Taxonomies Of Alcohol And Other Drug Interventions

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Social Research & Evaluation Pty Ltd ACN 113 241 973; ABN 40 113 241 973 David McDonald, Director 1004 Norton Road Wamboin NSW 2620 Australia

Phone: +61 2 6238 3706 Mobile: 0416 231 890 Facsimile: +61 2 9475 4274 Email: [email protected] www.socialresearch.com.au

Taxonomies of alcohol and other drug interventions A description and analysis of taxonomies of interventions concerned with alcohol and other drugs, including drug use, people who use drugs, and societal responses to these.

David McDonald Social Research & Evaluation Pty Ltd

18 September 2009

As this is a working paper, comments are invited. It was initially developed as part of the Drug Policy Modelling Program: http://www.dpmp.unsw.edu.au/ Its contents were used in the research published as Ritter, A & McDonald, D 2008, ‘Illicit drug policy: scoping the interventions and taxonomies’, Drugs: education, prevention and policy, vol. 15, no. 1, pp. 15-35.

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Contents Introduction and overview ............................................................................................. 1 Purpose....................................................................................................................... 1 Overview of the taxonomies ...................................................................................... 1 Comprehensive taxonomies ........................................................................................... 4 1. Stages along a continuum of interventions ......................................................... 4 1.1 The NIDA Drug Abuse Program Continuum .............................................. 4 1.2 The US Institute of Medicine (IOM) Mental Health Intervention Spectrum for Mental Health Disorders, aka Mrazek & Haggerty.......................................... 6 2. Taxonomies focusing on the aims of the interventions ...................................... 7 2.1 The United Nations International Drug Control Programme’s approach to national drug control strategies .............................................................................. 7 2.2 Demand reduction, supply reduction, harm reduction ................................ 8 2.3 Canada’s Drug Strategy 1998 .................................................................... 10 2.4 United States National Drug Control Strategy 2004 ................................. 11 3. Taxonomies focusing on the implementation sectors or lead implementation agencies .................................................................................................................... 12 3.1 Allocating responsibilities to the education, treatment and law enforcement sectors ............................................................................................. 12 3.2 Allocating responsibilities to the prevention, treatment and law enforcement sectors ............................................................................................. 13 4. Taxonomies focusing on the stage of development of a disease or condition .. 14 4.1 Primary, secondary and tertiary prevention ............................................... 14 4.2 The new epidemiology taxonomy ............................................................. 16 5. Taxonomies focusing on target systems ........................................................... 17 5.1 The public health model ............................................................................ 17 5.2 Drug, set and setting .................................................................................. 19 5.3 Drug-related harms and risks: types, who bears them and their sources ... 20 6. Taxonomies focusing on particular population groups ..................................... 21 7. Other taxonomies .............................................................................................. 22 7.1 Farrington’s taxonomy of crime prevention .............................................. 22 7.2 Social determinants of health .................................................................... 23 8. Hybrid taxonomies ............................................................................................ 24 Partial taxonomies........................................................................................................ 25 9. Prevention ......................................................................................................... 25 9.1 School-based drug prevention programs ................................................... 25 9.2 Gordon’s operational classification of disease prevention ........................ 26 9.3 The Ottawa Charter for Health Promotion ................................................ 27 10. Drug crime law enforcement ......................................................................... 28 10.1 Drug crime law enforcement ............................................................... 28 Infrastructure interventions .......................................................................................... 29 11. Research, monitoring and evaluation ........................................................ 29 12. Policy instruments ..................................................................................... 30 References .................................................................................................................... 31

Introduction and overview Purpose The purpose of this paper is to stimulate discussion of taxonomies of interventions that aim to impact on alcohol and other drugs, their use, people who use alcohol and other drugs, and societal responses to all of these. I suggest that this is worth doing for a number of reasons:  Many competing taxonomies exist, and virtually nothing has been written explaining and commenting on them.  Drug policy modelling work uses various taxa, so it is sensible to have an explicit statement of how they may be organized.  In communicating with people outside of our research team, we find that different people and agencies use different taxonomies. The effectiveness of our communications with them might be optimised if we can produce findings that match their approaches. For example, drugs policy people in Australia tend to think in terms of demand reduction, supply reduction and harm reduction, but this taxonomy is anathema to many abroad who might prefer to use the law enforcement, education and treatment sectors taxonomy.  In developing a data base of interventions, a solid rationale for its structure will be useful.

Overview of the taxonomies Approximately 20 taxonomies are sketched out in this paper. Some overlap exists. I have grouped them into:  comprehensive taxonomies  partial taxonomies  infrastructure taxonomies. The first covers approaches that deal with the full range of interventions whereas the second covers those addressing only some interventions, e.g. prevention only. The next level of the taxonomy has the comprehensive taxa in eight categories. This may be a little artificial, but it seems to work in most cases. These groupings of the comprehensive interventions are:  stages along a continuum of interventions  aim of the interventions  sector/agency responsible for the interventions  stage of the condition focussed upon  the target system  the population groups targeted  other approaches  hybrid taxonomies. The paper then lists three partial taxonomies:  drug education  preventive measures addressing particular population groups  actions for health promotion.

