Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Addaction
Evidence
submitted
Section
1
Page
Number
5
1
5
1
6
1
6
1
7
2
Stakeholder response table – guidance consultation
9
Comments
Please insert each new comment in a new row.
Recommendation 1: The identification and referral of vulnerable
or disadvantaged young people who are misusing substances
should not have an age threshold (e.g. over 16). There are
young people aged under 16 who will require this intervention.
Should we explore substance use other than cannabis and
stimulants?
Recommendation 2: Again there should not be an age threshold
of over 16 for this intervention and why limit to cannabis and
stimulant use?
Response
Please respond to each comment
Thank you for your comment. The revised
recommendation now extends to under 16 year
olds and a wider range of substances.
Thank you for your comment. Please refer to our
previous response.
Recommendations 3 & 4: This should be specifically linked with
the changes proposed in Care Matters as well as Every Child
Matters
Recommendation 4: There should not be an age threshold of
under 16, and schools should include colleges and further
education providers.
Recommendation 5: This provision should be available to young
people referred through all children’s services/professionals not
just schools.
Thank you for your comment. The guidance
‘considerations’ section refers to this point.
It would be useful to recommend evaluating the use of this
intervention with other age groups.
The revised guidance includes recommendations
for further research. You can suggest a future
topic for NICE guidance at
www.nice.org.uk/page.aspx?o=ts.home
Although the illicit drug use is identified as most prevalent
among young people aged between 16 and 24 years, we need
to widen the age range when defining which young people are
vulnerable or disadvantaged. This is particularly true for those
young people involved in commercial sex work who should
always be considered to be sexually abused young people.
Thank you for your comment. The Department of
Health asked NICE to undertake: ‘An assessment
of community-based interventions to reduce
substance misuse among the most vulnerable
and disadvantaged young people’. The guidance
focuses on children and young people aged
under 25. This is the age range covered by the
public service agreement (PSA) target for
Thank you for your comment. The revised
guidance focuses on vulnerable and
disadvantaged people up to the age of 25.
Thank you for your comment. The revised
recommendation is not limited to children referred
by schools.
p.1
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Adfam
Evidence
submitted
Section
Page
Number
Comments
Please insert each new comment in a new row.
5
11
5
12
Recommendation 3: At Addaction we are addressing this area of
research, as we have developed a pilot called the Intensive
Interventions Programme which includes structured support for
the families of young substance misusers. We are using an
intervention framework developed by the University of Bath and
Avon and Wiltshire Mental Health Trust, who are also evaluating
the pilot.
Recommendation 4: At Addaction we are addressing this area of
research, as we have developed a pilot called Breaking the
Cycle which aims to reduce the risk to young people affected by
parental substance misuse. This pilot is being evaluated by the
University of Bath and Avon and Wiltshire Mental Health Trust.
Whilst I recognise why the recommendations are phrased as
they are, i.e. they are based on the evidence, it is unfortunate
that they focus on young people of 16+, on cannabis and
stimulants and on motivational interviewing. This may not help
many practitioners. Neither am I convinced that US evidence,
particularly on prevention and young people, translates very well
to the UK experience.
I am pleased to see that the guidance document gives a very
clear message about its limitations.
General
Again, the recommendations do not represent the reality of the
lives of vulnerable young people. Most of them are not in regular
schooling and so the recommendations re referral to
Stakeholder response table – guidance consultation
Response
Please respond to each comment
substance misuse shared by the Home Office
and DfES (see ‘Tackling drugs, changing lives –
keeping communities safe from drugs’ Home
Office 2004). You can suggest a future topic for
NICE guidance at
www.nice.org.uk/page.aspx?o=ts.home
Thank you for this information. It is anticipated
that the guidance will be reviewed in March 2010,
when you may wish to submit your evidence.
Thank you for your comment. Please refer to our
previous response.
Thank you for your comments. The revised
recommendation relating to motivational
interviewing makes reference to those attending
secondary schools or further education colleges.
Unfortunately, there is a lack of evidence
supporting effectiveness of this approach for
younger children. There was evidence to support
the use of motivational interviewing (some of
which was from the UK) for reduction of use of
other substances (including alcohol and tobacco)
so it is recommended for young people who
misuse any substance.
Thank you for your comment. The guidance is for
all those working with vulnerable and
disadvantaged children and young people –
p.2
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Association of
Police Officers
Evidence
submitted
Section
Page
Number
Recommendations
General Issues
Page 5
Comments
Please insert each new comment in a new row.
motivational interviewing will be hard to implement.
It is noted that the guidance defines Community-based
interventions as “interventions or small scale programmes
delivered in community settings that seek to elicit changes in the
risk behaviour of the targeted population.” And not “Clinical
interventions with individuals who are dependent on
substances”.
This distinction may be a little opaque to many. It may help the
reader to be given the assistance of the different types of
possible interventions.
Response
Please respond to each comment
including settings outside school.
Thank you for your comment. The guidance has
been amended and the definition now includes
schools and youth services.
The review of effectiveness report provides
information about all the interventions that were
included (visit
http://guidance.nice.org.uk/page.aspx?o=352235)
It appears that this guidance sits in between general drug
education in schools and the more individually targeted
interventions introduced by the Drug Intervention Programme
via the criminal justice system or referral into treatment by a
health professional.
This needs to be made clearer.
British Association
for Counselling and
Psychotherapy
Recommendation 2
Page 5
2
9
Reference to other guidance documents may help, including the
ACPO “Joining Forces Drugs: Guidance for police working in
schools and colleges”
This refers to cannabis and stimulants. The term stimulants is
not often used by non-health workers and therefore may be
misunderstood.
Public health need and practice
The revised guidance refers to drug policy and
children’s education and health policies.
Thank you for your comment. The guidance has
been amended.
Thank you for your comment. The guidance has
been amended.
We suggest you include the word ‘educational’ under bullet point
6, on page 9, so that it reads ‘those with other health,
educational and social problems, at home, school and
elsewhere.’
Thank you. Your comments are noted.
Stakeholder response table – guidance consultation
p.3
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Comments
Please insert each new comment in a new row.
Whilst there is no direct evidence linking dyslexia with the
development of substance misuse problems, there are two
strong circumstantial reasons to suspect a link between early
dyslexia and later substance misuse problems.
1.
2.
Brighton Oasis
Project
Recommendation 1.
Recommendation 2.
Recommendation 3.
Stakeholder response table – guidance consultation
Response
Please respond to each comment
The high proportion of adult offenders who are
dyslexic, combined with the high proportion who are
substance users.
In the Youth Justice System 45% of Young Offenders
are reported to be substance dependent, 90% to have
misused illegal drugs, two thirds to have an educational
level below an average 11 year old and one third to
have a reading age below seven (Youth Justice Board
2006.)
It is possible that dyslexic children self-medicate to deal with
stress. If this link were established it would have implications for
treatment that could make a difference for many children.
We support the recommendation that vulnerable young people
"should" be identified, but we are concerned that the guidelines
do not go far enough to indicate how, or where identification is
currently working or lacking. There is a need to identify and
bring young people into services but we need solid ways of
doing this. This is why, at Brighton Oasis Project, we have
developed assertive outreach interventions to link the two issues
of teenage pregnancy and substance misuse.
The document states that parents need to be worked with.
There is no mention of carers. Many of the young people we
work with are Looked After Children or in hostels, and therefore,
work is done with their primary carer who is not their parent.
The recommendation that a demographic profile of under 25's
vulnerable to use is produced, but there are no further
recommendations around interventions for 19 – 25’s. There is a
massive gap in services for young people in this age range.
Thank you for your comment. The guidance has
been amended to include information about
target populations, who should take action and
what action they should take.
The recommendations cover both identification ,
referral and provision of services
Thank you for your comment. The guidance has
been amended.
Thank you for your comment. The guidance
focuses on vulnerable and disadvantaged people
up to the age of 25, however, there are areas
where evidence relates to particular age groups.
p.4
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Recommendation 4
page 17
Comments
Please insert each new comment in a new row.
They are too old for youth services and too young for adult
services, and are often therefore excluded. Brighton Oasis
Project believes that bridging / transitions services are
developed on a national level, to reduce drop out rates and the
potential of higher risk usage.
This recommendation mentions children of substance misusing
parents.The recommendations of Hidden Harm (ACMD 2003)
are really relevant here. Interventions offered to children of
substance misusing parents could really contribute to reducing
later substance misuse within this group. As a result of all the
initiatives that have sprung up nationally over the last few years
this hard to identify group is becoming much more accessible
and easier to reach and work with.
Response
Please respond to each comment
Thank you for your comment. The guidance has
been amended to refer to ‘Hidden Harm’.
Children with family members who misuse
substances are identified as a vulnerable group
at increased risk of substance misuse.
For young people one of the highest indicators of later
problematic substance misuse is coming from a family where
there is problem drug or alcohol use.
Work on Hidden Harm nationally goes to the heart of where
problematic substance misuse is sustained; within familial
dynamics – The Hidden Harm agenda attempts to intervene and
offer families and young people alternatives to the culture of
substance misuse they have been brought up with. This is
important preventative work.
Recommendation 1.
Stakeholder response table – guidance consultation
Therefore we urge those involved in the implementation of the
Hidden Harm recommendations and colleagues in this field
should form close alliances when considering early preventative
work.
Gender specific services should be considered and funded.
Patterns of substance use, age of first drug use and reasons for
using substances vary between young women and young men.
Our experience is that young women will actively request female
workers rather than just accepting this if offered. Our experience
The revised recommendations cover the
importance of local joint strategies for reduction
of substance misuse among vulnerable and
disadvantaged under 25 year olds.
Thank you. Your comment is noted. The
guidance ‘considerations’ section refers to this
point.
p.5
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Care Services
Improvement
Partnership,
incorporating
NIMHE
Commission for
Evidence
submitted
Section
Page
Number
General
Comments
Please insert each new comment in a new row.
is that young women who come to services will also have
histories of sexual abuse and partner or parental violence and
feel safer with a female worker or within a women’s drug service
which can specialise in offering support which are specifically
related to the concerns of young women.
It is useful to recognise that young people are individuals and
that ‘one size does not fit all’. Whilst the recommendations
are useful they need flexibility so that the holistic needs of the
young person are addressed. Ie. If a young person’s drug use
is in response to other problems then these other issues need to
be addressed eg. difficulties at home, difficulties with parents,
previous abuse, domestic abuse at home, etc. Some
individuals may engage in group work and others would respond
more positively to one to one interventions.
Response
Please respond to each comment
Thank you for your comment. The guidance
‘considerations’ section refers to this point.
General
The guidelines also need to clearly link to Local Safe Guarding
Procedures and how to assess when a child protection issue is
evident.
General
It would also be useful to expand on the children of problematic
drug users and how risk is identified and resilience factors built
into the work.
General
It would be helpful to make some connections
with work ongoing in "healthy schools" and also the potential for
working within children's centres and extended services
Thank you for your comment. The revised
recommendations refer to the policy context of
children and young people services, covering a
range of settings.
General
There is little focus on BME despite the significant
cultural issues in regard to substance misuse and some BME
groups
Thank you for your comment. The revised
’considerations’ section notes that there was a
lack of evidence relating to some groups,
including those from black and minority ethnic
groups. Further research is recommended.
Thank you for your comment. The guidance has
General
Stakeholder response table – guidance consultation
General
There is a general lack of reference to local authorities and
Thank you for your comment. It is expected that
the recommendations will be supported by local
protocols, including those relating to child
protection.
Thank you for your comment. The revised
recommendations refer to use of existing
assessment tools.
p.6
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Social Care
Inspection
Cumbria PCT
Evidence
submitted
Section
Page
Number
Comments
Please insert each new comment in a new row.
social care throughout the document, with the exception of the
recommendations. This may reduce the likelihood of buy-in by
people working in those bodies/areas, if social care is seen as
an add-on and the guidance as top-down. Perhaps more
thought could be given to including the social care sphere in the
body of the document eg. paragraph 1 of the Foreword etc.
The links to the Social Care Institute for Excellence are not
apparent in the document. As SCIE is responsible for
developing and promoting good practice in social care, this link
would be helpful, especially as the guidance ought to be
consistent with existing guidance.
Response
Please respond to each comment
been amended to include reference to local
authorities and the social care sector.
General
General
Section 1
6
Family members misuse drugs OR ALCOHOL
5
Rec 1 should add a brief intervention as well as training for
these staff members
Rec 5 need to recognise the influence of boredom and curiosity
as well as impulsive behaviour
Thank you for your comment. Interventions that
seek to prevent or reduce substance misuse in
the broadest sense (that is, drugs, volatile
substances, and tobacco or alcohol) were
included, provided that the intervention study
reported on outcomes relating to drug and volatile
substance misuse specifically. Guidance on the
prevention of alcohol or tobacco use alone in
vulnerable or disadvantaged young people is not
included.
Thank you for your comment. The guidance
‘considerations’ section refers to this point.
Thank you for your comment. The guidance has
been amended.
7
General
Stakeholder response table – guidance consultation
Do we need to note any influence of gender and of siblings too?
Thank you. Your comment is noted. The revised
guidance includes reference to the need for close
working between statutory and other agencies.
Thank you for your comment. Recommendations
are based on the process of individual
assessment of risks and needs, which would
include family context. In addition, the revised
‘considerations’ section refers to the need for an
holistic approach that takes the child or young
p.7
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Department of
Health
Evidence
submitted
Section
Page
Number
Comments
Please insert each new comment in a new row.
Section 2
8
Need to emphasise primary prevention - - 16 seems a late cutoff
point
General
Research that reports on drug use amongst young gay men
consistently reports significantly higher levels of illicit drug use
than comparable non-gay groups. Findings from “ Risk and
reflexion: findings from the United Kingdom Gay Men’s Sex
Survey 2004. Sigma Research, 2005 (ISBN 1 872956 81 5)”
report that over 65% of the national sample of men under 20
had used recreational drugs in the preceding twelve months.
Response
Please respond to each comment
person’s full range of needs into account.
Thank you for your comment. The guidance
focuses on vulnerable and disadvantaged people
up to the age of 25.
Thank you for your comment. The guidance
focuses on problematic substance misuse rather
than recreational use.
Recreational drug use questions were repeated in the 2005
Sigma Gay Men’s Sex Survey and full results are awaited.
Preliminary results again show elevated rates of illicit substance
misuse and higher rates of frequent use than comparable “less
vulnerable peers”.
General
Page
8/9
As such we would be grateful if you would consider including
young gay men in the guidance.
We feel it would be important to ensure that the definition of
vulnerable and disadvantaged groups reflects the current policy
as outlined in the Young People Public Service Agreement (YP
PSA) guidance document.
In our opinion, there is often a geographical dimension to both
“disadvantaged” and “vulnerable” due to material, environmental
or persistent health inequalities. This needs to be reflected in
the guidance and it may be appropriate to consider whether
young people living in Spearhead areas should be included
within this guidance.
Thank you for your comment. The guidance
covers children and young people aged under 25
regardless of where they live. This is the age
range covered by the public service agreement
(PSA) target for substance misuse shared by the
Home Office and DfES (see ‘Tackling drugs,
changing lives – keeping communities safe from
drugs’ Home Office 2004). The list of groups
defined as vulnerable and disadvantaged are
examples and not intended to be exhaustive.
There is a recognition that the list is already quite extensive
however you may wish to include LGBT young people and
Stakeholder response table – guidance consultation
p.8
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
General
Comments
Please insert each new comment in a new row.
those with learning disabilities.
In our view, there should be consideration of lesbian, gay,
bisexual and transgender young people. LGBT young people
have elevated rates of suicide, para suicide, STIs, mental ill
health and poor health behaviours.
Response
Please respond to each comment
Thank you for your comment. LGBT young
people are included with respect to the range of
specified risk factors.
If “vulnerability” is defined in terms of elevated rates of illicit
substance use young gay men are especially vulnerable.
Again, research that reports on drug use amongst young gay
men consistently reports significantly higher levels of illicit drug
use than comparable non-gay groups. Findings from “Risk and
reflexion: findings from the United Kingdom Gay Men’s Sex
Survey 2004.
Sigma Research, 2005 (ISBN 1 872956 81 5)” report that over
65% of the national sample of men under 20 had used
recreational drugs in the preceding twelve months.
Recreational drug use questions were repeated in the 2005
Sigma Gay Men’s Sex Survey and full results are due to be
published shortly. Preliminary results again show elevated rates,
amongst under 20 year old gay men, of illicit substance misuse
and higher rates of frequent use than comparable “less
vulnerable peers”. The Survey also confirmed that next two age
bands of respondents in both the 1999 and 2005 had even
higher rates of substance misuse- this may suggest
“normalisation” of substance misuse increases with age and
continue at significantly elevated rates in all age groups
amongst gay men.
General
Stakeholder response table – guidance consultation
Page 5
As such we feel that the guidance should reflect the specific
needs and vulnerability of these groups.
The guidance clearly states that it does not refer to clinical
interventions.
Thank you for your comment. The guidance has
been amended.
p.9
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Comments
Please insert each new comment in a new row.
