“We have the science,” said Kana Enomoto, acting deputy assistant secretary of the Department of Health and Human Services (HHS), where she is in charge of prevention and treatment of mental health and substance use disorders. “We know what to do.”
More than 60 prevention programs and policies are identified in Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health released last year (see ADAW, November 21, 2016), noted Enomoto. “These evidence-based interventions hold the promise of saving and restoring thousands of lives,” she said.
Because early substance misuse is linked to more serious problems in adulthood, many prevention programs are targeted to youth, said Frances M. Harding, director of the Center for Substance Abuse Prevention, one of the agencies under Enomoto’s direction. “According to research, risk factors increase the likelihood that a person will develop a substance use disorder [SUD], while protective factors can reduce the likelihood,” said Harding. “Substance use prevention programs are designed to target these factors to reduce risk and increase protection against SUD.”
Prevention research suggests that early childhood experiences can impact lifelong health. “The Adverse Childhood Experiences (ACEs) study investigated the impact of abuse (emotional, physical and sexual), household challenges (mother treated violently, household substance abuse, mental illness in household, parental separation or divorce, criminal household member) and neglect (emotional and physical) on later-life health and well-being,” said Harding. “The more adverse experiences reported, the higher the risk for substance use problems, such as alcoholism and drug abuse in adulthood. This suggests that intervening early in life with children and reducing children’s exposure to these events can reduce the incidence of substance misuse.”
Important risk factors include: poverty, child maltreatment, family dysfunction, family disruption, neighborhood disadvantage (e.g., the absence of settings that provide opportunities for healthy child development — settings for learning, social and recreational activities, child care, quality schools, health care services and employment opportunities), school disadvantage (e.g., high percentage of children from families in poverty, a higher number of inexperienced and academically unprepared teachers, a high student-to-teacher ratio and school size being either too large or too small) and association with deviant peers.
Important protective factors include: social support, coping skills, prosocial bonds or attachments to school, and having high expectations for students.
Interventions might include those designed to increase children’s competencies and positive mental health or strengthening families, schools or communities.
“Despite these shared factors, prevention may look different for those children whose parents have a history of substance use disorder,” said Harding. “Indeed, family history of SUD is an important risk factor for developing SUD later in life. And, while such family history might be associated with some of the risk factors noted above (e.g., family dysfunction and child maltreatment), treating the parent’s substance use disorder and facilitating his or her recovery is part of the prevention strategy, along with other strategies focused on family functioning.”
A 1994 meta-evaluation of D.A.R.E. (Drug Abuse Resistance Education) found that the program does affect attitudes toward drug use and police, as well as self-esteem, but does not have an effect on drug use behavior, said Harding. “In the same study, D.A.R.E. was found to be substantially less effective than programs emphasizing social and general competencies and using interactive teaching strategies.” The study was published in the American Journal of Public Health. Still, it was popular — especially with police departments — and continued to be used despite reports showing that it not only was ineffective but actually increased drug use (see ADAW, April 16, 2007).
And “Just Say No,” the first drug prevention federal concept articulated by Nancy Reagan, is not even a program anymore.
However, there are a number of school-based programs that have shown positive results.
There are also family-based programs that focus on young adolescents and their parents.
There are also harm-reduction approaches, in which young people may experiment with drugs and then stop, instead of moving on to an SUD, said Harding. “The Institute of Medicine developed a classification system for prevention interventions according to the population they target,” she said. The classifications are:
- Universal interventions target the general public and/or the whole population that has not been identified on the basis of individual risk.
- Selective interventions target individuals or a population subgroup whose risk of developing mental or substance use/misuse disorders is significantly higher than average.
- Indicated interventions target individuals at high risk who have minimal, but detectable, signs or symptoms of mental illness or substance use/misuse problems (prior to the diagnosis of a disorder).
“A harm-reduction approach often targets indicated populations that have already begun to use substances and the focus is not abstinence, but reducing overuse and misuse,” said Harding. Examples of prevention interventions that have demonstrated effectiveness in reducing substance misuse:
- Alcohol screening and brief intervention: Brief intervention sessions grounded in Motivational Interviewing and cognitive behavioral skills training.
- Brief Alcohol Screening and Intervention for College Students: Personalized feedback where a participant’s rate of drinking is compared with peer norms. They also receive information regarding perceived drinking risks and benefits, drinking behavior myths, alcohol effects and tolerance effects.
- Motivational enhancement therapy: Counseling intervention adapted from Motivational Interviewing to include normative assessment feedback for clients.
- Motivational Interviewing: Individualized counseling intervention designed to assist clients in addressing ambivalent attitudes related to a wide array of problem behaviors, including substance use.
Last year before UNGASS, Sue Thau, public policy consultant to the Community Anti-Drug Coalitions of America (CADCA), wrote a chapter on prevention in a paper for Drug Policy Futures. She explained the infrastructure needed to achieve population-level changes in substance use. Communities must engage in a five-step evidence-based process, she said:
- Assess prevention needs based on epidemiological data.