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It concludes by mentioning, for completeness, two other sets of interventions, not well captured elsewhere, that I have labelled ‘infrastructure’, namely:  research, monitoring and evaluation  policy instruments. A diagram summarising the taxonomies discussed follows. (Policy instruments is not included.)

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Comprehensive taxonomies 1.

Stages along a continuum of interventions

The originators of these taxonomies have explicitly stated that they should be seen as continua, and that they cover the full range of interventions. Two taxonomies are in this group: the NIDA Drug Abuse Program Continuum and the US Institute of Medicine’s Intervention Spectrum.

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The NIDA Drug Abuse Program Continuum

This taxonomy is a continuum with six stages: information → education → alternatives → intervention → treatment → rehabilitation/relapse prevention.

Source It was first published (so far as I know) in French, JF & Kaufman, NJ 1981, Handbook for prevention evaluation: prevention evaluation guidelines, NIDA, Rockville, MD, pp. 3-6, though in that version the continuum ends with ‘rehabilitation’, not relapse prevention. A decade later it reappeared in Bukoski, WJ 1991, ‘A framework for drug abuse prevention research’, in CG Leukefeld & WJ Bukoski (eds), Drug abuse prevention intervention research: methodological issues; NIDA research monograph 107, National Institute on Drug Abuse, Rockville, MD, pp. 7-28. In this version it is called ‘A model of comprehensive prevention’. The final step is ‘rehabilitation/relapse prevention’, reflecting new approaches to treatment. Bukoski states that ‘This approach recognizes that drug abuse encompasses a spectrum of behaviors from nonuse to dependency and includes a comparable range of theoretically based prevention strategies along this continuum of drug use’ (pp. 123). Comments This taxonomy immediately raises the confusing issue of labeling treatment and rehabilitation as ‘prevention’, an issue we return to later. It seeks to link the types of interventions to points in people’s drug using careers. Interestingly, after presenting the continuum, the authors proceed to label as ‘primary prevention’ the steps information → education → alternatives → intervention. This is an unsound use of the term ‘primary prevention’.

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This approach is no longer used by NIDA. I contacted them recently and they said they had never heard of it, despite the fact that Leukefeld & Bukoski’s NIDA research monograph is available on their web site! I have found this taxonomy useful in assisting policy makers to see the big picture. It clearly comes from the health sector and does not lend itself easily to incorporating law enforcement/criminal justice system interventions.

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1.2 The US Institute of Medicine (IOM) Mental Health Intervention Spectrum for Mental Health Disorders, aka Mrazek & Haggerty This taxonomy is a continuum with seven stages: Universal prevention → selective prevention → indicated prevention → case identification → standard treatment for defined disorders → compliance with long-term treatment → after-care.

Source Mrazek, PJ & Haggerty, RJ (eds) 1994, Reducing risks for mental disorders: frontiers for prevention intervention research, National Academy Press, Washington DC. The ‘prevention’ components is not original; it comes from Gordon (1987; 1983). Comments The ‘prevention’ stages of this continuum – or spectrum – are far better known than the treatment and maintenance stages. The authors acknowledge that their source for ‘prevention’ is Gordon 1983. This part of the taxonomy is extremely well known; indeed it is prominent in many contemporary discussions of prevention including the NDS prevention monograph (Loxley et al. 2004). It is important not to equate universal, selective and indicated prevention with primary, secondary and tertiary prevention. They are quite different dimensions, as discussed below. Like the NIDA continuum, it comes from the health sector. Law enforcement/criminal justice system interventions fit more easily, though, than in the NIDA approach.

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2.

Taxonomies focusing on the aims of the interventions

Four taxonomies are listed here. They are national drug control strategies or blueprints for such strategies. What they have in common is a focus on the goals that the interventions aim to achieve, rather than (say) the population groups to be targeted as in Gordon’s (prevention) part of the IOM taxonomy.

2.1 The United Nations International Drug Control Programme’s approach to national drug control strategies National drug control strategies should cover the following:  control and reduction of supply  suppression of illicit trafficking  reduction of illicit demand (prevention, treatment and rehabilitation)  cross-sectoral strategies. The four categories of interventions listed here are expressed as aims. Under each of the four are more detailed taxa, i.e. lists of the interventions that might be conducted so as to meet the specified aims. Source: United Nations International Drug Control Programme 1994, Format and guidelines for the preparation of National Drug Control Master Plans, UNDCP, Vienna.

Comment The UNDCP (now UN Office for Drugs and Crime: UNODC) is active in assisting the nations of the world to develop comprehensive national drug strategies. In earlier decades these had a heavy focus on supply side interventions but, since the adoption of the CMO (United Nations International Drug Control Programme 1988) and later UNGASS’ renewed commitment to demand reduction (United Nations 1998), the strategies have become better balanced. In 1994 UNDCP published its Format and guidelines for the preparation of National Drug Control Master Plans, based on much experience in developing nations. That document states that: A master plan is defined by UNDCP as the single document adopted by a Government outlining all national concerns in drug control. It summarizes authoritatively national policies, defines priorities and apportions responsibilities for drug control efforts. Master plans are a useful tool in the pursuit of the goal of consistent and comprehensive national drug control strategies. It is in furtherance of this objective that UNDCP has prepared this technical documentation on the preparation of master plans. The documentation has three parts: part one is entitled ‘General observations on the master plan’; part two is the ‘Sample format for the master plan’; and part three is ‘Guidelines for using the sample format’ (p. 2).

