DRAFT
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE
PUBLIC HEALTH INTERVENTION
GUIDANCE
DRAFT SCOPE
1 Guidance title
An assessment of community-based interventions to reduce substance
misuse among the most vulnerable and disadvantaged young people
1.1 Short title
Interventions to reduce substance misuse among vulnerable young people
2 Background
The National Institute for Health and Clinical Excellence (‘NICE’ or ‘the
(a)
Institute’) has been asked by the Department of Health to develop
guidance on public health interventions aimed at reducing substance
misuse1 among vulnerable and disadvantaged young people.
(b)
NICE public health intervention guidance supports implementation of
the preventive aspects of national service frameworks (NSFs) where a
framework has been published. The statements in each NSF reflect the
evidence that was used at the time the Framework was prepared. The
public health guidance published by the Institute after an NSF has
been issued will have the effect of updating the Framework.
Specifically, in this case, the guidance will support the following NSFs
and other government policy documents:

the ‘National service framework for children, young people and
maternity services’ and the ‘Updated drug strategy’ (Home Office
1
For the purposes of the guidance, substances are defined as agents that, when ingested in
sufficient doses, alter functioning. In the literature, ‘drug’ tends to refer to illicit compounds
although it is often used interchangeably with ‘substance’. Substance misuse is defined as
intoxication by – or regular excessive consumption and/or dependence on – psychoactive
compounds, leading to social, psychological, physical or legal problems. Problematic misuse
causes harm to the individual, their significant others or the wider community.
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2002) (both have been integrated within the ‘Every child matters:
change for children’ delivery programme (Department for Education
and Skills (DfES), the Home Office, and the Department of Health
(DH))

‘A new commitment to neighbourhood renewal: national strategy
action plan (Social Exclusion Unit 2001)

government strategies to reduce deaths and harms from volatile
substance abuse (VSA), (DH, the Home Office and the DfES 2005)

the public health white paper ‘Choosing health: making healthy
choices easier’ (DH 2004)

the health and social care white paper ‘Our health, our care, our say:
a new direction for community services’ (DH 2006).
The guidance will also support the broader aims of the National Treatment
Agency for substance misuse (NTA).
(c)
The guidance will provide recommendations for good practice, based
on the best available evidence of effectiveness, including cost
effectiveness. It is aimed at professionals with public health as part of
their remit working within the NHS, local authorities and the wider
public, private, voluntary and community sectors.
3 The need for guidance
a) Young people aged between 16 and 24 years show the highest
prevalence of illicit drug use in the UK, with 28% having used at least one
illicit drug in the previous year2. Misuse of substances is also increasingly
common in younger people. In 2003, 8% of 11–15 year olds reported
having taken volatile substances (gas/glue) in the preceding year3.
b) Vulnerable young people aged 10 to 24 years report higher levels of illicit
drug and substance misuse than their non-vulnerable peers and account
Chivite-Matthews N, Richardson A, O’Shea J et al. (2005) Drug misuse declared: Findings
from the 2003/04 British Crime Survey. London: Home Office.
3 Department of Health (2005) Out of sight? Not out of mind: Children, young people and
volatile substance abuse (VSA). London: Department of Health.
2
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for a disproportionate percentage of illicit drug users4. In the 2003 Crime
and Justice Survey5, 24% of vulnerable young people reported using illicit
drugs frequently during the preceding 12 months, compared to 5% of
those who were not vulnerable. There were significantly higher levels of
drugs use among young people who belonged to more than one
vulnerable group compared to those belonging to just one vulnerable
group.
c) There are significant direct and indirect health risks associated with the
use of all psychoactive substances. The former range from nausea and
anxiety to coma and death. Volatile substance misuse, in particular,
carries a risk of sudden death. The latter include an increased risk of
hepatitis or HIV infection (particularly with injecting drug use).
d) There are significant social costs associated with problematic substance
misuse1 among young people, including poor school attendance and
educational attainment, social exclusion and disruption of the family or
community.
e) It is difficult to determine the total economic and social costs of substance
misuse in the UK. The annual economic cost (including health service and
criminal justice costs) of Class A drug use alone, in England and Wales,
was estimated at £3.5 billion in 2000. Total social costs (including victim
costs of crime and the value of premature deaths) were estimated to be
substantially higher, at £12 billion6.
The 2003 Crime and Justice Survey (Becker & Roe 2005 – see below) identifies five
vulnerable groups of young people: ‘those who have ever been in care, those who have ever
been homeless, truants, those excluded from school and serious or frequent offenders’.
5 Becker J, Roe S (2005) Drug use among vulnerable groups of young people: findings from
the 2003 Crime and Justice Survey. London: Home Office.
6 Godfrey C, Eaton C, McDougall C et al. (2002) The economic and social costs of Class A
drug use in England and Wales, 2000. London: Home Office.
4
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4 The guidance
a) Public health guidance will be developed according to NICE processes
and methods. For details see Section 5.
b) This document is the scope. It defines exactly what the guidance will
(and will not) examine, and what the guidance developers will consider.
The scope is based on a referral from the Department of Health (see
appendix A).
4.1 Populations
4.1.1 Groups that will be covered
The guidance will cover all vulnerable and disadvantaged children and
young people up to the age of 25 years old, including:

children whose parents or other family members misuse drugs

young offenders (including those incarcerated within custodial or
secure accommodation settings of the criminal justice system)

those with conduct disorders

those with existing mental health disorders

children and young people who are or have been looked after by
local authorities or in foster care

those who are or have been homeless or who move frequently

school excludees and truants

those involved in commercial sex work

children and young people from some black and minority ethnic
(BME) communities

those from some socio-economically deprived groups.
4.1.2 Groups that will not be covered
The guidance will not cover interventions delivered to the wider population of
young people.
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4.2 Areas
4.2.1 Areas that will be covered
The guidance will include all selective or indicated7 interventions that aim to
prevent or delay the initiation of substance misuse (primary prevention)
among vulnerable and disadvantaged young people, or which aim to help this
group to reduce or stop their misuse of substances(secondary prevention).
(Selective interventions target subsets of the population at an increased risk
of substance misuse. Indicated interventions target people who already
misuse drugs or substances and are considered to be at increased risk of
dependency.)
The guidance will cover the misuse of illicit drugs, other substances (for
example, volatile substances) and prescription drugs, but not alcohol and
tobacco (see section 4.2.2). Community-based interventions that will be
considered are defined8 as: those micro-interventions or small-scale
programmes delivered in community settings that seek to elicit changes in the
risk behaviour of the targeted population.
4.2.2 Areas that will not be covered
a) Universal interventions or programmes targeting the entire population.
b) Interventions for the prevention and/or reduction of alcohol or tobacco use.
c) Treatment of drug or substance dependence9 or overdose. This includes
interventions covered by separate NICE guidance that is currently under
development (see section 6).
d) Psychosocial treatment of drugs or substance dependence. This is the
subject of separate NICE guidance (see section 6). However, it should be
7
Adapted from Sumnall H, McGrath Y, McVeigh J et al. (forthcoming) Drug use prevention
among young people. Evidence into practice. London: NICE.
8 Potvin L, Richard L (2001) Evaluating community health promotion programmes. In:
Evaluation in health promotion: principles and perspectives. WHO regional publications.
European Series 92:214.
9 Habituation or addiction to the use of a drug or substance, with or without physiological
dependence. Dependence is characterised by physiological or psychological effects on
withdrawal.
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noted that family psychosocial interventions will be included if the primary
or secondary aim is to prevent or reduce substance misuse in children or
young people who are related to someone who is dependent on an illicit
drug or substance.
e) The prevention or reduction of the associated harms of substance misuse.
This includes: needle exchange programmes, interventions promoting
vaccination against hepatitis B or tetanus, and interventions promoting
safe substance use (for example, to encourage adequate hydration when
using ecstasy).
4.3 Comparators
Interventions will be compared, where possible, against no intervention and
against each other.
4.4 Outcomes
4.4.1 Primary outcome measures
Among children and young people already misusing substances:

an increase in the number who stop misusing

reduction in use or frequency of use.
Among children and young people who are at risk of misusing substances:

reduction in the numbers who start misusing

delay in the time before initiation.
4.4.2 Secondary outcome measures

Changes in risk or protective factors that are likely to affect a young
person’s propensity to misuse substances (for example, knowledge,
intentions, attitudes, availability of services, school attendance,
family cohesion, ‘expressed emotion’, social exclusion, social
capital and community cohesion)