However, clinicians would view interventions as described in this
guidance and the recommendations, such as motivational
interventions or interventions based on motivational interviewing
techniques and brief and behavioural interventions and family
work/therapy interventions as clinical as they would be part of
structure plan of care. We feel that its is important that this
guidance clearly differentiates between the formal structured
approaches delivered by professionals trained to deliver such
interventions and those which are less structured and can be
delivered by practitioners trained to undertake interventions
based on these techniques described in the guidance.
Response
Please respond to each comment
The guidance acknowledges that different levels
of competency will be required according to
practitioners’ roles in screening, assessment and
intervention for the reduction of substance
misuse.
General
Page 4
In our view, there is limited evidence available to provide
comprehensive guidance in all areas, if it would be possible be
useful for the guidance to suggest where the evidence is
lacking.
It is also important that the messaging that this delivers does not
by default suggest that the priorities for delivery are cannabis
and stimulants as these are the key drugs referred to regarding
interventions. It is important that the guidance does not focus
on being substance specific and therefore by default lead the
reader to not consider the substances not mentioned.
Thank you for your comment. The revised
guidance refers to gaps in the evidence
(appendix B) and provides recommendations for
research (section 5). The revised
recommendations refer to all substances.
General
overall
Where reference is made to education and training, the
document should refer to the work of the Sector Skills Council
and in particular Skills for Health. Could this perhaps be listed in
the reference or other resources section.
Reference is made to trained professionals, and it would be
useful to provide a working definition for what is meant by
trained professionals. Would the guidance be referring to
professionals who have been assessed to be competent to
deliver interventions described in the guidance or having just
attended training? We feel that this needs to be clearly
Thank you for your comment. This reference has
been forwarded to the NICE Implementation
Team.
Page 5
Recommendation 1
and 2
Stakeholder response table – guidance consultation
Thank you for your comment. The guidance
emphasises the need for practitioners to have the
appropriate competencies for screening,
assessment and treatment in line with NTA
guidance.
p.10
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Comments
Please insert each new comment in a new row.
defined/described.
Response
Please respond to each comment
Thank you for your comment. The guidance has
been amended.
The term practitioner may be more appropriate as this guidance
will be relevant to the third sector organisations.
General
Page 5
General
Page 5
General
Stakeholder response table – guidance consultation
In our opinion, the guidance needs to be clear when it is
referring to practitioners being trained and when practitioners
need to be competent in a specific skill; otherwise there will be
no consistency in the delivery of interventions across the
country.
In our view, we feel that the term subbstance misuse needs to
have a working definition to ensure that it includes alcohol,
volatile substance abuse (VSA) and licit and illicit drugs so that
the reader does not make an interpretation of the terminology to
exclude any the other areas mentioned.
It may be useful to give examples of Definition of
intervention,such as motivational interviewing, brief interventions
etc as the current definition refers to small scale programmes
then inder recommendation 2 describes a specific type of
intervention (motivational interviewing)
In our opinion the age ranges that this work intends to cover
needs to be made clear in all areas. When it states over 16 –
does it mean 16-18 or 16-24 for example – this needs to be
made very clear.
It is important to recognise that systems in place for under 18s
Thank you for your comment. The revised
guidance includes a definition of substance
misuse. Interventions that seek to prevent or
reduce substance misuse in the broadest sense
(that is, drugs, volatile substances, and tobacco
or alcohol) were included, provided that the
intervention study reported on outcomes relating
to drug and volatile substance misuse
specifically. Guidance on the prevention of
alcohol or tobacco use alone is not included.
Tobacco and alcohol are the focus of other NICE
public health programme and intervention
guidance – see www.nice.org.uk/guidance/PHP
and www.nice.org.uk/guidance/PHI
Thank you for your comment. Motivational
interviewing has now been defined.
Thank you for your comment. The guidance
focuses on vulnerable and disadvantaged people
up to the age of 25, however there are areas
where evidence relates to particular age groups.
The recommendations have been revised to
p.11
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Recommendations
1 and 2
Page 5
and 6
Recommendation 1
(and other
recommendations
as noted)
Page 5
Recommendation 2
Page 5
Recommendation 5
Stakeholder response table – guidance consultation
Page 7
and
Comments
Please insert each new comment in a new row.
are different than those for over 18s. This may need to be
flagged up.
As mentioned in previous general comment, important not to
exclude drug categories such as alcohol, and other drugs.
Response
Please respond to each comment
clarify this.
You may like to be aware that there are national occupational
standards (NOS) that exist ( see skills for health) – relevant for
recommendations 1, 2 3, 4, 5
The NOS that might be relevant to look at are:
•
Recognise indications of substance misuse and refer
individuals to specialists
•
Relate to families, parents and carers
•
Raise awareness about substances, their use and
effects
•
Facilitate group learning
•
Carry out brief interventions with alcohol users
•
Counsel groups of individuals about their substance
use using recognised theoretical models
Counsel individuals about their substance use using recognised
theoretical models
Would you please clarify the term ‘Motivational interviewing’ –
does this describe motivational interviewing techniques? If it is
referring to a wide range of practitioners delivering interventions,
for which they may not have attained full training and
supervision for actual motivational interviewing.
Thank you for your comment. This reference has
been forwarded to the NICE Implementation
Team.
Motivational interviewing (MI) is lengthy and expensive. If the
guidance recommends that a broad range of practitioners are
trained to deliver MI then this may be difficult for implementation
as it will have an impact on training budgets and access to
training within local areas.
In our opinion the first sentence could be interpreted as referral
on to another external service. This would not be appropriate to
Thank you for your comment. The definition of
substance misuse has been revised.
Thank you for your comment. The guidance has
been amended to include a definition of
motivational interviewing within the Glossary.
Thank you for your comment. The guidance has
been amended.
p.12
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
appendi
xA
Recommendation 6
Page 7
Recommendation 6
Page 7
Section 2
Page 8
Section 2
Page 8
Section 2
Page 9
Stakeholder response table – guidance consultation
Comments
Please insert each new comment in a new row.
refer 10-12 years olds to specialist substance misuse services.
The wording therefore may need to be changed to ensure clarity
on what is meant.
There will be a consent issue for referral of young people under
16 ot other services or in school additional services. We
therefore feel the guidance needs to ensure that this is flagged
up where appropriate.
Response
Please respond to each comment
The guidance ‘considerations’ section refers to
this point.
We welcome this recommendation. However we feel that a
common core dataset should be agreed to ensure important
demographic and at risk factors should be included e.g.
ethnicity, sexuality etc
Common Assessment Framework (CAF) data is collected at
local level only and not national level and we consider that it will
not provide a demographic profile of vulnerable or
disadvantages under 25 year olds as far as we are aware and
therefore the two issues in recommendation 6 are not linked.
We consider the collection of data at local level to produce a
demographic profile needs further consideration to ensure it is
feasible and that the right organisations are in a position to
undertake this.
Paragraph 4: Does the annual economic cost of class A drugs
refer to young people, we would be grateful for clarification.
Factors that influence substance misuse we would suggest that
peer group influences are added to the list
Thank you. The guidance has been amended to
include reference to profiling.
Within the ‘policy background’ section you may like to note that
there is a competent based NOS that relates to the third bullet
point.
•
Recognise indications of substance misuse and refer
individuals to specialists
Thank you for your comment. This information
has been passed to the NICE Implementation
Team.
All local organisations working with children and
young people have local policies and protocols
relating to confidentially and consent and these
are likely to influence implementation of
recommendations.
Thank you. The guidance has been amended to
include reference to profiling.
Thank you for your comment. The guidance has
been amended to clarify this.
Thank you for your comment. The guidance has
been amended.
p.13
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Section 5
Doncaster Drug
Strategy Unit
Section 5
Page 11
Section 9
Page 14
Section 9
Page 13
Appendix A
Page 16
onwards
General
Comments
Please insert each new comment in a new row.
In our opinion the research recommendations should reflect the
need for information on how to address the needs of young
LGBT people in relation to substance misuse.
We would recommend the use of term ‘young people’ with a
specific focus on vulnerable Young people, so that other groups
are not excluded as they have not been mentioned, such as
truants, homeless and those involved in the sex industry as
mentioned earlier in the document.
It is our view that it may be useful to list the categories being
referred to when describing vulnerable and disadvantaged
young people.
In our opinion that the glossary should contain the definition
used throughout the document of both “vulnerable” and
“disadvantaged”
Would you please consider defining substance misuse to
include alcohol, licit and illicit drugs and volatile substances
Would you also please consider defining selective
interventions?
In our view, many comments made above were also relate
directly to statements in appendix A needs to be replicated
(particularly in the recommendations section)
Purpose not clear & document confusing.
Layout confusing
Response
Please respond to each comment
Thank you for your comment. PHIAC prioritises
research that would be most useful in updating
the guidance in the future.
Thank you for your comment. The guidance has
been amended to include reference to groups of
vulnerable and disadvantaged children and
young people.
Thank you for your comment. Definitions relating
to vulnerable and disadvantaged children are
included in the revised guidance
Thank you for your comment. Please refer to our
previous response.
Thank you for your comment. Selective
interventions are defined in the glossary.
Thank you. The guidance has been amended.
Thank you for your comment. A quick reference
guide is published at the same time as the
guidance. Implementation tools will also be
provided.
Document lengthy and needs to be clear
Recommendation 1
5
Need to clarify recommendations & produce a summary without
additional waffle.
Why over the age of 16?
Thank you for your comments The guidance has
been amended.
What is meant by appropriately trained staff?
Stakeholder response table – guidance consultation
The guidance focuses on vulnerable and
p.14
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Comments
Please insert each new comment in a new row.
Which target group is identified?
Where is the definition of the target group?
Are trained professionals available and how does this link into
workforce plans?
Response
Please respond to each comment
disadvantaged people up to the age of 25,
however there are areas where evidence relates
to particular age groups. The revised
recommendation refers to young people from
secondary school age being offered motivational
interviewing. Unfortunately, there is a lack of
evidence supporting effectiveness of this
approach for younger children.
The guidance ‘considerations’ section refers to
this point.
General
Whole recommendation appears fragmented.
Thank you for your comment. The guidance has
been amended.
Recommendation 2
5
No clear definitions of level of intervention, needs to be some
screening & assessment.
Thank you for your comment. The guidance has
been amended.
Recommendation 3
6
Recommendation in a confusing order.
Thank you for your comment. The guidance has
been amended.
Is this back to defining target group
Recommendation 4
Recommendation 5
6
Should it identify who and route to engage with these young
people?
Who is the appropriately trained staff?
7
Why does it keep repeating the bit on vulnerable &
disadvantaged C & YP?
What do you mean by behavioural techniques?
Thank you for your comment. The guidance has
been amended.
Thank you for your comment. The guidance has
been amended.
Who will run the group sessions?
The allocation of resources is beyond the remit of
Stakeholder response table – guidance consultation
p.15
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Drug Education
Forum
Evidence
submitted
Section
Comments
Please insert each new comment in a new row.
What funding is available?
Response
Please respond to each comment
this guidance.
We generally welcome this guidance and believe that it could be
helpful to those in the drug education field in meeting the needs
of vulnerable children and young people. However we do have
a number of concerns.
Thank you for your comment.
Recommendation 1
Any screening of young people over the age of 16 should be
done in a non stigmatising way. One of the risk factors for
problematic drug use is being labelled as a drug user.
The guidance ‘considerations’ section refers to
this point.
Recommendation 1
We wonder about advocating a single technique – motivational
interviewing – when the evidence, we have seen, is mixed about
its effectiveness with this group.
Thank you for your comment.
General
Page
Number
At a recent conference on drugs researchers from the Institute
of Psychiatry discussed their findings. They said that there was
no difference in outcomes between students who received
motivational interviews and traditional drug education.
My notes from the relevant section of the conference can be
downloaded here and here:
Recommendation 2
We again reiterate our concerns that the guidance does not
allow for interventions beyond motivational interviewing.
Recommendation 3
We fully support the reiteration of the DfES guidance to schools
about developing strategies to identify and support young
people for whom drugs may be a problem.
Stakeholder response table – guidance consultation
The statement relating to motivational
interviewing is derived from the publications of
McCambridge and Strang (2004, 2005), who
found significant intervention effects at 3, but not
12 months post MI after a single session of
around 60 minutes. Please refer to the main
evidence review at www.nice.org.uk/PHI004 In
addition, the Public Health Interventions Advisory
Committee (PHIAC) considered a number of
factors when developing the recommendations,
including information provided by cooptees and
expert testimonies. Members of PHIAC and
external contributors are detailed in appendix C
to the guidance.
Thank you for your comment. Please refer to our
previous response.
Thank you. Your comment is noted.
p.16
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Recommendation 4
Comments
Please insert each new comment in a new row.
Any screening of young people under the age of 16 should be
done in a non-stigmatising fashion, reducing the likelihood of
exacerbating risk factors.
We believe that the role of identifying vulnerable young people
needs to be much wider than schools. Many young people who
may develop problems with drugs will be excluded from school.
We believe there is a role for non-formal education to play a part
in identifying and supporting vulnerable young people and would
expect the guidance to reflect that.
We are concerned that there is currently not the capacity to
support vulnerable young people’s families particularly those
that are hard to reach.
Response
Please respond to each comment
Thank you for your comments.
The guidance is not targeted exclusively to
schools. Practitioners in a range of settings have
a role in screening and assessment of vulnerable
children and young people at risk of substance
misuse or misusing substances. The
recommendations recognise the importance of
the development of a local strategy for the
reduction of substance misuse among the target
group.
The guidance ‘considerations’ section also refers
to a number of these points.
We believe that the guidance should explicitly make reference to
how it should be applied to situations where the children and
young people are in the care of the local authority. Who in that
case would be the “parent”?
Recommendation 5
Educari
general
Recommendation 1
Glossary
Stakeholder response table – guidance consultation
5 & 16
14
We do not believe that there is currently the capacity in the
children’s workforce to meet the aspirations of Recommendation
5.
Thank you for your comment. The allocation of
resources is beyond the remit of this guidance.
This guidance is welcome and generally well-presented. More
clarity is needed in the way some of the definitions are given
and the recommendations framed.
Professionals are told to ‘identify vulnerable or disadvantaged
young people aged over 16 who are misusing substances’.
Thank you for your comment. The guidance has
been amended.
But the definition of ‘substance misuse’ is problematic; for
example, because, since all use of illegal drugs can lead to legal
problems - it therefore appears to define all illegal drug use as
Thank you for your comment. The guidance has
been amended.
p.17
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Comments
Please insert each new comment in a new row.
‘substance misuse’. This recommendation would be the
opposite of a targeted intervention and would impose too great a
burden on services.
Response
Please respond to each comment
The guidance focuses on vulnerable and
disadvantaged people up to the age of 25,
however there are areas where evidence relates
to particular age groups.
Furthermore, for example, tobacco use is included in the
definition; smoking is usually dependent use and can lead to
health problems. Yet it is not clear if the recommendations apply
to this – are the same interventions really considered
appropriate for all types of substances?
Recommendation 1
5 & 16
recommendations
definition of
vulnerable and
disadvantaged
general
Stakeholder response table – guidance consultation
9
(It would also be good to give an upper age limit or define
‘young people’)
In the next sentence, professionals are told to ‘refer those
misusing cannabis and stimulants…’. It is not clear whether this
means all young people misusing these substances (which
would be ridiculous as it would overload systems) or (as might
be reasonable if definitions were clear) only those who are
vulnerable or disadvantaged.
the recommendations that mention ‘referral’ are irresponsible
unless there are matching recommendations about the way in
which services to which young people are referred are to be
expanded to meet the big increase in referrals
The bullet-pointed list casts the net too widely, especially with
reference to those ‘from marginalised and disadvantaged
communities’ and ‘those with other health and social problems’.
More precise definitions are needed; otherwise groups such as
‘children with asthma’ are going to be included.
The reference to BME communities needs more elaboration
since there are big difference in levels of use and problematic
use in different BME communities; some more specificity is
needed here.
I would welcome a recommendation about tracking those who
have received an intervention. Both through following them after
Thank you for your comment. The guidance has
been amended to include information about
target populations, who should take action and
what action they should take.
Thank you. Your comment is noted.
Thank you for your comments. The guidance has
been amended.
The revised guidance states that only members
of ‘some’ ethnic communities are at risk of
misusing substances.
Thank you for your comment. The
recommendations are based on the process of
p.18
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Eurad
Evidence
submitted
Section
Page
Number
Comments
Please insert each new comment in a new row.
the intervention and by trying to ensure that multiple referrals
are avoided or at least, different services are aware of these.
Foreward and “aim
of guidance”
1, 8
I am most annoyed by the absence of the word “prevention”. I
know “reduce substance misuse” can be interpreted in many
ways including prevention, but why not spell it out clearly and
unambiguously?
Recommendation 1
5
Recommendation 2
5,6
Stakeholder response table – guidance consultation
Identifying young people who are misusing drugs is a very tricky
problem. Unless they confess or are caught with drugs, it is very
difficult to see how they can be targeted. This is a most sensitive
area. Just because a child has a parent who uses drugs does
not mean to say that they will do so. I recently met a young 22
year-old man whose father was an addict. He is heading the
Swedish youth attack on drug use.