This approach has worked quite well in many settings. It provides a framework for a broad, inter-sectoral approach. Its comprehensiveness is a good feature, but needs to be handled with care as most developing nations do not have the resources to undertake all—or even a lot of—the interventions listed.

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2.2

Demand reduction, supply reduction, harm reduction

Three aims of comprehensive global, national, regional and local drug strategies:  reducing the demand for illicit drugs  reducing the supply (or availability) of illicit drugs  reducing the incidence and/or prevalence and/or severity of harm related to drugs, drug use and societal responses to drugs and drug use, without necessarily requiring abstinence. Source: Perhaps best known in the Australian context through successive National Drug Strategies, the latest of which is Ministerial Council on Drug Strategy 2004, The National Drug Strategy; Australia’s integrated framework 2004-2009, Dept of Health and Ageing, Canberra. Comment It needs to be pointed out to an Australian audience that this taxonomy, with which we are so familiar, is little known in many parts of the world and, in many places, is rejected owing to the inclusion of harm reduction defined in this manner. The trichotomy was introduced into the NDS in the National Drug Strategic Plan 1993-97 where it states that ‘Harm minimisation is consistent with a comprehensive approach to drug-related problems using a balance of supply control, demand reduction and problem prevention’ (p. 4). Perusal of the fine print in official Australian strategies reveals that the term ‘reducing the supply’ or ‘reducing the availability’ of illicit drugs is rarely used. Instead, a far softer approach is taken: ‘supply reduction strategies to disrupt the production and supply of illicit drugs’. This markedly reduces the accountability of the criminal justice sector as all it is required to do is ‘disrupt’ the supply chain, not reduce the availability of illicit drugs. ‘Problem prevention’, as the term is used in the 1993-97 Strategy, is what we now call ‘harm reduction’. It comes from the work of Pittman (1980) and Room (1981). The exact terms supply-reduction, demand-reduction and harm-reduction (as three components of ‘harm minimisation’) were introduced in the 1998-2003 National Drug Strategic Framework (Ministerial Council on Drug Strategy 1998). The definitions of the three aims given in United Nations International Drug Control Programme 2000, Demand reduction: a glossary of terms, ODCCP studies on drugs and crime: guidelines, UN ODCCP, New York are useful, owing to the role and status of the publisher. Variations on the three categories of interventions exist in the literature, with one interesting twist being found in Hamilton & Rumbold (2004): In general, strategies to reduce drug-related harm can be characterised in one or more of the following ways: - demand reduction (prevention through information provision, education, and treatment) - supply reduction (regulation and law enforcement) - environmental responses that aim to assist people using drugs to do so in the safest possible manner. All these strategies can be part of a harm minimisation approach (p. 137, my emphasis).

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This taxonomy is being used with some success in the Asia/Pacific region, expressed as follows:  

Supply reduction: cultivation, processing, transport, distribution, finance Demand reduction: education about drugs, treatment for drug problems, community development  Harm reduction …Independent of each other, the three different approaches of supply, demand and harm reduction cannot be regarded as singularly effective. However, together they can complement each other - resulting in a favourable environment in which it is possible to contain the problem of illicit drug misuse and address the public health catastrophe of HIV/AIDS among IDUs (Costigan, Crofts & Reid 2003, p. 55).

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2.3

Canada’s Drug Strategy 1998

Canada’s Drug Strategy applies a taxonomy of interventions expressed as five goals:  reduce the demand for drugs  reduce drug-related mortality and morbidity  improve the effectiveness of and accessibility to substance abuse information and interventions  restrict the supply of illicit drugs  reduce the costs of substance abuse to Canadian society. Source: Health Canada 2004, Canada’s drug strategy, . Comment This strategy also emphasises its aims. Internationally, it is seen as similar to the Australian demand, supply and harm reduction trichotomy, and does indeed include harm reduction components, though they are not readily identifiable in this top level taxonomy. It is based on a fairly comprehensive legislative framework.

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2.4

United States National Drug Control Strategy 2004

The taxonomy of interventions covered by the 2004 US National Drug Control Strategy is also expressed in terms of a number of aims:  stopping use before it starts: education and community action  healing America’s drug users: getting treatment resources where they are needed  disrupting the market: attacking the economic basis of the drug trade. Source: Office of National Drug Control Policy 2004, 2004 National drug control strategy, Office of National Drug Control Policy, Washington, DC. Comment For many years the US strategies have been unusual in that the US Government has produced a new Strategy virtually each year, often with new goals and little in the way of evaluation. Greater continuity has been seen recently, though the Strategy is still subject to rapid change. This highlights how the types of interventions and the relative emphases given to them may remain more-or-less constant, while the top level of the taxonomy may change as part of political positioning. (The Strategy is described as ‘The President’s National Drug Control Strategy’ rather than the nation’s strategy, a very American approach to public policy.)

