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Prevention

Intervention and Treatment

Introduction and Overview

THE DRUG CRISIS IN AMERICA

Summary: Preventing substance use, particularly among youth, is not only a laudable goal in the interest of public health and overall financial savings, but it is one that is achievable. If a child does not use substances by age 21, they are unlikely ever to do so. Unlike many other disorders, substance use disorders––and the preceding initiation of substance use––are preventable. This underscores the importance of primary prevention and the need for early intervention when a young person initiates substance use. If we reduce the initiation of substance use, we will markedly reduce drug use and its consequences, including addiction.

While investment in prevention doesn’t show immediate returns, playing the long game and investing in prevention interventions can save lives and dollars.

– Nora Volkow, MD, Director of the National Institute on Drug Abuse
Goals
  • The past-year use of illicit drugs among 12–17-year-olds is reduced by 20% by 2030, from 14.7% in 2023 to 11.8% in 2030.
  • The mean age of past-year initiates of marijuana, cigarettes, and alcohol is increased by 10% by 2030.
  • The percentage of 12–17-year-olds that saw or heard drug or alcohol prevention messages in school is increased by 20% by 2030, from 68.1% in 2022 to 81.7% in 2030.
As detailed in the 2019 Institute of Medicine Report, at least 17 evidence-based family and parenting programs have been shown to significantly improve the quality of home life, helping to prevent many behavioral problems, including substance use. Numerous tested school-based interventions can prevent these problems as well, from early childhood into adulthood, by improving school climate, learning, and school attachment. Prevention strategies have the added benefits of improved academic performance, reduced bullying and violence, and better emotional and physical health that enhance positive community participation.

Certain policies, such as the legalization and commercialization of marijuana, have reduced risk perceptions and increased the availability of drugs, which are predictors of future drug use. There has been insufficient funding for prevention programs, and those that are funded and implemented are not always those grounded in evidence-based practices. The growing normalization of drug use threatens to reverse long-term declines in the youth use of drugs.

Every $1 invested in effective substance use prevention programs is estimated to result in savings of between $2 and $20. Extensive analyses of the costs and benefits of these programs indicate that most cost far less than they save in reduced healthcare, criminal justice, mental health, and educational costs, and in increased income among recipients. A 2016 report from the Surgeon General noted, “Interventions that prevent substance use disorders can yield an even greater economic return than the services that treat them.”

Summary: Prevention messaging, programming, and interventions can succeed only if enacted within a policy and environmental landscape that reduces the appeal, exposure, and access to substances. Legalization, at least in the United States, begets commercialization, wherein for-profit industries shape public perceptions and work to increase appeal for their products. Policies must counteract the growing influence of these well-funded, well-connected for-profit industries, addressing all spheres of the social ecological model of health.

Description: In order to protect youth from initiating substance use, progressing to regular use, and experiencing the harms of substance use, policymakers must:

  1. Counteract the impact of legalization of substances: Policies must blunt industries’ ability to commercialize their products. Limiting the reach of legalization will help to reduce the normalization of substance use and allow the public to have an accurate perception of their risks. At a minimum, new models of legalization should more closely adhere to how cigarettes, rather than alcohol, are regulated, since the taxes are for the most part quite high and increasing with inflation; there are significant, policy-imposed restrictions on marketing and packaging, including effective warning labels; and there are limits on extensions such as flavorings. This also includes regulation of the quantity of substance delivered. When possible, legalization and commercialization should be resisted.
  2. Demand reduction: Proven policies to reduce demand and use among youth include minimum age laws and their enforcement, higher prices (through taxes, minimum pricing, and restrictions on price promotions such as discounting and happy hours), restrictions on advertising and marketing, regulating the design and content of the products to reduce appeal (e.g., banning flavors, appealing packaging), and limiting exposure to substances by restricting public use and sale in areas where young people typically congregate (e.g., near schools, parks). Public awareness and education campaigns also help to inform the public and reduce demand––successful programs should be brought to scale. Anti-smoking campaigns contributed greatly to the reduction of cigarette use and should be considered as a model for drug use reduction.
  3. Supply reduction: Reducing supply can be accomplished through policies that restrict the amount and potency of nicotine, THC, and other addictive ingredients in products so that experimentation does not escalate to regular use; restrict the number of retail outlets that can operate within a given geography or population density; strictly enforce laws that prohibit sale to underage youth (where the penalties fall on retailers, not young people); and fund adequate data collection and monitoring of the drug supply to anticipate and address emerging and escalating drug threats.

