This research aimed to identify first aid strategies that members of the public could carry out to assist someone developing problem drug use or experiencing drug-related crises. We have shown that it is possible for experts to reach consensus on first aid for problem drug use that can be applied across several types of illicit drugs. Over one-hundred first aid strategies were endorsed from a comprehensive range of first aid suggestions. The endorsed strategies were written into a cohesive guideline document. This is currently the only resource that provides consensus on mental health first aid strategies for problem drug use between expert clinicians, carers, and consumers.
Although one of the aims of the study was to provide guidance on how community members could facilitate help seeking for problem drug users, there was generally low endorsement of directive methods or encouragement for them to seek help. For example, the strategies The first aider should suggest the person attends a support group, The first aider should offer to make an appointment
, and The first aider should enlist the help of others (such as a doctor, relative or friend) to confront the person as a group
, were all outright rejected in the first round of the survey. Rejection of the last item is consistent with the research evidence on confrontational approaches (e.g. Johnson Intervention)[20
], which highlights a low success rate in engaging the person with treatment services, as well as increasing the risk of long-lasting distress as a result of the perceived betrayal and secrecy involved in their organization [6
Rather, the guidelines indicate that the general approach the first aider should take is to remain supportive and approachable, support the person in seeking help or changing their behaviour if that is their wish, but not be overly forceful or impinge on their autonomy. Panel members wrote, "pushing 'seeking help' may interfere with the relationship and cause the drug user stress, which could exacerbate the drug taking" and "you can lead a horse to water but you can't make them drink.... you can't force a person to seek professional help, as they will probably continue to use more secretively, which can cause more harm to themselves". The endorsement that it is the drug user's decision to seek help, and first aiders should not force them to, is consistent with mental health first aid guidelines for other problems (e.g. problem drinking, suicidal thoughts and behaviours). These acknowledge that the role of the first aider is only to support and assist the person if they want to seek help, subject to particular caveats. However, the guidelines acknowledge the difficulty first aiders face in maintaining a good relationship with the person while accepting that they cannot make the person change if they do not want to reduce or cease their problem drug use. One endorsed exception to ensuring the person's autonomy was permission for first aiders to disclose the person's drug use to a professional when they were at risk of harming others.
Some family members or partners engage in enabling behaviours that potentially reinforce the person's ongoing drug use. These behaviours include specific types of caretaking (e.g. taking over childcare or paying living expenses) and attempts to stabilise external situations caused or exacerbated by drug use (e.g. making excuses or lying to others to protect the drug user) [21
]. These occur as a way of coping with the drug abuse when the person refuses to change their behaviour or seek help. Enabling behaviours are assumed to be maladaptive and are often a target for clinical interventions. Panel members were generally consistent with this view of enabling, with endorsement of most of the items that discouraged enabling behaviours. The strategy The first aider should not take on the person's responsibilities
was endorsed by all three panels in Round 1, and the strategies The first aider should not use drugs with the person
and The first aider should not cover up or make excuses for the person
were accepted in Round 2 after re-rating. However, The first aider should not provide the person with money to buy drugs
and The first aider should never get involved with helping the person acquire drugs, e.g. driving the person to meet the dealer
were not endorsed as first aid strategies. Strategies that took a harder line on discouraging enabling were less likely to be endorsed. For example, the strategies The first aider should deny the person basic needs, such as keeping them warm, clean and nourished
, and The first aider should hide or throw out the person's drugs
were only endorsed by about 3% of panel members.
The study involved an international sample of experts in problem drug use. These were selected as 'information-rich' sources of expertise. However, it was apparent after the first round of the questionnaire that panel members found it hard to relate to the concept of helping someone with a developing, rather than just an entrenched, drug use problem, and in situations beyond the more familiar physical health crises requiring physical first aid. Therefore, although a departure from the usual Delphi approach, it was decided to resubmit some strategies to the panel to rate. We emphasized more clearly that the strategies were for developing disorders, as well as entrenched drug problems, in order to make sure that strategies were not being rejected because panel members found them inappropriate for those with entrenched drug disorders alone. However, as noted above, panel members did not significantly change their ratings, indicating that first aid recommendations do not differ depending on the stage of problem drug use.
The guidelines were developed specifically for Western, English speaking countries and may have limited applicability to other countries. They also may not be applicable to cultural minorities within English-speaking countries. However, other mental health first aid guidelines have been adapted for other cultures (e.g. Problem drinking for Australian Aboriginal and Torres Strait Islander Peoples [23
]) so adaptations for other cultures are possible. The guidelines were designed to inform the content of MHFA training programs, and have been used in the development of an improved second edition of the MHFA training course [24
]. Although previous trials have found MHFA training effective in improving knowledge, reducing stigma and increasing helping behaviour [1
], studies of the updated training course are required to ensure its effectiveness and that there are not unintended harms, such as labelling people in a way that might increase stigma and marginalization. The use of the guidelines as a stand-alone document is also yet to be tested, but research is currently underway to investigate whether people who download the guidelines from the MHFA website find them useful in providing first aid.