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3. Taxonomies focusing on the implementation sectors or lead implementation agencies Two taxonomies are listed here. What they have in common is a focus not on the aims of the interventions (as above) but on who is responsible for their development and implementation, i.e. which sectors or which agencies have lead responsibility. This is the approach taken at a high level of conceptualisation.

3.1 Allocating responsibilities to the education, treatment and law enforcement sectors A simple taxonomy: education, treatment, law enforcement. Source: This taxonomy is widely used in Australia and abroad. It was used in describing the Australian National Campaign Against Drug Abuse when it as launched in 1985: Australia, Dept. of Health 1985, National Campaign Against Drug Abuse; campaign document issued following the Special Premiers’ Conference, Canberra, 2 April 1985, Australian Government Publishing Service, Canberra. (That source, at p. 4, actually refers to education, treatment/rehabilitation, research and information, controls and enforcement.) Another Australian National Drug Strategy source is: National Campaign Against Drug Abuse (Australia) 1992, Comparative analysis of illicit drug strategy, Monograph series, National Campaign Against Drug Abuse, no. 18, Australian Govt. Pub. Service, Canberra. The classification system is also used in Graycar, A, Nelson, D & Palmer, N 1999, ‘Law enforcement and illicit drug control’, Trends & issues in crime and criminal justice, no. 110 . This source is a detailed taxonomy of criminal justice system interventions. Comment This taxonomy is superficially attractive: it is simple and accords with a commonsense approach to thinking about interventions. It identifies from the outset the agencies or sectors with responsibility for the various types of interventions. Education departments do education, health departments do treatment, and criminal justice system agencies do law enforcement. This is how budgets are structured and bureaucracies organised. Things start to unwind, however, when cross-sectoral and multi-level interventions are contemplated. The challenges to the efficacy of drug education (in its many forms) makes this part of the package look particularly weak. The current attempts of the law enforcement sector to reposition its role as prevention (as well as or instead of law enforcement) reflecting, perhaps, a long-awaited recognition of the limitations of drug law enforcement, also challenges the taxonomy, leading us to its modification, the prevention–treatment–law enforcement approach, which comes next.

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3.2 Allocating responsibilities to the prevention, treatment and law enforcement sectors Another apparently simple taxonomy: prevention, treatment, law enforcement. Source: Ministerial Council on Drug Strategy 2004, The National Drug Strategy; Australia’s integrated framework 2004-2009, Dept of Health and Ageing, Canberra: The National Drug Strategy has strengthened Australia’s presence among drug treatment, law enforcement and prevention service providers internationally, where Australia’s model for dealing with drug issues is recognised as particularly effective (p. 3) … Priority areas • prevention; • reduction of supply; • reduction of drug use and related harms; • improved access to quality treatment; • development of the workforce, organisations and systems; • strengthened partnerships; • implementation of the National Drug Strategy Aboriginal and Torres Strait Islander Peoples Complementary Action Plan 2003–2006; and • identification and response to emerging trends (p. 5, my emphases).

Comment This is the taxonomy applied in the Drug Policy Modelling Program working paper ‘Drug policy responses for heroin’ (though the sequence there is prevention, law enforcement, treatment). It is messy, highlighting the need to address complexity thinking about drug policy. Changing ‘education’ into ‘prevention’ is superficially sound. It broadens the scope, recognising that (drug) education is part of prevention. It allows for intersectoral and multi-level preventive interventions, including those beyond the traditional ‘drugs field’, such as income maintenance and pre-natal well-being. On the other hand, confusion arises when professionals engaged in treating people for drug dependence label their intervention as ‘prevention’, and when police argue that imprisoning drug offenders (users, user dealers and traffickers) is prevention through incapacitation, and that making illicit drug seizures prevents drug-related harm (Australasian Centre for Policing Research 2003; Australasian Police Ministers’ Council 2003; Loxley et al. 2004; Williams, Keene & Williams 1995).

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4.

Taxonomies focusing on the stage of development of a disease or condition

This is the most well known group of taxonomies both within Australia and abroad, particularly in health and medical circles. It is being systematically misused, with resulting confusion as to the meanings of the taxa. This confusion is not surprising, as anyone using these taxonomies needs to discard the dictionary and adopt a Humpty Dumpty approach to lexicology. This is sometimes called ‘the public health model’, but I suggest that ‘public health model’ be reserved for the host-agent-environment taxonomy.