I again make a plea for the true dangers of cannabis to be
spelled out to users and non-users. The “appropriately trained
professionals” must know their facts and not rely on FRANK or
Drugscope to provide them as I said before. Instead of
statements like “there is no conclusive proof that cannabis or
skunk causes psychosis” we need quotes from Professor Robin
Murray who has done so much research on this matter like “Five
years ago 95% of psychiatrists would have said cannabis
doesn’t cause psychosis, I would estimate that now 95% would
say it does. It is a quiet epidemic” (8/10/06). Not to give a strong
message like this is a betrayal of our children, the very people
we as adults have a duty to protect.
I personally haven’t been involved in counselling or treating
young people for drug use but I would have thought that 1 or 2
sessions would be wholly inadequate. The aim must be to stop
them using rather than just cutting down.
Response
Please respond to each comment
needs assessment, agreed action plan and
review. The revised guidance includes a
‘considerations’ section which refers to close
working between agencies.
Thank you for your comment. The terminology
used reflects the original referral from the
Department of Health ‘An assessment of
community-based interventions to reduce
substance misuse among the most vulnerable
and disadvantaged young people’. ‘Reduce’ has
been interpreted to also mean prevent.
Thank you for your comment. Following the
referral from the Department of Health, the
guidance is primarily based on evidence of
effective interventions rather than evidence about
the psychoactive properties of substances.
Thank you for your comment. Evidence from the
UK (see McCambridge and Strang 2004)
suggests that a single 1 hour session of
motivational interviewing can be effective, at least
p.19
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Comments
Please insert each new comment in a new row.
Recommendation 3
6
Recommendation 4
6
Recommendation 5
7
Recommendation 6
7
My reservations again are how the schools are going to identify
pupils (See above). If children are truanting or have been
excluded then they will not be around to be assessed.
Will the “structured programme of support” be compulsory or
voluntary? Many “difficult” parents will not co-operate. Since
these are children who are not yet known to be using, the whole
emphasis must be on prevention, preferably from a scientific
perspective, not harm reduction which is appropriate only with
current users.
At least the number of sessions suggested for these younger
vulnerable children is more realistic. However no mention is
made of advising them of the dangers of drug use. It is laudable
to increase their communication, study and problem solving
skills and to set goals but unless they have been properly
informed about drugs, they may still be ignorant of the true cost
of a drug habit. Again the professionals need to be trained in
prevention techniques, not those of harm reduction.
I’m not sure that this ambitious aim of identifying those
vulnerable and disadvantaged under 25s is achievable. It is not
clear what is to be done with the information.
Policy Background
9
Stakeholder response table – guidance consultation
Official government policies such as “Tackling drugs:changing
lives….” (2004) aims to “reduce the use of class A drugs and the
frequent use of all illicit drugs by young people (under 25 years
old), in particular the most vulnerable, by 2008”. The aim should
be to stop class A drug use and stop ANY use of all illicit drugs.
The implication here is that infrequent use of all illicit drugs is
somehow OK. “Drugs: guidance for schools (DfES 2004a)
Says, “… - and respond to - the drug related needs of
Response
Please respond to each comment
in the short term, at reducing substance use in
vulnerable young people.
Thank you for your comment. Schools have a
role in identifying pupils who truant or are
excluded.
Thank you for your comment. The guidance has
been amended to clarify that vulnerable or
disadvantaged pupils should be offered a familybased programme of structured support.
Thank you for your comment. The revised
guidance includes a ‘considerations’ section
which refers to substance misuse interventions
as one component of a care plan that takes the
child or young person’s full range of needs into
account.
Thank you for your comment. The
recommendation has been amended to clarify
that a local profile of vulnerable and
disadvantaged young people will aid the
development of targeted local services through
further definition of the roles of local agencies
and practitioners.
Thank you for your comment.
Thank you. Your comment is noted.
p.20
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Home Office
Evidence
submitted
Section
Page
Number
Recommendations
for research 1, 4
and 5
Recommendations
for research 2
11,12
General
General
General
Stakeholder response table – guidance consultation
11
Comments
Please insert each new comment in a new row.
vulnerable pupils”, whatever that may mean! Statements need to
be unequivocal and say that drug use is not normal, illegal, and
will not be tolerated. At least the other 3 documents mentioned
use the word prevent/prevention, but their language also should
be tightened up.
Again this is encouraging as the word preventing is used, and
used first before “reducing and/or delaying the onset of
substance misuse…”
This is arguably the most important question. The people
designated to deliver these interventions to children must be
properly trained in prevention techniques and have a sound
knowledge of the science based facts surrounding drug damage
to themselves, others and the wider society. Harm reduction
should not be employed under any circumstances where
children are not using drugs. It gives them the “green light”.
The Home Office welcomes the draft guidance on community
based interventions amongst vulnerable and disadvantaged
young people
The guidance needs to address a clearly defined and
appropriate audience – HO would suggest Young people and
drugs commissioners.
There is clarity as to how this piece of guidance fits with the
existing policy context on young people and drugs jointly driven
through DH, HO and DfES. There is an existing structure of
delivery for drug services for young people and communicating
the evidence on what works must be mindful of this context.
Drug Action Teams/Community Safety Partnerships work jointly
with Children’s Services locally to reduce young people’s drug
use as set out in the Every Child Matters Change for Children
Young People and Drugs strategic guidance
(http://www.drugs.gov.uk/publication-search/youngpeople/every-child-matters.pdf ). Joint Commissioning Groups
in most areas, with representation from health, children’s
services, probation, police and other agencies agree on what
Response
Please respond to each comment
Thank you for your comment.
Thank you for your comment. Appropriate training
is now referred to in the ‘considerations’ section.
Thank you.
Thank you for your comment. The guidance has
been amended.
Thank you for your comment. The guidance has
been amended.
p.21
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
General
General
General
Recommendation 1
Stakeholder response table – guidance consultation
Page
Number
Comments
Please insert each new comment in a new row.
provision they will make available to address need across a
range of universal, targeted and specialist interventions.
The guidance states that ‘if an intervention has been omitted
from the recommendations this does not mean it should be
discontinued’ this is an absolutely crucial point given the policy
framework on young people and drugs and the paucity of
evidence from good quality evaluations.
It would be helpful to present the evidence available on
prevalence levels amongst vulnerable groups of young people.
Although there is currently a fairly narrow evidence base on
interventions that work with vulnerable groups, evidence is
available on particular vulnerable groups who are more likely to
take drugs. The government’s young people and drugs
programme draws on this evidence base and seeks to ensure
that local areas are targeting support to these vulnerable young
people who include truants, excludes, looked after children,
young offenders and children of drug misusing parents.
Central Government direct spending on young people and drugs
services is pooled into the Young People’s Substance Misuse
Partnership Grant (YPSMPG) which totals £64 million for
England in 2006/07. The expectation is for local areas to use
this ring-fenced fund in addition to mainstream funding to
reduce/prevent drug use and improve outcomes for young
people.
Recommendation 1 contains two parts: assessment and referral
for motivational interviewing. The suggestion that professionals
in the NHS, local authorities, education, social care, the
voluntary sector and the criminal justice system should identify
young people misusing substances fits well with Home Office
and DfES guidance that all vulnerable children and young
people in key risk groups for drug misuse are assessed at an
early stage as part of a wider needs assessment. This is in
alignment with the Every Child Matters Change for Children
agenda which has sought to address the needs of the child as a
Response
Please respond to each comment
Thank you. Your comment is noted.
Thank you for your comment. The overall
prevalence is defined and the revised
recommendations refer to the need to develop
local profiles of vulnerable populations.
Thank you for your comment. The revised
recommendations cover the importance of the
development of a local strategy within the context
of joint planning systems and commissioning.
Thank you for your comment. The revised
recommendations now comprise two distinct
recommendations in this area:
- the identification and referral to suitable services
of all vulnerable/disadvantaged young people (of
any age) who are (or who are at risk of) misusing
substances.
- offering motivational interviewing to secondary
p.22
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Comments
Please insert each new comment in a new row.
whole rather than individual issues in isolation.
Initial identification of drug use or risk of drug use should not be
regarded as an issue isolated from general assessments. Care
Matters – the reform Green Paper for looked after children –
proposes for example that drug screening be included for all
looked after children within regular health assessments. The
Common Assessment Framework – being introduced
throughout England by 2008 – is a tool for all professionals
working with children in assessment of need which again
grounds the recommendation in current policy context which
local practitioners and services will be engaged with.
Response
Please respond to each comment
school-aged children. Unfortunately, there is a
lack of evidence supporting effectiveness of this
approach for younger children. As evidence
supports the use of motivational interviewing for
the reduction of use of other substances (including
alcohol and tobacco), it is now recommended for
young people who misuse any substance.
The guidance ‘considerations’ section refers to
this point.
However, the age limit that is suggested here – aged over 16 –
appears to relate to the available evaluation evidence around
the effectiveness of motivational interviewing and does little in
terms of encouraging professionals working with children to
identify issues with drug use at an early stage. The
recommendation would be improved by rewording and
separating out the process of identification of young people’s
drug use from outlining what interventions may be most
appropriate from the evidence.
Recommendation 2
The implications of the requirement for professionals trained in
motivational interviewing to deliver the proposed interventions
must be acknowledged in order to give this guidance credibility
locally– understanding the resource implications for local
services involves advising who would be best placed to deliver
the motivational interviewing; what training this involves (as I
understand it there is no single recognised training or
accreditation for Motivational Interviewing) and how this time
would be resourced.
Thank you for your comment. The revised
guidance states that practitioners should have the
appropriate competencies with respect to
screening, assessment and intervention,
according to their role.
What about supervision of those delivering motivational
Stakeholder response table – guidance consultation
p.23
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Recommendation 3
and 4
Recommendation 6
General
Stakeholder response table – guidance consultation
Page
Number
Comments
Please insert each new comment in a new row.
interviewing? Who will provide this?
Many practitioners in young people’s substance misuse services
are already trained in motivational interviewing – but it is
generally externally provided and expensive – so many staff are
still awaiting such training and services cannot always afford to
support the training for all staff. The resource implications and
issues of accreditation would need to be addressed
It is unclear who in schools the guidance intends to take forward
identification of young people using substances. Again the
Common Assessment Framework is the routine tool that many
practitioners will be using with children deemed at risk to identify
their needs. Substance misuse is flagged within this tool –
guidance would be best placed to direct schools within the
policy context of the Every Child Matters Framework.
As in recommendation 1, there seems to be two issues rolled up
into these recommendations – the identification of at-risk
individuals and the types of interventions/services that they
might require.
It would be helpful if some guidance could be given as to which
young people would benefit from the different interventions
recommended.
The CAF will not be collecting data for all children and young
people – it is an assessment tool for children in need. Some
local areas may be using information from CAF assessments to
build a profile of the local population of vulnerable groups. Drug
Action Teams and Children‘s Services set targets according to
local need and
The most recent publication on young people and drugs is Every
Child Matters Change for Children: Young People and Drugs
this provides the policy background on bringing the work of
children’s services closer to drugs services. The Every Child
Matters Green Paper and ‘ECM: Change for Children’
publications are distinct publications.
Response
Please respond to each comment
Thank you for your comment. The guidance has
been amended.
The revised guidance refers to use of existing
screening and assessment tools such as the
Common Assessment Framework.
Thank you for your comment. The revised
guidance refers to developing local profiles of
needs by local agencies, in conjunction with the
regional public health observatory.
Thank you for your comment. Key documents
are referenced in the ‘background’ and
‘considerations’ sections.
p.24
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
General
Recommendation 5
General
Institute of Alchol
Studies
Recommendations
1-7
Comments
Please insert each new comment in a new row.
The policy background should also include Youth Matters Green
Paper which was published last year and includes proposals to
reform services for vulnerable young people – in ensuring the
guidance is credible the Integrated Targeted Youth Support
Service – for which guidance is due to be issued in January 07
would I anticipate be a key audience.
Do services providing this sort of intervention exist? It might be
better to phrase it in terms of “commissioners should seek to
commission” services of this type.
Consideration needs to be given to which groups would be best
placed to identify young people and families to such services.
It is important to make it clear that interventions appropriate to
the most problematic (opiate and crack) users are not
considered in this guidance as they require specialist treatment
services.
We regard this as a balanced approach, which we support in the
main. However, sadly, the efficacy of any of these approaches
is likely to be fairly low.
To our knowledge, there is no evidence available on 12 step
self-help groups for youth, but they do exist, and seem to do
well, and have the advantage of being cost-free. We cannot,
therefore, see the reason for not mentioning them at all.
Recommendations
Stakeholder response table – guidance consultation
1-7
It seems to us that, while the ideas contained in the draft
guidance and the intentions behind them are admirable, the
problem is that of translating these ideas into actual practice. If
the recommendations are to be more than worthy aspirations,
people such as teachers have to take a range of actions, which,
by any normal standard, are actually rather difficult and
demanding. The work of Cartwright et al from 1978*
demonstrated how social workers were reluctant to identify and
intervene in alcohol problems in their clients unless and until
Response
Please respond to each comment
Thank you for your comment. The policy section
has been amended accordingly.
Thank you for your comment. The guidance
‘considerations’ section covers this point.
Thank you for your comment. Clear definitions
are now included, however, the guidance does
not cover those dependent on drugs.
Thank you for your comment. PHIAC
acknowledges the limitations of the evidence in
this area – see the ‘considerations’ section.
PHIAC was only able to consider the evidence
available.
Thank you for your comment. The
recommendations provide practical standards.
p.25
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
International
Centre for Drug
Policy (St George’s
University of
London)
In-volve
Evidence
submitted
Section
Page
Number
Recommendation 6
7
Public health need
and practice
Vulnerable and
disadvantaged
young people
Glossary
8
General
Stakeholder response table – guidance consultation
8
14
Comments
Please insert each new comment in a new row.
they felt themselves to be competent and to have adequate
support in carrying out that role. If this applies to social workers
and other members of the helping professions, it is likely to
apply even more strongly to, for example, teachers, whose
primary purpose is not therapeutic. Without adequate
education, training and role support, teachers and others are
unlikely, in our view, to take the action that is needed for the
recommendations to become a reality. The question thus
becomes what kind of education, training and support is in
existence or could be made available, and we are uncertain of
what the position is in this regard. The draft lays considerable
weight on BESTS, but, to our knowledge, as these have never
been evaluated, there is no evidence to say whether or not they
perform the necessary functions. In any case, we are informed
by the Department for Education that BESTS are being
discontinued.
* Cartwright, A., Shaw, S., Spratley, T. & Harwin, J. (1978)
Responding to Drinking Problems. London: Croom Helm
Line 6 change ‘would’ to ‘should’, and also where it is repeated
on page 18 (Appendix A)
Para 4 – these figures can probably be updated from recent
Home Office publications (November 2006)
2nd bullet point – insert “and sibling” after ”parental”
4th bullet point – insert “comorbidity” into list of examples
Widen definition of “drugs” to include references to prescribed
drugs and Over The Counter drugs – these are frequently
abused and dependence on them acquired
Vulnerable and disadvantaged young people (yp) are certainly
at increased risk of drug/alcohol use and key to successful
intervention is engagement. There is good evidence that
services that are yp friendly, as defined by young people,
overcome this initial barrier. Services that are accessible in time
Response
Please respond to each comment
Thank you for your comment. The guidance has
been amended.
Thank you for your comment.
Thank you for your comment.
The revised guidance includes clear definitions.
Thank you. Your comment is noted.
p.26
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
General
General
General
General
Stakeholder response table – guidance consultation
Page
Number
Comments
Please insert each new comment in a new row.
and space, are yp accepting, have activities that engage interest
will see yp. Whilst at one level these appear truism there are
real difference between services on the ground that deliver to
the excluded and those that do not. Some of this is very basic
such as providing a place where those basic encounters over
coffee or food maybe with a video that provokes discussion and
the start of motivational work.
Much of the evidence was inevitably taken from formal studies
that are limited to very specific interventions and therefore
limited in terms of the application to the very groups looked at.
Time limited/formal entry interventions do have role but should
be fronted by outreach and informal access that enables the
excluded to feel more included and are of not only in the
community.
The emphasis on motivational interviewing, relaxation and
coping mechanism was good and a recognition that some the
less directional counselling will probably not work with these yp.
It was a pity that problem solving was mention rather than a
more solution focused approach that builds on what the yp
already have and brings self worth to those who do not have
much.
We have found that fundamental to working with these yp is
identity. If work on identity and difference is not attempted these
key basics to how yp operate in the world as excluded, drug
users, gang member, academic failure etc cannot be challenged
or changed. This also links with the community in which the yp
live, their social, religious/spiritual place and ancestral heritage –
all key to both current identity and potential positive change.
The studies/evidence seemed to be isolated from where yp
actually exist.
Our work has shown that these yp are assisted as much if not
more by a coaching process rather than a counselling process
although the studies behavioural evidence does, to a degree,
Response
Please respond to each comment
Thank you. Your comment is noted.
Thank you. Your comment is noted.
Thank you for your comment
Thank you. Your comment is noted.
p.27
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
General
General
Mentor UK
General
Evidence 1 - Men
UK
Mersey Care NHS
Trust
General
Section 1
Stakeholder response table – guidance consultation
4
Comments
Please insert each new comment in a new row.
support some of this.