- Build prevention capacity.
- Develop a strategic plan.
- Implement effective community prevention programs, policies and practices.
- Evaluate efforts for outcomes.
“The strength of this comprehensive approach is that it not only identifies a community’s issues, problems and gaps, but also its assets and resources,” wrote Thau. “This allows a community to plan, implement and evaluate its efforts across all community sectors in all relevant settings for individuals, families, schools, workplaces and the community at large.”
Generalized universal prevention programs to help build strong families and provide youth with the skills to make good decisions are necessary, said Thau. “However, there is also a need to focus specifically on environmental strategies, which include changing social norms and reducing access and availability through systems and policy changes,” she said.
The Drug-Free Communities (DFC) program, which is administered through the Office of National Drug Control Policy, has been a central component of demand reduction since 1998 when it started, said Thau.
The most recent (2014) national evaluation of the DFC program showed that “both perception of risk and perception of parental disapproval of illicit use of prescription drugs increased significantly within middle school and high school youth” in DFC-funded communities, while the percentage change in past 30-day illicit use of prescription drugs also decreased significantly within both middle school and high school youth.
When coalitions get to the implementation phase of the five-step evidence-based process, CADCA trains them on how to execute seven strategies to affect community change and achieve population-level reductions in youth drug use: providing information, enhancing skills, providing support, enhancing access/reducing barriers, changing consequences with incentives/disincentives, environmental improvements (parks, lighting, outlet density) and modifying or changing policies.
The average effective school-based drug prevention program in 2002 cost $220 per pupil, including materials and teacher training. Balance this against the $193 billion a year substance use disorders cost taxpayers, according to a 2011 report from the Department of Justice. These programs could have saved an estimated $18 per $1 invested if implemented nationwide.
Underage drinking, drunk driving
Perhaps the most obvious prevention success is alcohol. Raising the legal drinking age to 21 and drunk driving laws have had dramatic effects in reducing drinking by young people and in reducing alcohol-related traffic deaths, said Ralph W. Hingson, director of the Division of Epidemiology and Prevention Research at the National Institute on Alcohol Abuse and Alcoholism (NIAAA). “These are two areas where we have widely studied, clear and consistent benefits,” Hingson told ADAW.
In 1984, only 17 states had raised the drinking age to 21. Congress passed legislation withholding transportation funds to states that didn’t raise the drinking age. The states did. The good news is in the Monitoring the Future study of the National Institute on Drug Abuse: the proportion of high school seniors who engage in binge drinking has been cut in half since then.
There has also been a significant decline in alcohol-related traffic deaths, including alcohol-related traffic deaths of drivers under 21, said Hingson.
Laws aimed at adult drivers, such as lowering the alcohol limit to .08 and administrative license revocation, have produced further reductions in alcohol-related traffic deaths.
Since the early 1980s, alcohol-related traffic deaths have been cut in half, said Hingson. “As many as 300,000 lives have been saved as a result,” he said. This came in part because the Department of Transportation requires that fatally injured drivers be tested for alcohol.
This kind of research is essential, said Hingson. “The reason that Congress decided to raise the drinking age to 21 was because of research showing that in states where the drinking age was lower, there were increases in alcohol-related traffic deaths,” he said.
Screening and brief intervention (SBI) for alcohol problems is effective as well, said Hingson, especially if the drinking is at-risk but not heavy. It’s particularly important to prevent underage drinking, he said. “We know that the younger people are when they start to drink, the more likely they are to develop dependence at some time in their life,” he said. “There are also a number of studies of family interventions, in which parents talk to their children about alcohol and set boundaries.”
One of the problems with SBI is that few physicians use it, said Hingson. He conducted a national survey in 2012 using a probability sample of 18-to-39-year-olds. Two-thirds had seen a physician in the past year, but only 13 percent had been asked about drinking. “The people least likely to have been asked were the 18-to-24-year-olds — the people who could have benefited the most,” he said. For another study he did, published in JAMA Pediatrics, about 80 percent of 16-year-olds had seen a physician in the past year. Half were asked about drinking and smoking. But of those who reported being intoxicated six or more times, only one in four were told it would be a good idea to reduce their drinking, he said. “I don’t know why they weren’t being asked,” said Hingson, noting that one research from Brown University has recommended that every single college student should be given a brief alcohol intervention.
Marijuana is going to be the next issue in terms of driving safety, said Hingson. There is some evidence that there is an increased risk for traffic accidents with marijuana legalization. It is known that marijuana impairs performance. “Some people say that people will switch from alcohol to marijuana” in states that have legalized recreational use, said Hingson. NIAAA’s database includes marijuana.
The National Institute on Drug Abuse referred our questions to the Substance Abuse and Mental Health Services Administration.