Making connections — the questions we have to answer

1. J. Rehm (TU Dresden) Making connections — the questions we have to answer

2. Difference between researcher and policy maker “Because you don’t know where you are, where you’re going, or how to get there.” “Are you a policy maker?” “You’re in a hot air balloon.” Why yes.  How did you know?” Person goes up in a hot air balloon; it gets cloudy; he doesn’t know where he is; finally there is a break in the clouds, luckily, someone else is nearby: Because you gave me factually correct information that was completely useless “Why yes.  How did you know?” “Excuse me, can you tell me where I am?” “Are you a researcher?”

3. Information needs What are the information needs of modern societies with respect to drug use?

4. Extent, harm, costs • What is the extent of drug use? • Prevalence • Incidence • Trends • What is the harm attributable to drug use (short-term and long-term)? • Inherent to substance • Caused by circumstances of use • What are the costs to society? • What are the effects of potential interventions? • Effectiveness and cost-effectiveness

5. Implications of the illegal nature of illegal drug use Or, why standard methodology fails?

6. Examples for techniques which cannot be applied without problems • Representative general population survey techniques • Too many drug users outside sampling frame for drugs except cannabis • Non response problems of users • Cost-ineffective for rare events • Triangulation with sales data (as for alcohol or tobacco)

7. Solutions: new techniques • Capture re-capture techniques • Representative snowball sampling techniques Scientists can be creative, but the solutions are often based on potentially problematic assumptions, which are costly and developed for science rather than for daily practice or sustained monitoring (which country could do extensive studies with modern techniques yearly?)

8. We need an “experimenting society” (D.T. Campbell) Scientists could be most helpful if we would not pretend to have solutions which will not change over time Campbell, D.T. (1969). Reforms as experiments, American Psychologist, 24, 409-429. Campbell, D.T. (1976). Assessing the Impact of Planned Social Change. December 1976

9. Example: Sunday opening of alcohol monopoly stores in Sweden • Policy formulation • Experimental design wherever possible (e.g., within EU by randomizing countries or by different starting dates for different countries; within countries by randomizing regions) • Evaluation • Adaptation of policy if necessary • “Final” implementation • Continuous evaluation and changes We know relatively little about complex interventions and their effects. Experimentation would help us understand.

10. The problem of integrated policy decisions The very nature of integrated drug policy hinders causal conclusions

11. The example of Switzerland’s drug policy of the early 1990s Situation of “open drug scene” was perceived as insupportable within Swiss society and threatening to politicians. Drug overdose deaths were high. Often policy changes are triggered by crises. Interventions were sought to change the situation -> Swiss four pillar concept.

12. Interventions General four pillar strategy (repression, treatment, harm reduction, prevention) with multiple parallel changes • Supervised injection rooms • Heroin-assisted treatment • Extreme widening of MMT • Introduction of other treatment options • New style of policing • More $s for social integration. • Decentralization

13. Overdose deaths in Switzerland 1992/93/94: integrated Swiss drug policy implemented -> sustained success in reducing mortality Success: but what is causal?

14. Does causality matter practically? • It does, or do we believe that the exact same package would have the exact same success in Toronto? Or that it could be implemented politically in exactly the same way? • We need to identify causal impacts of policy • This could be done by experimentation including so-called natural experiments such as by staggered introduction of measures (example: Reagan’s policy of changing legal drinking age to 21 in the US -> different times of implementation in different states -> control conditions -> clear demonstration that whenever the laws was introduced it lead to a reduction in highway fatalities among 18-21 year olds).

15. Making connections Giving and taking

16. How to improve the situation • Policy makers should accept solutions as temporary -- to be tested • Experimentation should be introduced wherever possible • Routine monitoring should be constructed as to allow answering evaluative questions • Scientists should become more practical and innovative • Solutions should involve the civil society!