We would advocate that interventions should also include the
opportunity to use the process as a learning and alternative
educational process. That is engagement with services includes
an educational aspect so that, for example, yp with cannabis
use can join a programme that educates them about themselves
but also provides accredited training to start the integration
process. Ideally this should be backed by volunteer and even
employment opportunities through the service and beyond.
Suggest that evidence is gathered from the services in the UK
who are already working in a value for money services that are
engaging with these yp in positive way. There needs to be an
engagement between those delivering services and those
carrying out research.
• The fact that many of the recommended interventions are
either school based or involve referral from the young
person’s school, will mean that young people who are not
in school (as is the case with many vulnerable young
people) will be excluded from such interventions.
• There is an issue with the guidance omitting young people
who are being cared for by someone other than a parent
(i.e. looked after children), as these young people may be
some of the most vulnerable and should be taken into
account in recommendations such as these.
This guidance is in an area with well-developed joined-up
government policies. Because these policies are so wide
ranging, there is inevitably a more diffuse evidence-base for
services on the ground. There needs to be clarity therefore
about the factors leading to successful outcomes when
implementing the recommendations made here.
Lack of evidence – this is true because it is difficult to research
the factors leading to implementation of public health
approaches in a “pure” way. However, if we consider consensus
Response
Please respond to each comment
Thank you. Your comment is noted.
Thank you. Your comment is noted.
Thank you for your comment. The
recommendations now refer to practitioners
working with children and young people across a
range of settings; although certain vulnerable
groups such as those excluded from school
remain hard to reach.
Thank you for your comment. The guidance has
been amended.
Thank you. Your comment is noted.
Thank you. Your comment is noted.
p.28
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Section 1
5
Section 1:
Recommendations
5-7
Section 1:
Recommendations
5-7
Section 2
8
Stakeholder response table – guidance consultation
Comments
Please insert each new comment in a new row.
findings (relevant to public health interventions) the factors that
stand out are: clarity of treatment processes, training and
supervision of staff, mode of outreach and delivery of
intervention, and community treatment standards/monitoring.
It is for the reasons given above, that some interventions
wrongly applied have the contrary effect of encouraging drug
use. The appropriate mode of delivery of interventions should
therefore be more fully identified in this guidance. Also some
community interventions need to be specifically targeted at
certain groups of drug users as they will be ineffective or contraindicated with others. Research into Dialectical Behaviour
Therapy is very helpful in demonstrating these complex
interactions.
The intended audience may need help to appreciate how
important the interactions of different factors are, e.g.
motivational interviewing is unlikely to be effective unless it is
delivered by staff trained and/or supervised through a
recognised course with their training regularly updated. Also
attitudes of staff towards the intervention and the client group
will need to be monitored and actively supported or influenced
as appropriate if the approach is to remain effective.
Public health interventions lacking a strong evidence base and
intended for use in a wide range of community settings are
particularly open to differing local interpretations which may
water down or even undermine their effectiveness.
Arrangements for national monitoring are well advanced. It
would be very beneficial if NICE could consider issuing
supplementary guidance for monitoring and reviewing the local
impact of implementing evidence-based community
interventions in such a key area.
Definition of vulnerability: this is an important and accepted
definition. However it is also important to point out that drug
misuse is identified in other less disadvantaged groups of young
people who are in danger of forming lifestyle habits that may be
Response
Please respond to each comment
Thank you for your comment. The
recommendations now define delivery mode and
target groups.
The ‘considerations’ section in the revised
guidance now includes this point.
The ‘considerations’ section in the revised
guidance now includes this point.
Thank you for your comment. The NICE
Implementation Team is developing support tools
to accompany the guidance, including audit and
costing tools and implementation advice.
Thank you. Your comment is noted.
p.29
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
General
Section 5: Research
11-12
Michael Taylor
Comments
Please insert each new comment in a new row.
less visible but can have devastating impact on private life, such
as in the parenting of children where emotional and
psychological abuse is linked to adult personality development.
I would be pleased on behalf of the organisation I represent to
give further evidence of the above considerations for the
psychological welfare of young people as a result of their
parenting experiences, e.g. when influenced by parental drug
misuse.
There are many aspects of the comments above that we believe
should be developed into recommendations for further research.
In addition, research into the early signs and precursors to drug
misuse in all families should be funded. The model of interest to
be explored would be early identification rather than early
intervention with a pathway between the two approaches also to
be identified with the support of a research programme.
I offer a couple of observations.
Response
Please respond to each comment
Thank you. Your offer is noted.
Thank you for your comment. PHIAC has
prioritised the research requirements from a long
list.
Thank you. Your comment is noted.
In reading the draft document I was surprised that in discussing
vulnerability that no mention was made of single parent families,
nor of tobacco smoking. These two are factors easily observable
by primary care teams or at least GP teams.
National Addiction
Centre
General
1
Stakeholder response table – guidance consultation
5
I imagine that there is not the evidence linking such
vulnerabilities to future drug use.
PHIAC are to be congratulated on having done a difficult job
well. The lack of good quality evidence is a major handicap to
the development of guidance and what has been achieved
impressively narrows the gap between what is securely known
and can be inferred and what is needed and can be useful now.
It would have been additionally helpful to have the appendix on
gaps in the evidence to comment on this guidance.
The concern that some interventions may encourage drug use
has some foundation in evidence and is worthy of careful
consideration. This possibility is known to apply specifically to
Thank you. Your comment is noted.
Thank you for your comment. This possibility is
clearly highlighted in the guidance; and the
importance of appropriate implementation is
p.30
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
1
5
1
Stakeholder response table – guidance consultation
5
Comments
Please insert each new comment in a new row.
group rather than to individualised interventions. In particular,
evidence from a number of RCTs and at least one review
identify harmful outcomes in classroom settings where
interventions have targeted heterogeneous groups with different
prevention needs. In these studies primary prevention
interventions have led to further involvement in drug use among
children and young people who were pre-existing users, beyond
that seen in control conditions. There is no evidence to
substantiate concerns that individualised interventions have
similar effects. These issues were considered by the ACMD in
the recent ‘Pathways to Problems’ report.
Recommendation 1 proposes that generic professionals identify
and refer vulnerable or disadvantaged young people, as already
occurs. There is no indication in Recommendation 2 of the
settings in which professionals appropriately trained in
motivational interviewing may be found. The detailed
intervention content of Recommendation 2 is entirely
appropriate. It is likely to be problematic for specialist drug
services only to deliver motivational interviewing interventions.
Attendance at new services following referral may be an
unnecessary barrier to help for these young people. Generic
professionals such as youth workers, Connexions Advisors,
YOT workers and social workers already in contact with this
population are well-placed to develop drug prevention practice
and to have a more substantial role than referral. Training is also
likely to have wider individual practice and service development
benefits beyond contributing to drug prevention.
A small point but worthy of note: Recommendation 1 specifies
“motivational interviews” whereas Recommendation 2 specifies
“motivational interviewing”. There is a growing industry of
individual interventions claiming to be “motivational” in some
sense or other. The latter term makes a more specific reference
to the existing evidence-base and has increasingly welldeveloped fidelity and quality standards and should be preferred
Response
Please respond to each comment
stressed – see the ‘considerations’ section.
Thank you for your comment. The guidance has
been amended.
The ‘considerations’ section in the revised
guidance now includes this point.
Thank you for your comment. ‘Motivational
interviewing’ for the purposes of this guidance is
defined in the ‘glossary’.
p.31
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
1
5
1
6
4
Stakeholder response table – guidance consultation
11
Comments
Please insert each new comment in a new row.
for these reasons.
The specification of cannabis and stimulants seems a little odd
in view of evidence of effects on other drugs in the cited studies.
Why not refer to drugs in general, perhaps identifying the
possible need for further interventions among those with more
complex problems?
Perhaps the referral of individual adolescents and their families
identified in Recommendation 4 should be qualified in some way
to exclude compulsion and encourage a more person-centred
approach. No criteria are identified and referral of ‘problem
pupils’ and ‘problem families’ may seem an attractive way of
dealing with difficult situations. The effectiveness of subsequent
intervention seems likely to be contingent upon the referral
process itself being sensitively handled. As with previous
comments, it is not clear who should deliver these interventions,
and it may be that the growing levels of non-curriculum staff
within schools are well-placed to deliver interventions to pupils
themselves if appropriately trained, whilst family interventions
will require separate provision.
The section on implementation proposes some tools to assist
the capacity of localised organisations to deliver on these
recommendations. There is reason to be concerned that what
has been proposed will be insufficient. The drug prevention
training needs of professionals in contact with these young
people may not yet be well understood. There are workforce
development issues that will benefit from national strategic
consideration. Specialist treatment and other existing provisions
do not currently address the specific prevention nature of the
needs of these young people. For example, current training
provisions for motivational interviewing in general are
unsatisfactory. Dedicated training programmes applying this
approach to vulnerable and disadvantaged young people in this
approach do not yet exist. A long term strategic perspective on
these issues appears essential in addition to guidance on what
Response
Please respond to each comment
Thank you for your comment. The guidance has
been amended.
Thank you for your comment. The guidance has
been amended to use the term ‘offered’.
The recommendations have been revised to be
specific about target populations, who should
take action and what action they should take.
The ‘considerations’ section in the revised
guidance now refers to this point.
Thank you for your comment. Training and
competences are considered within NICE
implementation advice.
p.32
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
5
11/12
5
11/12
5
11/12
5
11/12
Stakeholder response table – guidance consultation
Comments
Please insert each new comment in a new row.
can be done relatively straightforwardly.
Recommendations 1, 4 and 5 involve specific targeting of three
identified vulnerable groups. Whilst agreeing that more research
is needed in these populations, it is not clear how and why these
have been selected or that these groups have more acute
needs for research evidence than other groups identified
elsewhere in this guidance. There are virtually no existing trials
that have been undertaken in this country with any of the
vulnerable groups.
Whilst all vulnerable groups will have somewhat distinct needs,
it does not follow that they should be separately targeted, which
would be an erroneous interpretation of Recommendations 1, 4
and 5. The existence of additional risk known to be attached to
membership of multiple vulnerable groups is also relevant here
It is possible that programmes which target vulnerable and
disadvantaged young people more broadly can be more
effective and cost-effective within each vulnerable group than
more narrowly targeted approaches, as well as making an
additional contribution to the reduction of the overall burden of
drug-related harm. At an individual level, it may be important for
a young person to have the opportunity to talk to someone
about their drug use in exactly the same way that other
teenagers do. This is often a good basis for rapport building and
subsequent discussion. Narrower and broader targeting
approaches should thus be evaluated.
If intervention guidance is going to prominently involve referral in
the context of multi-agency collaborative working, as it does
presently, it will be important to incorporate dedicated evaluation
of the effectiveness of this component in future studies.
As well as identifying research questions, it may be important to
also consider making a recommendation on study design. In
other areas, calls that too much funding is directed towards trials
are often heard, and are understandable. In relation to
prevention in this area, the paucity of high quality evidence
Response
Please respond to each comment
Thank you for your comment. The specific groups
were identified from the evidence of effective
interventions.
Thank you for your comment. The
recommendations cover a wider range of
vulnerabilities that place children and young
people at risk. The recommendations are based
on the process of individual assessment of risk
and needs, with recommended interventions for
specific groups based on evidence of
effectiveness.
Thank you. Your comment is noted.
Thank you. Your comment is noted.
p.33
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
5
11
5
11
General
National Drug
Evidence Centre
2
Stakeholder response table – guidance consultation
8
Comments
Please insert each new comment in a new row.
identified in the review to originate from this country was
understood to be a major problem. A specific recommendation
that RCTs will usually be the most appropriate study designs to
answer the identified questions may be helpful.
Recommendation 2 does not, in my own view, represent an
evidence-based need for further research. See earlier comment.
Recommendation 3 calls for specific evaluation of family-based
interventions. In light of the prominence given in the intervention
guidance, it would seem appropriate to also give motivational
interviewing similar status. The evidence-base for both is
strikingly under-developed, and whilst the need for family-based
interventions has already been recognised within the HTA
process, a similar need for research on the contribution that
motivational interviewing may make to drug prevention has not.
The guidance should perhaps recognise that the “5% of less
vulnerable” young people that use illicit drugs represents a
larger number of young drug users than does the “24% of
vulnerable young people” that are illicit drug users. That is, that
most young drug users are not from disadvantaged groups.
Disadvantaged young users may be at higher risk of going on to
develop problematic use, so there is a public health justification
for prioritising their needs, but this isn’t made explicit in the
recommendations.
There are more up to date estimates of economic & social costs,
see Gordon et al, in Singleton et al, at:
http://www.homeoffice.gov.uk/rds/pdfs06/rdsolr1606.pdf
Response
Please respond to each comment
Thank you for your comment. The concern about
unintended adverse effects of interventions
appear to be specific to group rather than
individual interventions, delivered in settings such
as classrooms.
This concern is highlighted in the guidance and
evaluation of any adverse effects of interventions
is also included in the research
recommendations.
The guidance has been amended.
Thank you. Your comment is noted.
Thank you. The guidance has been amended.
p.34
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
2
National Treatment
Agency
General
General
Page
Number
8
Comments
Please insert each new comment in a new row.
“Illicit drugs use in the UK is most prevalent among young
people aged between 16 and 24 years.” – this is not the case for
all drug types; e.g. opiate use is more common among older age
groups.
Policy Context.
The young peoples substance misuse policy context is not
highlighted. Every Child Matters: Young People and Drugs
(DFES 2005) underpins the young peoples Drug Strategy.
Hidden Harm ACMD 2003 provides details about parental drug
use referred to in Recommendation 5.
There are two different substance misuse treatment systems
one for under 18’s ( defined in Essential Elements NTA 2005)
and an adult system.( Models of Care NTA 2006). Each system
has a slightly different definition of treatment and funded in
different ways. From an implementation perspective it may be
useful to identify possible funding streams for both adult and
young people’s systems.
Definitions:
The document defines substance misuse as ‘intoxication
…regular excessive consumption and/or dependence ... leading
to social, psychological physical and legal problems’ (page 5).
This broad definition fits with abuse/dependence in DSM IV.
However, the following sub-paragraph notes that clinical
interventions for individuals who are ‘dependent’ on substances
are not considered. The authors have included dependence in
the definition of misuse. It is unclear what group are included or
excluded. The document appears to single out cannabis and
stimulants, other combinations that are common in clinical
practice are not mentioned.
General
Vulnerable Groups:
The introduction highlights that certain vulnerable groups have
been admitted. Latest Home Office statistics identify that not all
vulnerable groups are homogeneous and that even in the most
Stakeholder response table – guidance consultation
Response
Please respond to each comment
Thank you. Your comment is noted.
Thank you for your comment. The guidance
refers to these documents. The revised
recommendations emphasise the importance of
developing a joint strategy – which would be the
vehicle for assessing and accessing the
resources available.
Thank you for your comment. The guidance has
been amended.
Thank you for your comment. The guidance
states that children and young people at risk have
multiple vulnerabilities and needs. The
recommendations are based on the process of
needs assessment, agreed action plan and
p.35
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
General
Page
Number
Comments
Please insert each new comment in a new row.
vulnerable of groups for substance use, misuse is not a majority
activity. We advise that when discussing risk the paper should
reflect protective and resilient factors. Also by identifying certain
groups there may be a tendency to identify distinct group
characteristics or group needs. This conflicts with the reality of
vulnerable young people being in many different groups
sometimes with high substance misuse harm and sometimes
with high non substance misuse need/harm. The NTA would see
that for under 18’s those in the former category would require
structured specialist substance misuse treatment the latter being
more likely to require interventions described in the guidance.
Competency for both assessors and practitioners:
This is mentioned but not defined. Motivational interviewing is a
tool rather than a therapeutic approach. Many people working
with under 18’s outside the specialist young people’s drug
system or CAMHS are unlikely to be competent practitioners in
regards to motivational interviewing. Even within the young
person’s substance misuse treatment system practitioners are
likely to have attended a two day courses but does this make
them competent?
Practitioners may be a more useful term than professionals
given many youth support services and treatment services are
based in the voluntary sector.
Competency seems very relevant when even the guidance “
expressed concern that some interventions may encourage drug
use if not delivered appropriately by trained professionals”.
Response
Please respond to each comment
review.
Thank you for your comment. The guidance
states that practitioners from a range of settings
should have the appropriate range and level of
competences with respect to their role in the
prevention of substance misuse (ie screening,
assessment and treatment)
NICE implementation tools are being developed
and will provide further advice on competencies
and training.
Individuals conducting interventions in the cited studies included
qualified social workers or psychologists, professionals with
broad training in many aspects of child development,
psychopathology, family functioning and other matters. Many
substance use workers to whom these young people will be
referred in UK systems will not be trained in this way. In light of
the potentially iatrogenic effects of interventions if delivered by
Stakeholder response table – guidance consultation
p.36
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
General
Stakeholder response table – guidance consultation
Page
Number
Comments
Please insert each new comment in a new row.
untrained people and highlighted by the document, this is an
important issue. Substance use services should be encouraged
to employ ‘appropriately trained professionals’ but specialist
substance misuse services that include NHS and other
professionals should be responsible for those young people who
are both vulnerable and engaged in harmful substance use.