The engagement of communities or vulnerable or disadvantaged
young people in an intervention or strategy
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
Hospitalisation or death

Outcomes related to the criminal justice system.
4.5 Key questions
What interventions are effective and cost-effective in reducing substance
misuse among the most vulnerable and disadvantaged young people,
compared with one another, no intervention or usual practice?
The effectiveness of each intervention will be further examined by asking:

what factors or determinants does it aim to influence (for example,
modulation of risk factors, promotion of resilience/protection)?

how valid and appropriate are the outcome measures used to
assess effectiveness? (For example, self-report versus biologically
validated measures of substance misuse.)

how does the content influence effectiveness?

how does the delivery influence effectiveness?

does effectiveness depend on the job title/position of the intervenor,
or other factors such as age, gender, sexuality or ethnicity? What
are the significant features of an effective deliverer?

does the site/setting influence effectiveness?

does the intensity or length of the intervention influence
effectiveness or duration of effect?

how does the impact vary according to the target population (for
example, in terms of age, gender, ethnicity, nature of
vulnerability/disadvantage)? What are the most effective ways of
engaging vulnerable and disadvantaged young people? What
factors cause vulnerable young people to drop out of – or
disengage from – substance misuse prevention programmes?

is there any differential impact on inequalities in health within and
between different vulnerable and disadvantaged groups?

to what extent is effectiveness influenced by the level and nature of
substance misuse (for example, type of user, type of substance
used, length of use, poly-substance use)?
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
how much does the intervention cost (in terms of money, people,
time)? What evidence is there on cost effectiveness?

what are the barriers/facilitators to implementation? (For example,
resistance from young people, policy drivers, funding and staff.)

how acceptable is the intervention, both to vulnerable and
disadvantaged young people and their parents/carers?

What are the adverse or unintended outcomes of the intervention?
(For example, stigmatisation, disruption of community cohesion.)
4.6 Target audiences and settings
The guidance will be aimed at professionals working in the NHS, in other
public sector organisations, the private sector and in the voluntary and
community sectors that have either a direct or indirect role in and/or
responsibility for addressing substance misuse among vulnerable or
disadvantaged young people.
4.7 Status of this document
This is the draft scope, released for consultation in February 2006, to be
discussed at a stakeholder meeting on 10 March 2006. Following
consultation, the final version of the scope will be available at the NICE
website in April 2006.
5 Further information
The guidance will consider the best available evidence from experimental,
observational and qualitative research that is appropriate to address the key
questions in section 4.5.
The public health guidance development process and methods are described
in The Operating Model for the Centre of Public Health Excellence, available
at: www.nice.org.uk/page.aspx?o=248187 The detailed process and methods
manuals will be available from the NICE website in March 2006.
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6 Related NICE guidance
NICE is developing the following related guidance (the scheduled date for
publication is provided in brackets):
Clinical guidelines
Drug misuse: Opiate detoxification of drug misusers in the community and
prison settings (September 2007).
Drug misuse: Psychosocial management of drug misusers in the community
and prison settings (September 2007).
Technology appraisals
Methadone and buprenorphine for the treatment of opiate drug misuse (March
2007).
Naltrexone as a treatment for relapse prevention in drug misusers (March
2007).
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Appendix A: Referral from the Department of Health
The Department of Health asked the Institute to undertake:
An assessment of community-based interventions to reduce substance
misuse among the most vulnerable and disadvantaged young people.
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