4.1

Primary, secondary and tertiary prevention

The well-known triad of primary prevention, secondary prevention and tertiary prevention. Source: The primary prevention – secondary prevention taxonomy was introduced in Commission on Chronic Illness (USA) 1957, Chronic illness in the United States, vol. 1, Prevention of chronic illness, Published for the Commonwealth Fund by Harvard University Press, Cambridge, MA. I am not aware of any origin for the threepart taxonomy, namely adding the taxon ‘tertiary prevention’ to the other two. It probably evolved without serious thought as to how confusing it is. Discussed in Gordon 1983 & 1987 and (a similar discussion) in Mrazek & Haggerty 1994. Comments The US Commission on Chronic Illness (CCI) was quite clear what it was doing: talking about the prevention of chronic illnesses for which we have sound knowledge about the patterns of biological causality. The Commission coined these definitions:  ‘Primary prevention means averting the occurrence of disease’ (p. 16)  ‘Secondary prevention means halting the progression of a disease from its early unrecognized stage to a more severe one and preventing complications or sequelae of disease ... secondary prevention frequently merges into treatment...’ (p. 28). Gordon and his followers have pointed out that this approach is of little use when dealing with behaviour and conditions with complex and largely-unknown causal webs. In any case, it is especially to be noted that primary and secondary prevention draw attention to the stages of development of a condition, not to a population group (in contrast to Gordon’s universal, selective and indicated prevention). It emphasises how treatment is not prevention, and how confusing the term ‘tertiary prevention’ is when it is equated with treatment. That said, many examples exist of people writing about ATOD interventions using the three-part taxonomy and applying their own definitions. In this way they are moving away from the taxonomy’s origins and the original meanings of the individual taxa. For example, Hamilton (2004) argues that ‘Most people who commence drug use do

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not progress to especially harmful or dependent drug use, but there is a hierarchy of possible opportunities for prevention interventions’ (p. 163). She then describes a ‘hierarchy of prevention opportunities’, namely:  primary prevention: preventing the uptake of drug use among non-users  secondary prevention: preventing risky or problematic use and preventing use progressing to dependency (including preventing harm among early users)  tertiary prevention: reducing harm among problem users and helping to reduce or discontinue use (includes treatment interventions)  preventing harm to others (loc. cit.). While this is far from the CCI approach, it is useful in its own right.

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4.2

The new epidemiology taxonomy

This is an elaboration of the familiar but confusing triad discussed above. It entails four taxa: primordial prevention, primary prevention, secondary prevention and tertiary prevention. Source: Beaglehole, R, Bonita, R & Kjellström, T 2000, Basic epidemiology, Updated reprint, WHO, Geneva. Comments This approach uses the now-traditional though confusing taxonomy which addresses the stages of development of a disease or condition (1°, 2°, 3°), but adds ‘primordial prevention’ preceding primary prevention: Four levels of prevention can be identified, corresponding to different phases in the development of a disease...: - primordial; - primary; - secondary; - tertiary. All are important and complementary, although primordial prevention and primary prevention have the most to contribute to the health and well-being of the whole population (p. 85).

The authors explain that ‘The aim of primordial prevention is to avoid the emergence and establishment of the social, economic and cultural patterns of living that are known to contribute to an elevated risk of disease’ (p. 86). Primordial prevention addresses underlying conditions leading to causation and targets the total population and selected groups. Primary prevention addresses the early stage of disease and targets the total population, selected groups and healthy individuals. Secondary prevention addresses the early stage of disease and targets patients. Tertiary prevention addresses the late stage of disease (treatment, rehabilitation) and targets patients. It can be seen, then, that the authors are attempting to combine a stages of disease taxonomy with a population group targeted taxonomy, with confusing results.

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5.

Taxonomies focusing on target systems

The title of this top level taxon probably needs explanation. It covers three taxonomies all of which focus on the targets of the interventions. However, the targets are not simple ones such as population groups (a separate top level taxon discussed below). Rather, it deals with target systems. This concept is not novel; it was introduced into social work in the 1970s and remains prominent in that profession (Pincus & Minahan 1973). The approach utilises systems thinking. It attempts to deal with inter-related processes and feedback loops. By ‘target system’ I mean a dynamic system that provides a number of points that intervention can target in order to achieve the goals of the intervention, recognising that intervening at one point is likely to produce impacts at other points, and that these interactions can be modelled. For example, a person’s problematic use of a particular type of drug could be modified by intervening with the individual (e.g. providing treatment), or with the person’s environment (e.g. incapacitating the person by means of imprisonment) or by substantially reducing the availability of the drug in question (e.g. through police crackdowns on user-dealers). This is the target system, as different from a target person or population group.

5.1

The public health model

The traditional public health and epidemiologic model: host, agent and environment. Source: This model dates back to the 1920s. The earliest exposition of which I am aware was that of the famous American public health scholar Wade Hampton Frost who, in 1928, gave the following summary of the conditions for epidemic transmission of disease: The factors concerned in keeping up this equilibrium [of transmission of micro-organisms from host to host] and in bringing about the changes from one level of prevalence to another are: 1) A specific microorganism capable of producing the infection and the disease… 2) A host population (man being usually the host to which we refer) containing susceptible individuals in sufficient number to keep up the infection. 3) Such conditions of environment as are necessary for bringing the specific microorganism into potentially effective contact with infectible (sic) hosts (Frost 1976, pp. 143-4).

Frost’s concept of the environment was far narrower than our current approach. The model was described by Cassel in 1976 as ‘the well-known triad of host, agent and environment in epidemiologic thinking’ (p. 107). Cassel’s paper has been characterised as one of the defining articles in the field of social epidemiology (Krieger 2001, p. 669). What this means for the taxonomy is the importance in the alcohol and other drugs field of Cassel’s emphasis on what he called the ‘psychosocial environment’. Comments The host-agent-environment system lies at the heart of contemporary public health and epidemiological thinking and provides a particularly useful taxonomy of interventions concerning alcohol and other drugs. It works well for all sectors and for intersectoral and multi-level interventions.