Response
Please respond to each comment
Resources
Vulnerable children and young people represent a considerable
minority. For instance, at least 10% of the adolescents surveyed
by the National Statistics (2004) survey were judged to have a
mental disorder. If all or even half of these young people, who
represent only a proportion of the vulnerable groups at
increased risk listed by the document, were referred to an
intervention, it would immediately overwhelm all existing
targeted services in the UK.
Thank you for your comment. The guidance
highlights that vulnerable children and young
people have significant needs. The
recommendations relating to referral to services
focus on those individuals assessed to be at high
risk.
Relationships with other services
For the sake of rational use of resources, interventions should
be delivered through existing services, (schools, child and
adolescent mental health or substance use services, or a
combination) however enhanced. This is crucial to avoid
duplication or development of parallel services.
The guidance states that the recommendations
should be implemented within the existing
frameworks for children and young people and
drug prevention.
Substance misuse in context:
The listed interventions are aimed at substance misuse.
However, this should be seen in context. Many of these young
people will have multiple needs and for some, substance misuse
may be only a relatively minor aspect, or marker, of other
difficulties. It is crucial that any service (such as an augmented
CAMHS) to which they are referred has the staff competence to
evaluate the full range of difficulties they suffer so that
comprehensive interventions can be put in place. Without an
The guidance acknowledges that these groups
have multiple vulnerabilities and a range of
needs.
p.37
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Recommendation 1
5
Comments
Please insert each new comment in a new row.
agreed distinction between use and misuse of cannabis it is
difficult to see how such interventions can have successful
outcomes.
The first part of this recommendation is referred to in the Home
Office document Identifying Substance misuse need HO 2003.
The evidence base is about cannabis and stimulants but the
action should refer to all substances. Are these professionals “
targeted youth support workers”?. Whoever they are they should
not be specialist drug workers but they should be supported and
possibly supervised by specialist drug workers.
This recommendation notes that individuals over 16 should if
appropriate be referred for one or more motivational interviews.
It is unclear what is meant in the guidelines ‘if appropriate’. If
judgment is required, those who are screening need to have
appropriate experience to judge whom to screen and refer.
Perhaps these should be professionals such as teachers,
general practitioners or school nurses.
This recommendation also should refer to the Common
Assessment Framework where need among vulnerable young
people is most likely to be identified. From this perspective
need will be identified before the intervention which would be
the logical sequence.
This recommendation also assumes competency in assessing
as well providing motivational interviewing. Does every young
person using cannabis or stimulants require one or more
sessions of MI?
Response
Please respond to each comment
Thank you for your comment. The guidance
states that practitioners from a range of settings
should have the appropriate range and level of
competences with respect to their role in the
prevention of substance misuse (screening,
assessment and treatment).
NICE implementation tools are being developed
and will provide further advice on competencies
and training.
The guidance refers to use of existing screening
and assessment tools, such as the Common
Assessment Framework.
Practitioners should have the appropriate
competencies relating to their role in prevention
of substance misuse.
The intensity of the intervention such as number
of sessions will be dependent on level of need
and risk.
The guidance is based on a tailored approach of
individual risk assessment and referral to the
appropriate services.
This contrasts with the latest draft of the NTA guidance on
comprehensive substance misuse assessments which suggests
identifying need and then the type of intervention to meet this
need. This is consistent with the Every Child matters “tailored
approach” to need.
Stakeholder response table – guidance consultation
p.38
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Recommendation 2
Page
Number
5
Comments
Please insert each new comment in a new row.
The term motivational interviewing has many meanings, some
see it as a style of interviewing though it can be an intervention
if it includes feedback and identification of consequences of
stopping or continuing substance misuse. It is probably best
used in a stepped care approach so that individuals who are
identified as at risk can be followed up with more structured
treatment.
Response
Please respond to each comment
Thank you for your comment.
Motivational interviewing has now been defined in
the ‘glossary’.
The guidance has been amended. The Dennis et
al. 2004 study is no longer used to support this
recommendation.
The report cites the research of McCambridge and Strang and
the Dennis et al (2004) study to justify the use of motivational
interviewing. However, these studies are quite different and
used different treatments. The McCambridge study was not for
vulnerable young people but college students and the MI was
done by Jim McCambridge himself. It was more of a brief
intervention with a motivational component However, the Dennis
study was for those with cannabis use, and many had other
complex needs, often ‘vulnerable’ in the terms of the draft
document. It utilised motivational enhancement therapy (MET)
rather than MI. This structured treatment was manual-based,
and highlighting the competence issue, delivered by trained
therapists often at doctorate level. It may be that the stepped
care concept should also apply here: if young people receive a
brief intervention and not change their behaviour during follow
up, referral for specialist treatment will be required. Otherwise,
some vulnerable young people will receive MI by untrained staff
thinking that is all they require, perhaps in effect diverting them
away from specialist resources.
There is no discussion of referral for those under 16 who are
actually misusing or using drugs. In addition, there is no
indication noted about training requirements. The MET was a
structured manual delivered therapy with trained professionals,
significantly different to the situation in England where many
workers are not professionally trained and may have
Stakeholder response table – guidance consultation
p.39
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Comments
Please insert each new comment in a new row.
experienced only brief training. The recommendation should
note what appropriate background and training is appropriate;
the common 1-2 day training which is the norm does not change
practice.
Response
Please respond to each comment
In line with the HAS review , The Substance of young need
(HAS 2001) and Essential Elements (NTA 2005) this
recommendation seems to suggest interventions by practitioners
based in young people specialist treatment services( ECM,YP
and Drugs 2005) or tier 3 / 4 services (HAS). However these
services are described they offer a more comprehensive range
of interventions than simply MI. Again this range is consistent
with the concept of numerous substance related needs rather
than a single focus on motivation.
Recommendation 3
6
Recommendation 4
6
Stakeholder response table – guidance consultation
Motivation however is extremely important. Most interventions
within the young person’s treatment system are aimed at
assisting the young person to consider their options from an
informed perspective and then set goals for reducing or stopping
their use of substances. Unless the young person agrees that
their drug use is problematic MI programmes are likely to be
unrealistic and wasteful of scarce resources that could be used
elsewhere.
The NTA fully support this recommendation but would like to see
the policy context developed. E.g. identification should happen
through the CAF, possibly through Social Inclusion Teams as
part of the Extended Schools Strategy. CAF’s should be
followed by CAF Action Plans and reviews. NTA perspective is
that this should be contained within the school system
supported by Young Peoples treatment services. The
importance of this is that BESTs and other services are not
universal and provision throughout England is patchy.
This recommendation has resource implications. Who will
provide these family based interventions. Research, if it’s the
Thank you for your comment. The guidance is set
within the context of the Common Assessment
Framework and existing systems and structures
for children and young peoples services.
Thank you for your comment. The family-based
programme should be provided in the context of
p.40
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Recommendation 5
6
Comments
Please insert each new comment in a new row.
Liddle et al work, was based on highly trained qualified family
therapists with rigorous supervision. Outside of CAMHS these
services don’t exist. The recommendation suggests the
interventions happen before CAMHS. Essential Elements states
that all Local Authority areas should have staff able to offer a
family based intervention including parental work but this would
not necessarily be MI focused.
At present Family Therapy services have an extremely high
threshold and such parents are unlikely to meet threshold
criteria.
Also this recommendation includes parents who misuse
substances. This may confuse issues. The government
response to Hidden Harm available from DFES, highlights three
very different types of parental interventions. Parents whose
children use drugs; parents whose problematic drug use
develops problems for their children through addictive patterns
etc and drug using parents who require drug treatment. Such a
perspective enables easy identification of referral pathways
which would be a welcome addition to the paper.
This recommendation has significant resource implications. It
suggests that those children under 16 ‘at risk’ of substance
misuse should be referred with their parents for a relatively
intensive structured programme of support. The level of
intervention envisaged is potentially equivalent to that offered in
child and adolescent mental health service day units of which
there are relatively few in the UK.
In keeping with professional practice in the UK, any such
intervention should have a preceding stage of detailed
assessment. This could involve the CAF or its equivalent in child
and adolescent mental health services. In order to engage
families and young people and because it is important to identify
sources of difficulties such as abuse, unrecognised learning
disability, or mental disorder, this is a crucial stage.
Stakeholder response table – guidance consultation
Response
Please respond to each comment
the local strategy and services commissioned
and is likely to include CAMHS or other such
providers.
Thank you for your comment. NICE recommends
cost-effective interventions. Funding and
resource implications are beyond the remit of
NICE guidance.
The revised recommendations refer to the use of
screening and assessment tools, including the
Common Assessment Framework and those
available from the National Treatment Agency.
p.41
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Recommendation 6
Nottinghamshire
Healthcare NHS
Trust
General
General
Stakeholder response table – guidance consultation
Page
Number
7
Comments
Please insert each new comment in a new row.
The population described overlaps heavily with the ‘child in
need’, the educational special needs and the CAMHS
populations. Any new services need to fit within this network of
established services.
The content of the group interventions is very specifically
described by the recommendation. However, the later text linked
to evidence statement 64.1 merely refers to ‘multi-component’
interventions. The precise content of therapy sessions is subject
to considerable debate and the science presented here appears
insufficiently advanced to specify with such detail what the exact
content of interventions should be
Home Office, Department of Health and NTA are providing data
that may assist this. NTA is trying to focus not on demographic
data on prevalence of vulnerable people or prevalence of drug
use, but on treatment need. This should help service planning
based on need.
This guidance is mainly appropriate for non-health agencies,
particularly Social Services and education. It deals with the
identification of those at risk and suggests a few methods for
preventing that risk being realised. Those identified might need
tier 1 or 2 interventions which do not involve services like those
provided by this Trust. NADT would receive direct referrals of
those who have severe problems.
The whole document seems very ‘thin’ and the evidence base is
weak as acknowledged. Main weakness is that there is no
mention of the need to improve awareness of drugs issues as a
whole in those who come into contact with the vulnerable
groups the report identifies, especially educators and social
work staff. Social workers in particular, dealing with vulnerable
children and young people seem content not to ‘know about
drugs’ and probably miss some indicators in their clients.
Response
Please respond to each comment
Thank you. Your comment is noted.
Thank you for your comment. NICE public health
guidance focuses on the promotion of good
health and the prevention of ill health for those
working in the NHS, local authorities and the
wider public and voluntary sector.
Thank you for your comment. The
‘considerations’ section in the revised guidance
document now covers this point.
p.42
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Re-solv
Royal College of
Nursing
Evidence
submitted
Section
Page
Number
General
Section 2
Page
9/10
Section 5
Page 11
General
General
General
general
Stakeholder response table – guidance consultation
Comments
Please insert each new comment in a new row.
Regret the draft Guidance does not include VSA, and excludes
vulnerable people under 10. The prevention message we
consider needs to start at 5. We have seen
2 deaths of 7 year olds.
Response
Please respond to each comment
Thank you for your comment. The definition of
‘substance misuse’ provided in the guidance
includes volatile substances. The guidance
focuses on vulnerable and disadvantaged people
up to the age of 25, however, there are particular
areas where evidence relates to particular age
groups.
Policy Background should include
Thank you for your comment. The guidance has
Out of Sight? …… Not Out of Mind
been amended.
Children, Young People and Volatile Substance Abuse.
A Framework for VSA 2005 (Department of Health).
Recommendations for Research
The Public Health Interventions Advisory
Suggested addition:
Committee identified a number of gaps in the
What interventions have been effective and cost effective in
evidence. However, there is a limit to the number
preventing Volatile Substance Abuse deaths and causing the
of research recommendations that it can make.
deaths from Volatile Substance Abuse to fall from 152 in 1990 to You may wish to suggest a future topic for NICE
47 in 2004.
guidance at
www.nice.org.uk/page.aspx?o=ts.home
Thank you for your comment.
The RCN welcomes the opportunity to review this document.
The main issue of contention from a number of respondents has Thank you for your comment. The revised
been clarification of the age scope. Interventions aimed at over
guidance focuses on vulnerable and
16s will be different to those below that age. This makes for a
disadvantaged people up to the age of 25,
confusing document.
however, there are areas where evidence relates
to particular age groups.
Further, this guidance covers a wide age range and we are not
Thank you for your comment. The guidance has
sure whether some of the recommendations can be equally
been amended.
applied to all, for example school based recommendations are
not appropriate after 16 with most schools and parent
programmes not likely to be useful above a certain age.
We, therefore, suggest that the guidance needs to be clear
Thank you for your comment. Please refer to our
about what population the guidance is and/or is not for.
previous response.
p.43
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
General
Recommendations
1&2
Page 5
Recommendation 3
and 4
Recommendation 5
Recommendation 5
6
Recommendation 6
Recommendation 5
Recommendation 6
Stakeholder response table – guidance consultation
7
Comments
Please insert each new comment in a new row.
The Guidance has limitations which are acknowledged, in that
certain populations are omitted - this needs to be very clear
when put in the public domain.
Response
Please respond to each comment
Thank you for your comment. Please refer to our
previous response. Please also note that the
revised guidance sets out ‘considerations’ in
developing the recommendations.
These are not written in a way that reflects a motivational
interviewing approach (client self-efficacy etc).
Thank you for your comment. The guidance has
been amended.
Schools are asked to identify vulnerable pupils - this will require
a large injection of money on appropriate training, to enable
schools to become identifiers of this vulnerable groups
Which professionals and which service might this role be
attached to?
Thank you for your comment. NICE is unable to
comment on funding allocations.
We envisage that this will require large financial investment if it
is to be meaningful.
Why has the age range been set so tight (10-12) when
increasingly it can be argued that maturity is not being achieved
by 16 in many marginal groups? Should the age range of this
group be extended to 10-14?
Identification of a population up to age 25 will be very difficult in
practice as in some areas services are configured in such a way
that this would straddle several different services.
Parent skills training will need to be at a time convenient for the
parents and this group, (not 9-5 which typically happens) if the
chances are maximised to gain engagement which is likely to be
difficult enough with this group. We, therefore, consider that
there is a need for out-of-hours parent groups.
The opening sentence lists service providers but misses out
mental health trusts. These often work with young people 1625, especially males, because no one else will. The mental
health trusts need to be included.
NICE is unable to comment on funding
allocations.
Thank you for your comment. The guidance has
been amended.
Thank you for your comment. The guidance
focuses on vulnerable and disadvantaged people
up to the age of 25, however, there are areas
where evidence relates to particular age groups.
Thank you for your comment. The guidance has
been amended.
Thank you for your comment. The guidance does
not specify the hours within which the
interventions should occur. However, it does
suggest that programmes are drawn up with the
parents or carers.
Thank you for your comment. The guidance has
been amended to reflect the role of local
agencies and practitioners and referral criteria
and pathways.
p.44
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Section 2
Page
Number
8
Section 2
8&9
Section 2
Stakeholder response table – guidance consultation
9
Comments
Please insert each new comment in a new row.
Under “Factors that influence …” there are in our view some
groups that are missing.
1) Peer pressure
2) Rite of Passage
3) Looked after children or excluded from school.
As above, we are surprised that peer involvement is not
measured. Also should we not be aiming to reduce substance
misuse among all young people?
The section on policy does not appear to refer to any Welsh or
Scottish policy.
Response
Please respond to each comment
Thank you for your comment. The guidance has
been amended.
Thank you for your comment. Peer involvement
was considered. Please refer to the main review
of effectiveness which contains numerous
evidence statements that refer to peers
(www.nice.org.uk/page.aspx?o=352252). Peer
involvement is also mentioned within the
supporting evidence as set out in appendix A.
Please note that the Department of Health asked
NICE to undertake: ‘An assessment of
community-based interventions to reduce
substance misuse among the most vulnerable
and disadvantaged young people.’
Thank you for your comment. Please note that
NICE guidance on public health covers England
only (see
www.nice.org.uk/page.aspx?o=guidetonice)
p.45
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Appendix C
Page
Number
22
Comments
Please insert each new comment in a new row.
The Public Health Interventions Advisory Committee appears to
be heavily medical influenced which will lead to medical models
of care. However, if the target groups are to achieve outcomes
they will need a more social model approach. The group needs
a mental health nurse and a practice nurse. A voluntary sector
representative from a local charity should also be involved.
Appendix C
22
As above the RCN is keen to nominate nurse representatives to
be involved in future work.
General
Stakeholder response table – guidance consultation
There does not appear to be any reference to the work that
followed on from the Fraser Rulings. References - HardingPrice et al (1991); Drug Misuse and Caring for Children;
NDSCCG; Grimsby or ANSA (1997); Working with Children and
Young People; Pinpoint Communications; Kingston-on-Thames.
Response
Please respond to each comment
Thank you for your comment. We endeavour to
ensure that membership of PHIAC is
multidisciplinary, comprising public health
practitioners, clinicians (both specialists and
generalists), local authority employees,
representatives of the public, patients and/or
carers, academics and technical experts.
Committee members responsible for this
guidance are listed in the appendices and include
a professor of health psychology a designated
nurse for looked after children and several other
professional and lay personnel. NICE also works
with patients, carers, patient organisations and
the public to produce guidance that addresses
their issues and to make sure that it reflects their
views and meets their healthcare needs.
NICE advertised for new members to join PHIAC
in October 2006 – so unfortunately we are not
currently looking for applicants.
Thank you for your comment. The revised
guidance includes a ‘considerations’ section
which acknowledges that confidentiality may be
an issue, especially if the individual is a minor.
