduction project an amount be included for the support of local NGOs, or that at least each regional field office or every field advisor has a budget for the support of local NGOs in the field of demand reduction. A ceiling could be put on the amount any one organization could have in one year without clearance from Vienna.

To achieve these goals it will be necessary to coordinate efforts and to seek partners from the specialised agencies. Already work is being undertaken with WHO/PSA in joint projects, as well as WHO (Euro), ILO and UNESCO. Joint projects with UNICRI are anticipated. This cooperation will continue at all levels and include joint position papers. A joint position paper on "Women, drug abuse and HIV/AIDS" is in preparation for UNDCP, UNOV/CSDHA/DAW, and WHO/PSA. The draft will then be sent to other United Nations organizations and bodies in an attempt to gain a wider endorsement. As other papers are written so efforts will be made to make them joint position papers with the other relevant agencies.

In order to optimise the experience of those people engaged in delivering programmes, cooperation between developing countries will be promoted. The exchange of experience will be encouraged in of the countries with similar cultural, social and economic conditions and comparable drug problems.

A core of expertise exists within the organization but this is being supplemented by a network of experts around the world who are able, for example, to carry out rapid assessment studies following the guidelines established by the Programme.

In addition, a series of training programmes for training trainers in improving the quality of data collection and the monitoring of drug abuse have been conducted. A series of seminars and workshops have been conducted jointly with WHO (Euro) in eastern Europe on the same theme.

However, to tackle the problem at all with any hope of achieving solid results, commitment to the concept and goals of demand reduction must be sought and courted at the very highest levels. If this cannot be achieved then demand reduction will comprise merely of a collection of fragmented and uncoordinated activities with limited impact upon a global situation which, in many parts of the world, is continuing to deteriorate with alarming speed.