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Its origins and limitations have been described by Krieger (2001, p. 669): First, psychosocial theory. As is typically the case with scientific theories, its genesis can be traced to problems prior paradigms could not explain, in this case, why it is that not all people exposed to germs become infected and not all infected people develop disease. One response, first articulated in the 1920s and refined in the 1950s as epidemiologists increasingly study cancer and cardiovascular disease, is to expand the aetiological framework from simply ‘agent’ to ‘host-agent-environment’. Despite conceptual expansion, several restrictive assumptions still pervade the new framework’s very language. ‘Agency’, for example, remains located in the ‘agent’ —typically an exogenous entity that acts upon a designated ‘host’; terminology alone renders it inhospitable to conceive of the ‘host’ having ‘agency’! ‘Environment’, moreover, serves as a catch-all category, with no distinctions offered between the natural world, of which we humans are a part and can transform, and social institutions and practices which we, as humans, create and for which we can hold each other accountable. Gaining complexity without an explicit accounting of social agency, the model becomes increasingly diffuse and, by 1960, the spiderless ‘web of causation’ is born.

Beaglehole and Bonita (1997) also have a problem with the way the host-agentenvironment model is used by epidemiologists: Another early textbook listed the ‘personal characteristics’ with which the epidemiologist is primarily concerned: demographic, biological, socio-economic, and personal living habits. By focusing on the agent, host and environment as the principal determinants of disease occurrence, the social system became sidelined and it has largely remained outside the consideration of epidemiologists (p. 98).

This is perhaps less a criticism of the model as a criticism of those epidemiologists who conceptualise ‘environment’ too narrowly, failing to attend sufficiently to the social system as a component of ‘environment’.

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5.2

Drug, set and setting

The public health model of host, agent and environment has been reworked by Zinberg into drug, set and setting. Source: Zinberg, NE 1984, Drug, set, and setting: the basis for controlled intoxicant use, Yale Univ. Press, New Haven & London. Comments Zinberg’s formulation can be seen as an application of the traditional host-agentenvironment system to the field of drug use and drug-related harm. While the subtitle of his book is important for his argument about the concept of ‘drug abuse’, for our purposes the interlocking system of drug (= agent), set (= host) and setting (= environment) is the taxonomy of interest. As with its predecessor, this taxonomy works equally well with diverse and multiple sectors and levels of interventions. It has provided some of the conceptual framework for understanding the impacts of law enforcement strategies on treatment seeking behaviour (e.g. Weatherburn, Lind & Forsythe 1999) and is an important tool in conceptualising and operationalising a net harm approach.

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5.3 Drug-related harms and risks: types, who bears them and their sources This taxonomy focuses on drug-related harms and risks, identifying the types of harms and risks, who bears them, and the sources of the harms and risks. Source: Part of this taxonomy was published by one of the early harm reduction theorists, Russell Newcombe (1992). It was taken to a deeper and even more useful level by Robert MacCoun, Peter Reuter and Thomas Schelling in a 1996 journal article and this formulation has been reproduced in an important contemporary book (MacCoun, R. J. & Reuter 2001). Comments Newcombe (1992) presented a taxonomy of drug-related harm. It has two axes: first, the type of harm (health, social and economic) and second, the level at which the harm occurs (individual, community or society). MacCoun and Reuter usefully complexified this. They point out (as did Newcombe) that a number of sources of alcohol and other drug-related harm may be identified. This may be displayed as a matrix showing, on one axis, the types of harms (health, social & economic functioning, safety & public order, and criminal justice) and identifying on the other axis who bears the harm or risk (drug users, dealers, intimates, employers, neighbourhoods and society) and the primary sources of harm (drug use, the illegal status of drugs and enforcement) (pp. 102-112). This taxonomy, then, has three taxa: the types of harms and risks, who bears them, and the sources of the harms and risks. The authors identify one intervention taxon—enforcement—within their list of sources of harm, but this is too limited an approach. Other interventions can be included, for example drug education and treatment programs, as they also have potentials for creating drug-related harms as well as benefits. As with the other taxonomies in this section—target systems—this one is of great practical value. It is a fine tool for a net harm analysis, as acknowledged in the Australian Capital Territory Government’s, ACT Alcohol, Tobacco and Other Drug Strategy 2004-2008. I have drafted a definition of the net harm approach, building on MacCoun & Reuter (who do not use the term), as follows: A net harm approach to policy and intervention development is one which takes into account both the anticipated positive and negative consequences of interventions, and weighs one against the other. It includes looking broadly to identify the consequences of one intervention for other interventions. Core elements of a net harm analysis include (a) identifying who bears the human and financial costs/harms (e.g. drug users; families; neighbours; communities) and (b) identifying what are the sources of the drug-related costs/harms (e.g. drug use itself; the legal status of a drug; or interventions aiming to reduce certain types of drug-related costs/harm through law enforcement, education, treatment, etc.). If the likely impact of an intervention is limited to shifting the burden of harm from one sector to another (especially from the general community to drug users) this should be made explicit in the planning process and judgments made, based upon a net harm analysis, as to the appropriateness of proceeding.

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6.