However, clarification of circumstances pertaining
to parental consent is beyond the remit of this
guidance.
p.46
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
General
Page
Number
Comments
Please insert each new comment in a new row.
Early identification: We consider that the guidance should
include the cross over factors between tobacco and alcohol use
and use of solvents and drugs amongst young people. There is
some Canadian research that has highlighted the benefits of
early intervention with smokers and drinkers in. Terms of
preventing use of 'harder drugs'.
General
Greater consideration should be given to the relationship
between the club scene and the use of stimulants and alcohol.
There is good international evidence to show that a significant
proportion of young people are drawn into this form of drug use
rather than opiates. Greater emphasis should be given to
interventions that will address the needs of this group.
General
Diversion schemes have featured as a possible intervention to
assist young people find alternatives to drug use. Many
disadvantaged young people have limited access to such
schemes therefore the cost benefits of investment in such
schemes should be considered.
Stakeholder response table – guidance consultation
Response
Please respond to each comment
Thank you for your comment. These issues are
important, but it was necessary to keep the
guidance within manageable boundaries so that it
could be completed within the time and resource
constraints. Interventions that seek to prevent or
reduce substance misuse in the broadest sense
(that is, drugs, volatile substances, and tobacco
or alcohol) were included, provided that the
intervention study reported on outcomes relating
to drug and volatile substance misuse
specifically. Tobacco and alcohol are the focus of
other NICE public health programme and
intervention guidance – see
www.nice.org.uk/guidance/PHP and
www.nice.org.uk/guidance/PHI You may wish to
suggest a future topic for NICE guidance at
www.nice.org.uk/page.aspx?o=ts.home
Evidence on selective and indicated interventions
that aimed to prevent or delay the initiation of
substance misuse (‘primary prevention’) by
vulnerable and disadvantaged young people was
considered. It was also included if it aimed to help
these groups to reduce or stop their misuse of
substances (‘secondary prevention’). The
guidance does not cover recreational use by the
general population.
Please refer to the previous response. The
guidance considered all available evidence.
p.47
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Royal College of
Paediatrics and
Child Health
Evidence
submitted
Section
Page
Number
General
General
General
General
Recommendation 3
Stakeholder response table – guidance consultation
6, 17
Comments
Please insert each new comment in a new row.
The guideline could be better aligned with clinical practice if the
Guideline Development group were to co-opt three additional
experts with special expertise or a special interest in substance
misuse: a paediatrician, a psychiatrist; and a clinical
psychologist.
The guideline could be written with greater clarity. For instance,
it would help to clarify which substances are included. It is
implied, but not clearly stated, that alcohol and tobacco are
included.
The recommendations would be easier to read without the
irritating repetition. The population at risk of substance misuse
could be defined in a separate section, and then referred to by
some phrase, such as ‘the population at risk’.
The document would also be clearer to read if the goal of
intervention were defined in the language of epidemiology as
being secondary prevention. Primary prevention (such as whole
school interventions) and tertiary prevention (such as treating
those who are already dependent on substances) seem to have
been excluded from the scope – which would be clearer if this
were stated using this terminology.
This could be clarified by specifying what would be done in
schools to help those who are vulnerable that is not already
being done. “Appropriate support…or…referral to other
services” is not specific enough.
Response
Please respond to each comment
Thank you for your comment. NICE public health
interventions guidance has a Public Health
Interventions Advisory Committee (PHIAC) and
not a Guideline Development Group. PHIAC
considers evidence from people with relevant
expertise. These are listed in the guidance
appendices. You may wish to refer to documents
outlining the public health guidance process and
methods at
www.nice.org.uk/page.aspx?o=300576
Thank you for your comment. The guidance has
been amended.
Thank you for your comment. The guidance has
been amended.
Thank you for your comment. NICE public health
guidance focuses on the promotion of good
health and the prevention of ill health – so tertiary
prevention/treatment of those already dependent
is not included. We aim to write our guidance as
clearly and succinctly as possible, so that it is
accessible to all potential users.
Thank you for your comment. The guidance has
been amended.
p.48
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Recommendation 4
Royal
Pharamaceutical
Society
Page
Number
6, 18-20
Recommendation 5
7, 18,
21
Forward an / or
Recommendations
1-2 & /
or 4-5
Stakeholder response table – guidance consultation
Comments
Please insert each new comment in a new row.
This recommendation seems to suggest that elements of a
multimodal approach developed by Dishion and others should
be applied to parents of vulnerable young people. There is
however considerable evidence to suggest that elements of a
multimodal approach may not work if used in isolation from the
other elements (e.g. in relation to multisystemic therapy); and
the paragraph suggests that motivational interviewing is the
main component that matters, which may be misleading.
The studies referred to here are multi-component programmes
that have been shown to improve behaviour and reduce the use
of tobacco, alcohol and cannabis. The way the
recommendation is written suggests that two elements are being
extracted, the young persons’ group and the parents’ group.
While these may be very effective in the hands of professionals
trained in the multi-component programme, they may be less
effective if used in isolation by insufficiently trained personnel.
Also, it is not clear what would motivate either the parents or
young people to attend these groups, especially as it seems
likely that the target population would not have a sufficient level
of problems (yet) to make their parents concerned enough to
want help.
It was difficult to interpret clearly the scope of the guidance i.e.
the reduction in substance misuse of current substance
misusers and reducing the risk of identified potential substance
misusers (i.e. vunerable and disadvantaged young people). The
age range for which this guidance is targeted should be more
explicitly
Response
Please respond to each comment
Thank you for your comment. The guidance has
been amended. The ‘considerations’ section in
the revised guidance document now covers this
point.
Thank you for your comment. The guidance has
been amended. The ‘considerations’ section in
the revised guidance document now covers this
point.
Thank you for your comment. The guidance has
been amended.
p.49
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
General
SCAN
Draft guidance,
general
Stakeholder response table – guidance consultation
Page
Number
Comments
Please insert each new comment in a new row.
The guidance describes “Community based interventions or
small scale programmes delivered in community settings that
seek to elicity changes in the risk behaviour of the targeted
population” (page 5). Within the recommendations there was no
mention of interventions around harm reducation associated
with substance misuse. Providers of the interventions described
in the recommendations hould incorporate harm reducation
advice / support into the intervention. Current or potential
substance misusers should be aware of harm reducation
strategies and services available in the community (e.g. Needle
Exchange Schemes)
Response
Please respond to each comment
Thank you for your comment. The Department of
Health asked NICE to undertake: ‘An assessment
of community-based interventions to reduce
substance misuse among the most vulnerable
and disadvantaged young people.’ The primary
outcome measures focused on reductions in the
numbers of vulnerable and disadvantaged
children and young people who start misusing
substances, and/or a delay in the time before
initiation: Among this group already misusing
substances, primary outcome measures focused
on increases in the number who stop misusing
substances and reductions in use or frequency of
use. The guidance did not aim to assess the
harm associated with substance misuse.
This is a helpful document and its findings should inform
practice. However, it examines a much more limited body of
literature than is available in many other areas of health care,
and only one research project from the UK. Perhaps the
recommendations should be more circumspect. Also, they
require context and integration with practice realities.
Thank you for your comment. The guidance has
been amended.
p.50
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
As above
Stakeholder response table – guidance consultation
Page
Number
Comments
Please insert each new comment in a new row.
Definitions
There is a need to explain and clarify a number of terms:
Substance – which substances are being included and excluded
Use/ misuse/ dependence
Vulnerable and disadvantaged or most vulnerable and
disadvantaged
‘Clinical’
Types of interventions: motivational interviewing, brief
intervention, family therapy, group therapy, multicomponent
interventions may be described as such but might have different
components and duration in different settings.
For example,
The document defines substance misuse as ‘intoxication
…regular excessive consumption and/or dependence ... leading
to social, psychological physical and legal problems’ (page 5.).
This broad definition fits with abuse/dependence in DSM IV.
However, the following sub-paragraph notes that clinical
interventions for individuals who are ‘dependent’ on substances
are not considered. The authors have included dependence in
the definition of misuse. It is unclear what group are included or
excluded. The document appears to single out cannabis and
stimulants, other combinations that are common in clinical
practice are not mentioned.
Response
Please respond to each comment
Thank you for your comment. The guidance has
been amended.
NICE public health guidance focuses on
the promotion of good health and the prevention
of ill health, so clinical interventions for
dependency on substances are not considered.
p.51
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
As above
As above
As above
Stakeholder response table – guidance consultation
Page
Number
Comments
Please insert each new comment in a new row.
Competence
Individuals conducting interventions in the cited studies included
qualified social workers or psychologists, professionals with
broad training in many aspects of child development,
psychopathology, family functioning and other matters. Many
substance use workers to whom these young people will be
referred in UK systems will not be trained in this way. In light of
the potentially iatrogenic effects of interventions if delivered by
untrained people and highlighted by the document, this is an
important issue. Substance use services should be encouraged
to employ ‘appropriately trained professionals’ but specialist
substance misuse services that include NHS and other
professionals should be responsible for those young people who
are both vulnerable and engaged in potentially harmful
substance use.
Resources
Vulnerable children and young people represent a considerable
minority. For instance, at least 10% of the adolescents surveyed
by the National Statistics (2004) survey were judged to have a
mental disorder. If all or even half of these young people, who
represent only a proportion of the vulnerable groups at
increased risk listed by the document, were referred to an
intervention, it would immediately overwhelm all existing
targeted services in the UK.
Relationships with other services
For the sake of rational use of resources, interventions should
be delivered through existing services, (schools, child and
adolescent mental health or substance use services, or a
combination) however enhanced. This is crucial to avoid
duplication or development of parallel services.
Response
Please respond to each comment
Thank you for your comment. The
‘considerations’ section in the revised guidance
document now covers this point.
Thank you for your comment. Please note that
information about allocation of resources is
beyond the remit of this guidance.
Please refer to our previous comment.
p.52
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
As above
As above
As above
Page
Number
Comments
Please insert each new comment in a new row.
Substance misuse in context
The listed interventions are aimed at substance misuse.
However, this should be seen in context. Many of these young
people will have multiple needs and for some, substance misuse
may be only a relatively minor aspect, or marker, of other
difficulties. It is crucial that any service (such as an augmented
CAMHS) to which they are referred has the competence to
evaluate the full range of difficulties they suffer so that
comprehensive interventions can be put in place.
There is great heterogeneity in the characteristics of the
samples. As a result, there is also overlap between groups.
This has implications for the implementation of ‘applicable’
interventions.
Assessment / judgement of applicability – This seems an
important component of the guidance. There are four
categories – which criteria were used to assign studies to a
particular rating, i.e. A, B, C or D?
As above
Population studies in clinic settings: Age range – There is a wide
age range of children / adolescents studied. This makes
general extrapolation difficult. What is appropriate at 13 may not
be at 23.
As above
Population studies in clinic settings: Sample characteristics – In
some studies, these are not clearly stated. There is great
variability with which information on the sample with regard to
substance use is reported (examples are use of multiple
substances, quantity / frequency of use, misuse or
dependence).
Stakeholder response table – guidance consultation
Response
Please respond to each comment
Thank you or your comment. The ‘considerations’
section in the revised guidance document now
covers this point.
Thank you for your comment. The guidance has
been amended.
Thank you for your comment. Please refer to the
NICE public health guidance process and
methods manuals at
www.nice.org.uk/page.aspx?o=300576
particularly sections 4.2 and 4.3.1.1 of the
methods manual.
Thank you for your comment. The guidance has
been amended. There are areas where evidence
relates to particular groups with particular
characteristics and any distinctions should now
be clear.
Thank you for your comment. The guidance has
been amended.
p.53
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Draft guidance,
Foreword
Page
Number
1
As above
Draft guidance,
Recommendations
Draft guidance,
Recommendations,
General issues
General
5
Comments
Please insert each new comment in a new row.
Differentiation between substance use and misuse. This was
noted in the first consultation. It is important to clearly
differentiate the criteria for each term. For example, is the
overall objective of an intervention to reduce misuse, rather than
use? The philosophy and goal of the intervention may impact
upon the interpretation of the outcome.
Is the guidance about the “most vulnerable and disadvantaged”
or the “vulnerable and disadvantaged”? The definitions of and
differentiation between the two groups may be important.
There is some repetition at the end of each recommendation –
the last five or six lines.
Second bullet point: The relationship between risk and
substance use / misuse – This relationship is of an association
(rather than causation). Thus, care needs to be taken in the
conceptualisation of the overall framework of the guidance. We
cannot be sure that removal / reduction of risk (assuming that
this is possible) is likely to lead to a change in behaviour,
because we do not know if and by what mechanism the
relationship is causal.
Response
Please respond to each comment
Thank you for your comment. The Department of
Health asked NICE to undertake: ‘An assessment
of community-based interventions to reduce
substance misuse among the most vulnerable
and disadvantaged young people’. Substance
misuse is defined in the revised guidance. For
further information on the public health guidance
process and methods, see the NICE manuals
(www.nice.org.uk/page.aspx?o=300576)
Thank you for your comment. The guidance has
been amended.
Thank you for your comment. The guidance has
been amended.
Thank you for your comments. The evidence
shows an association between risk and
substance use/misuse. However, the
recommendations are based on the best
evidence of effectiveness in changing
behaviours. You may wish to suggest a future
topic for NICE guidance (see
www.nice.org.uk/page.aspx?o=ts.home).
Perhaps it is worth making reference to critical reviews of the
strength of the relationships to risk factors.
In this regard several (though relatively few) studies used a risk
index, which might be one way of stratifying those at some risk
or at “most” risk (e.g. Campbell et al, 2002).
The study by Nair et al (2003) is useful in differentiating
outcome.
Stakeholder response table – guidance consultation
p.54
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
As above
As above
As above
As above
Stakeholder response table – guidance consultation
Page
Number
Comments
Please insert each new comment in a new row.
It is not clear what substances are included. Recommendation
2 notes stimulants and cannabis. What about opiates and other
illicit drugs and alcohol, nicotine and prescription drugs? What
about multiple substance users which is a commonplace reality
in today’s teenage environment.
Prevention intervention or treatment intervention: It would be
helpful to separate out which are prevention and which
treatment interventions. This might clarify which type of
interventions is being targeted for use and/or misuse and/or
dependence.
There are examples of quite a number of studies, which note
that the subjects / clients / patients are in treatment settings.
The interventions are the same as or similar to those used in
dependent users. Is there definite evidence from the studies
quoted that dependent users were not included? For example,
Dennis et al (2004) explicitly uses DSM-IV criteria for
dependence. “Users” included multiple substance users.
Perhaps some were dependent? Examples are listed in Table 1.
As noted above clarification with regard to inclusion and
exclusion criteria are needed. Treatment of dependence
generally requires clinical treatment interventions including
pharmacological treatment (but not only pharmacological
treatment) within a comprehensive treatment plan of other
psychological interventions and social support eg housing and
education.
Will forthcoming NICE guidance focus on young people under
the age of 18?
Response
Please respond to each comment
Thank you for your comment. The guidance has
been amended.
Thank you for your comment. NICE public health
guidance focuses on the promotion of good
health and the prevention of ill health – so tertiary
prevention/treatment of those already dependent
is not included.
Thank you for your comments. This stakeholder
consultation relates to the draft guidance and not
the evidence. With regard to ‘definite evidence’,
studies were assessed using a number of
checklists, as set out in a document outlining the
methods for the development of NICE public
health guidance (see
www.nice.org.uk/phmethods). The appendices to
the main review of effectiveness also contains
sample forms (see
www.nice.org.uk/page.aspx?o=352252). NICE
public health guidance does not focus on tertiary
prevention/treatment of those already dependent
(please refer to our previous response).
Thank you for your question. Forthcoming NICE
public health guidance is listed at
www.nice.org.uk/guidance/topic/publichealth
You may wish to suggest a future topic for NICE
guidance (see
www.nice.org.uk/page.aspx?o=ts.home).
p.55
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Draft guidance,
Recommendations,
General issues
Page
Number
5, line
11
Comments
Please insert each new comment in a new row.
“Clinical interventions with individuals who are dependent on
substances are not considered…” As noted above, this
sentence requires clarification. What does it mean? Does
“clinical” equate to dependence and / or prescribing?
It cannot be stressed sufficiently that it is very important to
characterise and differentiation the populations being described
with regard to nature and extent of substance
use/misuse/dependence, to describe the nature and extent of
interventions provided and to take into account the limitations of
studies when evaluating outcome so that conclusions balanced
and recommendations are potentially practical.
This notes that individuals over 16 should, if appropriate, be
referred for one or more motivational interviews. It is unclear
what is meant in the guidelines by ‘if appropriate’. If judgement
is required, those who are screening need to have appropriate
experience to judge whom to screen and refer. Perhaps these
should be professionals such as teachers, general practitioners
or school nurses.
Perhaps “Professionals… should be trained to identify…”
should be recommended. This has very great resource
implications, of course.
Draft guidance,
Recommendations,
Recommendation 1
5
As above
5
It is important to clarify why in some recommendations “over 16”
is the threshold whilst in others ‘under 16’ is targeted.
Draft guidance,
Recommendations,
Recommendation 2
5
Why are cannabis and stimulants the only ones included?
See note above
Stakeholder response table – guidance consultation
Response
Please respond to each comment
Thank you for your comments. Pleaser refer to
our previous responses.
Thank you for your comments. The guidance has
been amended.
Thank you for your comment. The guidance
focuses on vulnerable and disadvantaged people
up to the age of 25, however there are areas
where evidence relates to particular age groups.
Thank you for your comment. The guidance has
been amended.
p.56
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
As above
Page
Number
Comments
Please insert each new comment in a new row.
Provision of motivational interviewing for those over 16 with
cannabis or stimulant misuse. The term motivational
interviewing has many meanings, some see it as a style of
interviewing though it can be an intervention if it includes
feedback and identification of consequences of stopping or
continuing substance misuse. It is probably best used in a
stepped care approach so that individuals who are identified as
at risk can be followed up with more structured treatment. The
report cites the research of McCambridge and Strang and the
Dennis et al (2004) study to justify the use of motivational
interviewing. However, these studies are quite different and
used different treatments. The McCambridge study was not for
vulnerable young people but college students and the MI was
done by Jim McCambridge himself. It was more of a brief
intervention with a motivational component.
Response
Please respond to each comment
Thank you for your comments. The guidance has
been amended. ‘Motivational interviewing’ for the
purposes of the guidance is now clearly defined.
The guidance also sets out ‘considerations’ in
developing the recommendations, which includes
reference to the issue of practitioner
competencies.
The Public Health Interventions Advisory
Committee (PHIAC) consider a number of factors
when developing recommendations, including
information provided by cooptees and expert
testimonies.
However, the Dennis study was for those with cannabis use,
and many had other complex needs, often ‘vulnerable’ in the
terms of the draft document. It utilised motivational
enhancement therapy (MET) rather than MI. This structured
treatment was manual-based, and highlighting the competence
issue, delivered by trained therapists often at doctorate level. It
may be that the stepped care concept should also apply here: if
young people receive a brief intervention and not change their
behaviour during follow up, referral for specialist treatment will
be required. Otherwise, some vulnerable young people will
receive MI by untrained staff thinking that is all they require,
perhaps in effect diverting them away from specialist resources.
Stakeholder response table – guidance consultation
p.57
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Draft guidance,
Recommendations,
Recommendation 3
Draft guidance,
Recommendations,
Recommmendation
s 4 and 5
6
As above
Stakeholder response table – guidance consultation
6-7
Comments
Please insert each new comment in a new row.
There is no discussion of referral for those under 16 who are
actually misusing or using drugs. In addition, there is no
indication noted about training requirements. The MET was a
structured manual delivered therapy with trained professionals,
significantly different to the situation in England where many
workers are not professionally trained and may have
experienced only brief training. The recommendation should
note what appropriate background and training is appropriate;
the common 1-2 day training which is the norm does not change
practice.
Appropriate.
Response
Please respond to each comment
Thank you for your comment. The guidance has
been amended. Specific details about
background and training requirements of
particular professionals and others is beyond the
remit of this guidance.
These are most significant. They suggest that those children
under 16 ‘at risk’ of substance misuse should be referred with
their parents for a relatively intensive structured programme of
support. The level of intervention envisaged is potentially
equivalent to that offered in child and adolescent mental health
service day units of which there are relatively few in the UK.
Thank you for your comments. The
‘considerations’ section in the revised guidance
document now covers this point.
In keeping with professional practice in the UK, any such
intervention should have a preceding stage of detailed
assessment. This could involve the CAF or its equivalent in child
and adolescent mental health services. In order to engage
families and young people and because it is important to identify
sources of difficulties such as abuse, unrecognised learning
disability, or mental disorder, this is a crucial stage.
The population described overlaps heavily with the ‘child in
need’, the educational special needs and the CAMHS
populations. Any new services need to fit within this network of
established services.
Thank you.
Thank you for your comment, please note that
information about allocation of resources is
beyond the remit of this guidance.
p.58
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
As above
Draft guidance,
Recommendations,
Recommendation 6
Stakeholder response table – guidance consultation
7
Comments
Please insert each new comment in a new row.
The content of the group interventions is very specifically
described by the recommendation. However, the later text linked
to evidence statement 64.1 merely refers to ‘multi-component’
interventions. The precise content of therapy sessions is subject
to considerable debate and the science presented here appears
insufficiently advanced to specify with such detail what the exact
content of interventions should be.
Appropriate
Response
Please respond to each comment
Thank you for your comment. Evidence
statements are, by definition, succinct and do not
necessarily include information about intervention
content. The Public Health Interventions Advisory
Committee (PHIAC) considered a wide range of
information when developing the
recommendations. You may wish to refer to
documents outlining the public health guidance
process and methods at
www.nice.org.uk/page.aspx?o=300576
Please refer to our response above.
p.59
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Draft guidance,
Public health need
and practice, Policy
background
Page
Number
10
Comments
Please insert each new comment in a new row.
Recent evidence on the extent of substance
use/misuse/dependence can be sourced from the Advisory
Council on the Misuse of Drugs’ document Pathways to
problems (2006) to give some idea of the nature and extent of
the problems that may require different levels of support.
Response
Please respond to each comment
Thank you for your comment and references.
Additional references
National Statistics (2005) Mental Health of Children and Young
People in Great Britain. Palgrave Macmillan. Basingstoke.
Jensen PS. Weersing R. Hoagwood KE. Goldman E. (2005)
What is the evidence for evidence-based treatments? A hard
look at our soft underbelly. Mental Health Services Research.
7(1):53-74.
(1996) The nature and treatment of adolescent substance
misuse (NDARC Monograph No. 26). New South Wales:
NDARC.
As above
As above
Stakeholder response table – guidance consultation
Spooner, C., Mattick, R. & Howard, J. New Zealand Health
Technology Assessment (1998) Adolescent therapeutic day
programmes and community-based programmes for serious
mental illness and serious drug and alcohol problems: A critical
appraisal of the literature (NZHTA Report No. 5). Christchurch:
NZHTA.
ACMD Hidden Harm (2003) and the new implementation
guidance which is soon to be issued is also a useful resource
Perhaps strength of evidence versus applicability should be
tabulated. This might give some indication or guidance as to
what change can be anticipated.
Thank you for this reference.
Thank you for your comment. The process
considered both quality of evidence and
applicability. (see sections 3.4, 3.6, 4.2, 4.3 and 6
of the main review of effectiveness at
www.nice.org.uk/page.aspx?o=352252 and
appendix D of the revised guidance at
www.nice.org.uk/PHI004
p.60
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
22
Comments
Please insert each new comment in a new row.
Committee membership
The public health expertise of the committee is acknowledged
but the inclusion of senior ‘field’ professionals (e.g. psychiatrists,
social workers) might have aided in presenting the
recommendations in a less theoretical and more obviously
practical style.
Section 5.3a
42, last
line
The Dennis study is on cannabis abuse and dependence. It is
not clear whether the other studies included dependent
populations as they do not state if subjects are dependent or
not. The Liddle studies were in also in clinical populations.
Section 5.3a
44
Section 5.3a
As above
45
Draft guidance,
Appendix C
As above
Stakeholder response table – guidance consultation
Evidence statements 56.2 and 58 do not have applicability
ratings.
Evidence statements 60 and 62 do not have applicability ratings.
Applicability ratings – It may not always be appropriate to
recommend interventions across a broad range of settings. For
example, the McCambridge study was on students in higher
education. The interventions may not be appropriate to young
people whose verbal and literacy skills and capacity to think in
the abstract may be more limited.
There is a need to calculate the training and intervention
resources required to implement Recommendations 1 and 2 by
extrapolating from the evidence of prevalence (See ACMD
(2006) Pathways to problems).
Response
Please respond to each comment
Thank you for your comment. Membership of
PHIAC is multidisciplinary, comprising public
health practitioners, clinicians (both specialists
and generalists), local authority employees,
representatives of the public, patients and/or
carers, academics and technical experts.
Committee members responsible for this
guidance are listed in the guidance appendices.
NICE also works with patients, carers, patient
organisations and the public, to produce
guidance that reflects their views and meets their
healthcare needs.
Thank you for your comment, however this
stakeholder consultation relates to the draft
guidance and not the evidence (see
www.nice.org.uk/page.aspx?o=SubstanceMisuse
Int&c=296726). The draft guidance did not
contain a section 5.3a (see
www.nice.org.uk/page.aspx?o=384010).
Thank you for your comment. Please refer to our
previous response.
Please refer to our previous response.
Thank you for your comment. The Public Health
Interventions Advisory Committee (PHIAC)
considered a number of factors when developing
recommendations, including information provided
by cooptees and expert testimonies. Members of
PHIAC and the external contributors are detailed
in the guidance appendices.
Thank you for your comment, please note that
information about allocation of resources is
beyond the remit of this guidance.
p.61
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Section 5.3a
Page
Number
55
Comments
Please insert each new comment in a new row.
Conclusions – Second paragraph – Elaborate / clarify. This type
of approach was also considered… after suitable adaptation.
Section 5.3a
56
Young substance users, paragraph 3 – Would be very cautious
about improvements because of
•
Relatively short follow-up
•
Characteristics of sample
Healthcare settings
Perhaps it is important to stress the following issues:
•
There are relatively few studies on young substance users
(21)
•
Substances used may vary and may be multiple
•
Settings vary – some are non-clinical
•
Sample sizes are generally small. For example, Tait et al,
2004 (n=127), McCambridge (n=200), Aubrey (n=77).
•
Attrition rates may be sizeable, sometimes not reported
(Liddle et al).
•
Importantly, in terms of recommendations, interventions
similarly described may differ quite substantially (p228, 233,
237).
•
Therapists vary: nurse, social worker, health.
•
Follow up is not longer than 12 months.
•
Self-report is not always validated.
•
There are problems with randomisation in one of the larger
studies (Dennis et al, 2004).
Section 5.3a
PHIAC 7.4a
22411 and
14
Response
Please respond to each comment
Thank you for your comment, this stakeholder
consultation relates to the draft guidance and not
the evidence (see www.nice.org.uk/PHI004). The
draft guidance was 31 pages long and did not
contain a section 5.3a or ‘Conclusions’ section.
Thank you for your comment. Please refer to our
previous response.
Thank you for your comments. Please refer to
our previous responses.
If recommendations are going to be made it appears that it is on
very few studies and only on in the UK that is on a specific
population which may not be generalisable and where benefits
are not clear.
Stakeholder response table – guidance consultation
p.62
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
As above
As above
As above
As above
Section 5.3a
Schering Plough
Ltd
Section 5.3a
Stakeholder response table – guidance consultation
229, line
4
342
Comments
Please insert each new comment in a new row.
Note: P16 (PHIAC 7a) Oliansky et al 1997 is given RCT+ (A). Is
this correct?
Perhaps more needs to be made of the relatively small sample
size of some studies, e.g. Tait et al, 2004 (127 subjects);
Aubrey, 1998 (77 subjects); McCambridge & Strang, 2004/2005
(200 subjects).
Dunn et al included only 2 studies on young substance users.
Tait & Hulse (2003) includes 2 studies of multiple substance
use. The better rated studies appear to have had some
limitation, e.g. high drop-out rate, non-report of trial methodology
check list.
•
Brief intervention
•
Family therapies
•
Group therapy
•
Counselling
These terms may mean very different interventions in different,
though relatively few, studies. It is therefore very difficult to
compare outcomes. For example, see Table 2.
Were participants more or less likely? Table 5.4.3 indicates less.
1.6: The only difference between groups is the intervention
under investigation.
Response
Please respond to each comment
Thank you for your comment. Please refer to our
previous response.
Thank you for your comment. Please refer to our
previous responses.
Thank you for your comment. Please refer to our
previous responses.
Thank you for your comment. Please refer to our
previous responses..
Thank you for your comment. Please refer to our
previous responses.
Thank you for your comment., This stakeholder
consultation relates to the draft guidance and not
the evidence (see www.nice.org.uk/PHI004).
p.63
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
General
Page
Number
Comments
Please insert each new comment in a new row.
As the stakeholder comments on this document have
suggested, it seems that the guidance has been simplified firstly
due to a diverse evidence base, and secondly to ensure
compatibility and implementation across the diverse target
audience. However as a consequence the guidance lacks a
strong direction and risks being overlooked or ignored.
For this reason we urge the NICE audit team to issue audit
criteria in March 2007 which are explicit and tailored to each
organisation likely to implement the guidance. It would be useful
to allow the audit criteria to be updated six months from the
publication of the guideline: this would help to incorporate
information from the field allowing a clearer audit across
schools, drug intervention groups, police, GPs, and others.
General
Concerning the children of drug-using parents, NICE suggest
that parental drug therapy (e.g. methadone) plus counselling is
not remarkably more effective at mitigating child outcomes than
the parental drug therapy on its own. Accordingly, the guideline
does not make any recommendations in this group.
The narrow focus in this group misses an important risk factor
for substance misuse among the young: namely, the possible
access of children and teenagers to potent medications in the
home which have been prescribed to treat the parent’s drug
misuse.
Stakeholder response table – guidance consultation
Response
Please respond to each comment
Thank you for your comments. The guidance has
been amended.
NICE public health guidance is for those working
in the NHS, local authorities and the wider public,
private and voluntary sectors. NICE public health
intervention guidance makes recommendations
on clear activities (interventions) to promote a
healthy lifestyle or reduce the risk of developing a
disease or condition.
The recommendations are likely to be reviewed in
2010. CASPE is carrying out a review exercise to
consider all aspects of the process for developing
audit criteria. You may wish to register your
comments at
www.nice.org.uk/page.aspx?o=auditcriteria
Thank you for your comment. There are many
risk factors for substance misuse among the
young. The Public Health Interventions Advisory
Committee (PHIAC) considers a number of
factors when developing recommendations,
including information provided by cooptees and
expert testimonies. There are areas where
evidence relates to particular age groups with
particular characteristics and the
recommendations reflect this.
p.64
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Sheffield PCT
Evidence
submitted
Section
Section1.Recomme
ndation 1.
“Professionals in the
NHS, local
authorities,
education, social
care, the voluntary
sector and the
criminal justice
system should
identify vulnerable
or disadvantaged
young people aged
over 16 who are
misusing
substances.”
Section1.Recomme
ndation 1.
“Professionals in the
NHS, local
authorities,
education, social
care, the voluntary
sector and the
criminal justice
system should
identify vulnerable
or disadvantaged
young people aged
over 16 who are
misusing
substances.”
Stakeholder response table – guidance consultation
Page
Number
Page 5
Page 5
Comments
Please insert each new comment in a new row.
What governance do NICE recommendations have over
employees within local authorities, education, social care, the
voluntary sector and the criminal justice system?
A requirement for all these agencies to screen and identify
‘vulnerable young people’ has existed for many years as part of
the National Drug Strategy but without a clear directive from the
relevant national government departments progress has been
slow and difficult.
Response
Please respond to each comment
Thank you for your comment. NICE guidance
applies to the NHS where compliance is checked
by the Healthcare Commission. Although NICE
public health guidance has no statutory or other
purchase in other sectors, engagement with
stakeholders and working via DH with other
government departments, NICE will produce
public health guidance to address the needs of
local government, the education sector and
others to meet their public health responsibilities.
The statement does not suggest an upper age limit. The
national drug strategy and NTA guidance treats services for
under 18s as separate to over 18s.
Thank you for your comment. The guidance has
been amended. It covers children and young
people aged under 25. This is the age range
covered by the public service agreement (PSA)
target for substance misuse shared by the Home
Office and DfES (see ‘Tackling drugs, changing
lives – keeping communities safe from drugs’.
Home Office 2004).
p.65
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Section1.Recomme
ndation 1.
“Professionals in the
NHS, local
authorities,
education, social
care, the voluntary
sector and the
criminal justice
system should
identify vulnerable
or disadvantaged
young people aged
over 16 who are
misusing
substances.”
Section 1.
Recommendation 1.
”They should, as
appropriate, refer
those misusing
cannabis and
stimulants for one or
more motivational
interviews by
appropriately trained
professionals.”
Page
Number
P5
p.5
Comments
Please insert each new comment in a new row.
Identifying substance misuse in young people is not
straightforward. There are no universally approved/trialled
screening tools or accredited training. Young people may not
identify a problem themselves or cover up any substance use,
especially at key universal assessment points where questions
about substance misuse might most routinely be asked.
If the wording is ‘should identify’ are there legal challenges
where a young person develops a drug problem and this was
NOT identified by, for example, an education professional?
Response
Please respond to each comment
Thank you for your comment. The Public Health
Interventions Advisory Committee (PHIAC)
considered a number of factors when developing
recommendations. The revised guidance sets out
some of these ‘considerations’ and acknowledges
that confidentiality may be an issue, especially if
the individual is a minor.
‘as appropriate’ is a useful qualifyer here, but how are
practitioners to define what is ‘appropriate’?
Thank you for your comment.
Is this definitely saying that alcohol, VSA users or
opiate/tranquilizer users should NOT be referred for these types
of programmes?
Evidence on the ground would suggest that the likelihood of
most young people identified in this way having the inclination to
consent to such a referral or turn up for an appointment is very
low. What should the practitioner do if the young person doesn’t
want to be referred?