Taxonomies focusing on particular population groups

I am not aware of any comprehensive taxonomies that focus on particular population groups and that fit better here than elsewhere. The Gordon/IOM/Mrazek & Haggerty prevention spectrum is population focused, but is not comprehensive, addressing prevention only. As Gordon (1983) stated, ‘…we propose to define prevention as measures adopted by or practiced on persons not currently feeling the effects of a disease, intended to decrease the risk that the disease will afflict them in the future’ (p. 25). This is discussed below, under ‘partial taxonomies’.

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7.

Other taxonomies

This is a residual taxon for comprehensive high level taxa that do not seem to fit well elsewhere.

7.1

Farrington’s taxonomy of crime prevention

Four groups of approaches to crime prevention: criminal justice, situational, community/social and developmental. Source: Farrington, DP 1996, Understanding and preventing youth crime, Joseph Rowntree Foundation, [England]. The taxa are described as ‘Four strategic approaches: law enforcement, developmental, situational, community’ in Tonry, M & Farrington, DP (eds) 1995, Building a safer society: strategic approaches to crime prevention, Univ. of Chicago Press, Chicago. (Tonry & Farrington 1995) Comments: A powerful taxonomy that was further developed, with particular reference to drugs, in the landmark report National Crime Prevention 1999, Pathways to prevention: developmental and early intervention approaches to crime in Australia, National Crime Prevention, Attorney-General’s Department, Canberra. Although labelled a ‘crime prevention’ approach, it fits nicely with drug use since that behaviour is, in most jurisdictions (though not all) a crime. Treatment fits in this schema among the ‘developmental strategies’, where one seeks to intervene to assist people at actual or potential developmental crisis points.

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7.2

Social determinants of health

Ten different but interrelated social determinants of health and well-being: 1. the social gradient - the need for policies to prevent people from falling into longterm disadvantage 2. stress - how the social and psychological environment affects health 3. early life - the importance of ensuring a good environment in early childhood 4. social exclusion - the dangers of social exclusion 5. work - the impact of work on health 6. unemployment - the problems of unemployment and job insecurity 7. social support - the role of friendship and social cohesion 8. addiction - the effects of alcohol and other drugs 9. food - the need to ensure access to supplies of healthy food for everyone 10. transport - the need for healthier transport systems. Source: Wikinson, R & Marmot, M (eds) 2003, Social determinants of health: the solid facts, 2nd edn, WHO, Copenhagen. Comments: This is a taxonomy of interventions that, research evidence indicates, can contribute to health and well-being generally. While it has a strong preventive emphasis, it also covers down-stream interventions and identifies ‘addiction’ as one of the issues demanding attention. (It is odd that a WHO publication is still using the expression ‘addiction’.) It is particularly useful in reminding people of the need for intersectoral approaches, and of the limited capacity of the ‘drugs field’, as we usually define it, to achieve societal goals relating to alcohol and other drug related harms. If we really took a comprehensive approach, the drugs field would include interventions in all the areas listed, among others.

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8.

Hybrid taxonomies

This taxon is unpopulated at present. Although some taxonomies listed elsewhere include more than one taxonomy—most prominently the IOM/Mrazek & Haggerty approach—in each case they seem to fit better elsewhere than here.

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Partial taxonomies This section lists a number of partial taxonomies, i.e. those which cover only part of the intervention spectrum. Four are listed: school-based prevention programs, Gordon’s public health prevention taxonomy, the Ottawa Charter for Health Promotion and a taxonomy of law enforcement interventions. It is actually beyond the scope of this paper to cover this material (the paper focuses on comprehensive taxonomies) but I have included them to clarify some points and to inform readers who may not be aware of these approaches.

9.

Prevention

Three taxonomies addressing various aspects of prevention are mentioned here.

9.1

School-based drug prevention programs

Contents of the programs: knowledge, affective issues, refusal skills, generic skills, safety skills, extracurricular activities, other. Source: Tobler, NS & Stratton, HH 1997, ‘Effectiveness of school-based drug prevention programs: a meta-analysis of the research’, Journal of Primary Prevention, vol. 18, no. 1, pp. 71-128. Comments: A number of taxonomies of drug education exist. This one is comprehensive with respect to school-based preventive interventions. What is particularly attractive is that it was developed inductively from a meta-analysis of 120 programs for which evaluations have been published.

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9.2

Gordon’s operational classification of disease prevention

Universal, selective and indicated prevention measures, targeted at three different population groups. Source: Gordon, RS, Jr. 1983, ‘An operational classification of disease prevention’, Public Health Reports, vol. 98, pp. 107-9. Gordon, R 1987, ‘An operational classification of disease prevention’, in MM Silverman & JA Steinberg (eds), Preventing mental disorders: a research perspective, National Institute of Mental Health, Department of Health and Human Services, Rockville, MD, pp. 20-6. Comments: This taxonomy was published two decades ago and was an important departure from the single factor theory of disease causation (reflecting germ theory) apparently still prominent then. It was incorporated into the US Institute of Medicine’s (IOM’s) Mental Health Intervention Spectrum for Mental Health Disorders, aka Mrazek & Haggerty, discussed above. Here is what Gordon actually said: In summary, we propose to define prevention as measures adopted by or practiced on persons not currently feeling the effects of a disease, intended to decrease the risk that the disease will afflict them in the future. Prevention is classified into three levels on the basis of the population for whom the measure is advisable on cost benefit analysis. Universal measures are recommended for essentially everyone. Selective measures are advisable for population subgroups distinguished by age, sex, occupation, or other evident characteristics, but who, on individual examination, are perfectly well. Indicated measures are those that should be applied only in the presence of a demonstrable condition that identifies the individual as being at higher than average risk for the future development of a disease (Gordon, R. S., Jr. 1983, p. 109).