Most existing guidance tells us that where young people are
identified as substance misusers (as opposed to just using
recreationally) that they should be referred for specialist
assessment and support (Tier 3 or treatment). This
recommendation seems to be saying something slightly different
Stakeholder response table – guidance consultation
The revised recommendations refer to any
substances.
The Public Health Interventions Advisory
Committee (PHIAC) considered a number of
factors when developing the recommendations,
including information provided by cooptees and
expert testimonies. Members of PHIAC and
external contributors are detailed in appendix C.
The guidance focused on interventions that
aimed to prevent or delay the initiation of
substance misuse (‘primary prevention’) by
vulnerable and disadvantaged young people, or
which aimed to help these groups to reduce or
p.66
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
Comments
Please insert each new comment in a new row.
and makes no reference to existing structures around the Tiered
Model of Need (HAS 2001).
Response
Please respond to each comment
stop their misuse of substances (‘secondary
prevention’). This equates to tiers 1 and 2.
The recommendations are concerned with early
identification, screening and assessment of those
at high risk of misusing substances or are
currently misusing substances; and referral to
appropriate services. The guidance emphasises
that this process is undertaken within the context
of existing systems; specifically the Common
Assessment Framework (CAF). Reference is also
made to the National Treatment Agency models
of care which are based on the four tiers of
service.
Section 1.
Recommendation 2.
“They should help
the young person to
consider their
options and set
goals for reducing or
stopping their use of
substances.”
Stakeholder response table – guidance consultation
p.5
Again, experience tells us locally that many young people have
no inclination to set goals for reducing their substance use. This
recommendation should recognise this and consider harm
reduction advice as an alternative in these cases.
This guidance did not consider tertiary
prevention/treatment of those already dependent.
Thank you for your comment. The Department of
Health asked NICE to undertake: ‘An assessment
of community-based interventions to reduce
substance misuse among the most vulnerable
and disadvantaged young people.’ Primary
outcome measures focused on reductions in the
numbers of vulnerable and disadvantaged
children and young people who start misusing
substances, and/or a delay in the time before
initiation: Among this group already misusing
substances, primary outcome measures focused
on increases in the number who stop misusing
substances and reductions in use or frequency of
use. The guidance did not aim to assess the
harm associated with substance misuse.
p.67
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Section 1.
Recommendation 3.
“Schools should
identify pupils who
are vulnerable to
substance misuse,
as well as those
who are already
misusing
substances….”
Section 1.
Recommendation 3.
“In the case of
vulnerable pupils
who have
behavioural
problems, schools
should work with
behaviour and
education support
teams (BESTs) and
the pupils’ parents.
Schools should
work with the
education welfare
service and
children’s trusts to
ensure that all the
pupils identified
receive appropriate
support at school or
through referral to
other services”
Stakeholder response table – guidance consultation
Page
Number
P6.
Comments
Please insert each new comment in a new row.
Perhaps an audit of how many schools actually achieve this in
line with the guidance would be useful as it is in practice quite a
task.
Again, there are few tools to assist schools with this process.
P6
Response
Please respond to each comment
Thank you for your suggestion. CASPE is
carrying out a review exercise to consider all
aspects of the process for developing audit
criteria. You may wish to register your comments
via www.nice.org.uk/page.aspx?o=auditcriteria
It is not clear from this description whether the ‘appropriate
support’ is wider support around a range of issues or specifically
relates to substance misuse related services.
Thank you for your comment. The guidance has
been amended.
The description implies that where a vulnerable pupil does not
have a ‘behavioural problem’ that the school should not work
with BEST teams or the pupil’s parents.
The revised recommendations no longer refer to
BEST teams.
BEST Teams are no longer in existence, at least in our local
area.
p.68
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Section 1.
Recommendation 4.
“Schools should
identify vulnerable
or disadvantaged
adolescents aged
under 16 who are at
an increased risk of
misusing
substances. They
should refer these
adolescents and
their families to a
structured
programme of
support.”
Section 1.
Recommendation 5.
“Professionals
trained in
behavioural
techniques should
provide groupbased therapy for
10–12 year olds
who are referred by
schools because of
their behavioural
problems and
vulnerability to
substance misuse.”
Stakeholder response table – guidance consultation
Page
Number
p. 6
Comments
Please insert each new comment in a new row.
This is no doubt well intentioned but a bizarre recommendation.
Effectively it says that all young people whose parents or other
family members misuse drugs, those with behavioural or mental
health problems, looked after children, those who are homeless,
young offenders, school excludees and truants, and those
involved in sex work should all receive the described family
programmes.
This would mean, for our local area, thousands of families, and
setting up this kind of programme would require intensive
resourcing.
Response
Please respond to each comment
Thank you for your comments. The guidance has
been amended.
The description does not clearly say whether the interventions
are aimed at parenting in a general sense or whether specific
focus on the substance misuse is required.
p.7.
The vast majority of families identified through this process
would not, experience would tell us, voluntarily attend the
programmes described.
It is not clear whether this is recommended in addition to the
interventions described in recommendations 3 and 4.
The age limit is unusually specific.
Thank you for your comments. The guidance has
been amended. The guidance focuses on
vulnerable and disadvantaged people up to the
age of 25, however there are areas where
evidence relates to particular age groups.
It is not clear whether the interventions described are fairly
universal parenting and life skills type interventions (and
therefore potentially beneficial against a range of outcomes) or
specifically tailored around substance misuse.
The potential numbers involved here are again potentially huge
under the existing description.
p.69
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
GENERAL
GENERAL
Stakeholder response table – guidance consultation
Page
Number
Comments
Please insert each new comment in a new row.
The document does not make clear enough a definition of
substance misuse as opposed to substance use (or recreational
substance use). This is a key factor in determining the
appropriate level of intervention. The document therefore is
inherently flawed as it seems to base it’s recommendations that
an accepted definition of substance misuse is in operation
across a range of children’s service delivery areas. In reality the
fact that substance misuse is so difficult to pin down as a
concept is a key block to developing consistent preventative
responses.
The document should make clear that some young people,
including those in ‘vulnerable groups’ use a range of substances
in a non-problematic way.
The second key issue that is not recognised by the document is
the role of young people’s views on their own ‘problems’, and
the consequent motivation to be inclined to do anything about
them. The assumption seems to be that the identification of
‘substance misuse’ is a straightforward task where practitioners,
parents and young people all happily agree the definition of a
‘problem’. What possible attraction is there for a 15 year old
heavy cannabis user in attending a ‘motivational interview’ on a
voluntary basis if he does not believe that his use of cannabis is
a problem needing help?
Response
Please respond to each comment
Thank you for your comments. The guidance has
been amended.
Thank you for your comment. The Department of
Health asked NICE to undertake: ‘An assessment
of community-based interventions to reduce
substance misuse among the most vulnerable
and disadvantaged young people’. The
‘considerations’ section in the revised guidance
document now covers this point. You may wish
to suggest a future topic for NICE guidance at
www.nice.org.uk/page.aspx?o=ts.home
p.70
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Page
Number
GENERAL
Tacade
Recommendation 1
Recommendation 2
5
5
Recommendation 3
6
Recommendation 4
6
Recommendation 5
7
Recommendation 6
7
Stakeholder response table – guidance consultation
Comments
Please insert each new comment in a new row.
The document appears in general to ignore some key issues in
relation to the potential need for the interventions described.
Response
Please respond to each comment
Thank you for your comments. There is a lack of
universal consensus around some definitions.
For example there are a myriad ways one could define a ‘truant’
but if at a basic level we take the definition as a young person
who has ever taken a days unauthorised absence from school
(the definition used in the British Crime Survey) we end up with
thousands and thousands of young people. It would in fact be a
dangerous overstatement to say that all these young people
should automatically be required to attend additional lifeskills
groups and parenting courses in order to prevent possible future
drug use as seems to be suggested in recommendation 4.
A distinction was made between the scale of the
intervention (for example, in terms of such things
as duration, intensity and frequency) and the
scale of the target population.
The potential scale these programmes would need to be, based
on the recommendations as they are, would be in direct
contradiction of the general issues in the introduction on page 5,
that the interventions are ‘micro interventions’ or ‘small scale’.
Agree
This could be a difficult area as acceptance of substance misuse
as harmful by YPs is low.
Training would have to be in place in all schools at all levels to
identify such YPs, the current workload and change in attitude
teachers have to getting close to their YPs in light of civil action
around sex abuse and political correctness claims means often
teachers miss the signs.
Agree they should but do they have the skills in place to do so?
Also once referred are the resources available to cope with the
possible demand?
Will there be enough resources to make this happen and of the
right quality?
This I believe already happens in respect of DAATs and would
just need coordination with the other agencies. But what do you
do with the results?
Thank you.
Thank you for your observation.
Thank you for your comment. The
‘considerations’ section in the revised guidance
now covers this point.
Thank you for your comment. Please refer to our
previous response. Please also note that
information about allocation of resources is
beyond the remit of this guidance.
Thank you for your comment. Please refer to our
previous response.
Thank you for your comment. The guidance has
been amended.
p.71
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Vul., & dis. YP
Page
Number
9
Policy
10
Implementation
10-11
Research
12
Needs to be linked fully to the identified needs of the vulnerable.
Glossary
14
Would suggest drugs definition in line with WHO
Evidence
statements
19-
The effect each intervention has on individual families or YPs
may not be as effective as on another and so it is good to see a
wide range of evidence has been sought. The problem with
such evidence is making it available in a understandable format
to all those concerned.
Stakeholder response table – guidance consultation
Comments
Please insert each new comment in a new row.
Will there be a national data base to maintain this information as
many YP and their families are transient in nature moving from
one PCT to another. Often records are months in catching up
and many YPs could slip through the net as it were.
Not all of these policies may be important to the agencies
identifying the YPs and as such information exchange could be
a problem.
Will training be offer to those wishing to use the NICE tools?
Response
Please respond to each comment
Thank you for your comment. The guidance has
been amended.
Thank you for your comment. This section
outlines numerous policies and it is recognised
that some policies might be more pertinent to
particular agencies, compared to others.
Thank you for your question. Use of tools is being
considered, and has been explored with users
through workshops. The costing tools are
released with a ‘how to use’ sheet and there is an
email address that people can use
‘[email protected]’to ask questions about the
costing tools, plus [email protected] for more
general feedback.
Thank you for your comment. The guidance has
been amended.
Thank you for your suggestion. After much
deliberation the definition in the guidance was
chosen. It does not conflict with that used by
WHO and is much more succinct (8 lines of text –
see
www.who.int/substance_abuse/terminology/who_
lexicon/en/ )
Thank you for your comment. There are
difficulties in using a universal language that is
welcomed by everyone involved in the guidance
development process. We aim to write our
guidance as clearly and succinctly as possible, so
that it is accessible to all potential users.
p.72
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Evidence
Statements
Page
Number
19 -
Evidence
statements
19 -
Cost-effectiveness
21
Standing committee
22
26
Stakeholder response table – guidance consultation
Comments
Please insert each new comment in a new row.
Training must be in the forefront of using these evidence
statements and by do so effectively you can signpost workers in
the correct direction at least as a starting point to engage the
family or YP
The flaw with some evidence statements is there ability to
‘pigeon hole’ people into certain areas without exploring all the
facts or having the time to do so correctly. Often YP are wrong
placed and instead of improving according to the statement do
quite the reverse.
Cost should be focus on obtaining interventions with the YP etc,
however small and not ‘wasted’ on too much research, unless
that research is part of the monitoring of the client base
effectively.
Will this be an effective committee and not just one which meets
talks and produces little? It does cover a lot of people who
unless I am mistaken have extremely busy workloads within
their own professions, are they going to give the required
amount of time, energy and focus to help this guidance work?
Again here the question of what is effective, how do we judge
that? Abstinence, reduction, harms prevention and
minimisation, education or a greying of each? A reduction of
someone substance misuse from seven days a week to five is
effective but some agencies have been known to disagree.
Provision of education which may or may not be accepted.
Response
Please respond to each comment
Thank you for your comment. The
‘considerations’ section in the revised guidance
document now covers this point.
Thank you for your comment. The
‘considerations’ section in the revised guidance
document now refers to this point. In addition,
ensuring that activities do not increase misuse
among this population is considered as a
recommendation for research.
Thank you for your comment. Please note that
information about allocation of resources is
beyond the remit of this guidance.
The PHIAC was formed in 2005. Guidance has
already been published in three intervention
areas and is in development for a further eight.
Thank you for your comment. There is a lack of
consensus around different concepts and
definitions for substance misuse. You may wish
to refer to documents outlining the public health
guidance process and methods at
www.nice.org.uk/page.aspx?o=300576 which
explain how effectiveness is judged.
In addition, appendix D of the revised guidance
summarises the methods used to develop it.
p.73
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
The document
The Mentor
Foundation
(International)
Page
Number
All
Comments
Please insert each new comment in a new row.
A good base from which to work, but it needs to be more than
guidance to be effective, it needs to have a PI attached to make
accountability part of the way it works.
1.
The Mentor
Foundation
2.
3.
4.
5.
6.
Stakeholder response table – guidance consultation
The reference to other “vulnerable groups” who have
not been the focus of this work gives concern. Would it
better to state at the outset those groups that have
been the focus and identified as such and then make
reference to those who have not been the focus and
the need for work and support to them. To some
degree all young people are “vulnerable” in different
ways and to different degrees.
The definition of substance misuse remains unclear
and should be specific in terms of reference to legal as
well as illegal substances and should also address the
misuse of prescribed and over the counter drugs.
What is the distinction between use and misuse of
cannabis?
Recommendations 1 and 2
a. Is one hour really sufficient? What about the
need for the interviewer’s training and
qualifications in the area of substance use and
misuse, prevention, education etc. What about
the follow up?
Recommendation 3
a. This appears very general and starts with
schools to say the obvious and then opens up
to other groups still linked to a school
recommendation? What about those not
attending school?
Recommendation 4
Response
Please respond to each comment
Thank you for your comment. The
recommendations aim to contribute to the
achievement of the PSA target for reducing
substance misuse of all those under 25
Thank you for your comments. The guidance has
been amended.
1. The guidance sets out groups included in the
definition of vulnerable and disadvantaged
children and young people. There are areas
where evidence relates to particular sub-groups.
Where evidence is lacking, the guidance
recommends further research.
2. The guidance has been revised to include a
definition of substance misuse that includes
reference to legal and illegal drugs.
3. The guidance focuses on substance misuse
and a definition is provided.
4. Please note that there are areas where
evidence relates to particular intervention
characteristics. The ‘considerations’ section in the
revised guidance document now covers this
point.
5. Please note that there are areas where
evidence relates to particular intervention
characteristics.
p.74
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Evidence
submitted
Section
Stakeholder response table – guidance consultation
Page
Number
Comments
Please insert each new comment in a new row.
a. I presume the understanding of the term “at
risk” will be explained somewhere in the
document.
b. Is there a need to be more specific about who
would be providing the extra input/support
once identified as “at risk”?
7. Recommendation 5
a. Whilst this may be extremely valuable given
the right context, provision and providers
surely the stress should be on the need for all
children to receive this input as part of their
basic education
8. Recommendation 6
a. I am concerned that the categorising of
vulnerable groups in this way misses out so
many individuals who are equally vulnerable
but who do not fall into any of the identified
categories.
Response
Please respond to each comment
6. The revised guidance recommends that
practitioners use screening and assessment tools
to identify vulnerable and disadvantaged young
people at risk of misusing substances, such as
the Common Assessment Framework and those
available from the National Treatment Agency.
6. b) The guidance has been amended.
7. Please note that there are areas where
evidence relates to particular intervention
characteristics. In addition, the Department of
Health asked NICE to undertake: ‘An assessment
of community-based interventions to reduce
substance misuse among the most vulnerable
and disadvantaged young people’.
8. Please note that there are areas where
evidence relates to particular sub-groups. Where
evidence is lacking, the guidance recommends
further research. You may wish to suggest a
future topic for NICE guidance at
www.nice.org.uk/page.aspx?o=ts.home
p.75
Public Health Interventions Advisory Committee
Substance Misuse Consultation on the Draft Guidance – Stakeholder Response Table
November to December 2006
Stakeholder
Organisation
Training &
Development
Agency for Schools
Evidence
submitted
Section
1
Page
Number
6
1
7
Stakeholder response table – guidance consultation
Comments
Please insert each new comment in a new row.
Recommendation 3&4: The development of skills and systems
in schools for the identification of vulnerable pupils is underway,
and also a culture change placing responsibility with staff and
governors for wellbeing of the child in addition to educational
attainment. However, NICE needs to be aware that these
developments will take time to deliver consistent practice in
identification and early intervention, and progress is patchy at
present. Therefore there is a capability issue for some schools
with these recommendations in the short to medium term. For
example, the requirement for all schools to use referral
mechanisms into specialist teams is by 2010, although the
mechanisms should be in place ahead of this.
Recommendation 5: The TDA is not aware of any systems in
place or in development for the identification of pupils vulnerable
to substance use (as opposed to more general behaviour
problems) before the age of 10. There are vulnerability matrices
in use in some senior schools, but not in the primary school age
group currently.
Response
Please respond to each comment
Thank you for this information. It will be passed to
the NICE Implementation Team.
Thank you for this information. It will be passed to
the NICE implementation team.
p.76