This taxonomy of prevention is probably the most widely used in public health at present, and is applied in domains far wider than ‘disease prevention’. It has been discussed from time to time (sometimes critically) in publications of the Australian Network for Promotion, Prevention and Early Intervention for Mental Health (Auseinet).

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9.3

The Ottawa Charter for Health Promotion

Health promotion is the process of enabling people to increase control over, and to improve, their health. Five key actions in health promotion:  building healthy public policy  creating supportive environments  strengthening community action  developing personal skills  re-orienting health services. Source: International Conference on Health Promotion 1986, ‘Ottawa Charter for Health Promotion, WHO/HPR/HEP/95.1’, First International Conference on Health Promotion, Ottawa, 17-21 November. Comments: The Ottawa Charter describes its scope as follows: Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being.

As set out here, actions directed at improving health and well-being lie both within, and far beyond, the narrowly-conceived ‘health sector’. By extension, the actions listed may be seen as an important taxonomy of preventive interventions in the alcohol and other drugs field.

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10.

Drug crime law enforcement

10.1 Drug crime law enforcement            

high level drug trafficking control drug seizure multi-agency supply reduction approaches street-level control police crackdowns: undercover policing, drug sweeps community policing problem-oriented policing policing drug hot spots place managers third party policing and the use of civil remedies civil forfeiture law diversionary law enforcement strategies: drug action teams, cautioning, mandatory treatment services, drug courts.

Source: Graycar, A, Nelson, D & Palmer, M 1999, ‘Law enforcement and illicit drug control’, Trends & issues in crime and criminal justice, no. 110. Comments: The first author states that: This paper is a basic catalogue of law enforcement responses to illicit drug use. As one of the most important issues facing Australia today, the use of illicit drugs has no simple solution, and will require policy and intervention responses from agencies across the spectrum of education, treatment and rehabilitation, and law enforcement. Partnership between government and the community is essential in dealing with the issues that confront us. Recognising the diversity and value of complementary approaches, this paper looks at only one aspect of our response to illicit drugs, a law enforcement perspective (Graycar, Nelson & Palmer 1999, p. 1).

Australian drug policy researchers and practitioners may find this taxonomy of value as it has been produced in Australia, reflecting the perceptions of Australian people involved in the criminal justice system both operationally and from a research and policy perspective.

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Infrastructure interventions The final group of interventions cover some that do not fit neatly into the taxonomies described above. I have called them infrastructure interventions, meaning interventions that provide the foundations (or could or should provide the foundations) for the types of interventions that fall within the many taxonomies discussed above.

11.

Research, monitoring and evaluation

Three infrastructure interventions: research, monitoring and evaluation, that underpin interventions in the demand, supply & harm reduction taxonomy, and the host, agent, environment taxonomy. (Host, agent and environment are labelled by ADCA individual, drug and community.)

Source: Alcohol and other Drugs Council of Australia 2004, Submission to the National Drug Strategy Evaluation from the Alcohol and other Drugs Council of Australia, Alcohol and other Drugs Council of Australia, Canberra. Comments: This taxonomy adds a new dimension to thinking about interventions. Most of the preceding approached cover activities that are somewhat proximate to drug use, drugrelated harm or to their risk and protective factors. These three interventions, on the other hand, are more distal, providing evidence about, for or against particular policies and intervention strategies, and their implementation.

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12.

Policy instruments

The term ‘policy instrument’, routinely used in public administration/public policy circles, is synonymous with the term ‘intervention’. Policy instruments are ‘the methods used to achieve policy objectives’ (Althaus, Bridgman & Davis 2007, p. 87) or ‘the means by which a policy is put into effect’ (op. cit., p. 246.) The five main classes of policy instruments used in Australia are, according to Althaus, Bridgman & Davis (op. cit., p. 89):  Policy through advocacy—educating or persuading, using information available to government.  Policy through network—cultivating and leveraging relationships within and across government and with external partnership bodies to develop and implement desired goals and behaviours.  Policy through money—using spending and taxing powers to shape activity beyond government.  Policy through direct government action—delivering services through public agencies.  Policy through law—legislation, regulation and official authority.

Source: Althaus, C, Bridgman, P & Davis, G 2007, The Australian policy handbook, 4th edn, Allen & Unwin, Crows Nest, N.S.W. Comment This five-instrument taxonomy is a relatively simple, condensed approach, but nonetheless is one that works well in an Australian context. It is familiar to public servants and aligns closely with their styles of operating. These factors, along with the fact that it applies equally well to all sectors including education/prevention, treatment and law enforcement, makes it a useful addition to the categorisation of interventions.

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