Summary: A visionary strategy should promote a health standard that normalizes the non-use of substances. This strategy should strengthen protective factors and address risk factors. Legislative actions should mitigate the impact of adult use and inform the attitudes of youth.

Description: The multiple life-course conditions that influence whether an individual will develop an addiction are alterable and, in many cases, preventable. Protective conditions can be strengthened, while detrimental conditions can be attenuated or eliminated altogether. Implementation of effective policy solutions will, in turn, inform wiser expenditures with potential to make a measurable dent in the drug problem.

  1. Programs and policies need to be implemented across the life-course, with special emphasis on early childhood and adolescence. For example, the Drug-Free Communities Support Program from the national Office of National Drug Control Policy represents a scalable youth-focused program that engages diverse sectors of a community. Infrastructure at the community level and supported by federal legislation is needed to systematically and effectively implement this visionary health standard, from universal prevention to more targeted and indicated interventions. A community-based comprehensive service delivery system would provide and sustain an array of evidence-based preventive services. Local, state and federal policies can thus be formulated to equip communities to meet the diverse needs, values, customs, and preferences of their members in a culturally appropriate way.
  2. Programs and policies should also be incorporated into cross-sector service delivery systems (e.g., child welfare, healthcare, education with a focus on K-12, justice, integration with faith-based communities), which would substantially expand the scale at which benefits are achieved. The end goal is to spur a shift in cultures, priorities, and practices that, in turn, influence policies, distribution of resources and system-level relationships. Proactive strategies for early identification of the warning signs and preventing exposure to contributory conditions during childhood are most promising. In short, true improvements in our nation’s drug policies require a more balanced portfolio that supports tertiary approaches (e.g., treatment, regulations) and a hefty dose of prevention, guided by empirical evidence.
  3. A “Culture of Prevention” should normalize prevention practices in our daily lives to foster healthy developmental pathways and avoid negative outcomes. There are three basic drivers of normalization. First, increasing knowledge that the science of human development has potential to change attitudes and mindsets. The second driver is that underage substance use greatly risks the normal development of the still maturing adolescent brain. The third driver is the adoption of the active ingredients of proven programs, which have been shown to influence specific behaviors. Integrating a wide range of these practices and principles into daily interactions has potential to more broadly and sustainably promote health and wellbeing, independent of a particular intervention or limited money stream.

Summary: There is a need to develop and sustain the proper infrastructure for substance use prevention at all levels of government. Absent this explicit focus, youth substance use issues are usually ignored and subject to denial.

Description: The necessary infrastructure to achieve population-level changes requires the following evidence-based processes: 1) assess prevention needs based on epidemiological data; 2) build prevention capacity; 3) develop a strategic plan; 4) implement effective prevention programs, policies, and practices; 5) evaluate efforts for outcomes; 6) ensure these efforts are sustainable through adequate funding and emphasis; 7) and ensure all efforts reflect cultural competence for the populations and subpopulations being served.

  1. The baseline level of implementation for substance use prevention should include the mix of strategies, programs, policies, and services to meet identified needs for “universal” prevention (aimed at everyone who has not yet initiated use) throughout all relevant settings (community, schools/peers, workplace, houses of worship, family, etc.). As part of the comprehensive process for planning, implementation, and evaluation, states and communities will have identified needs and gaps for programs and services for higher risk subgroups in the population including individuals and groups identified as “selected and indicated” under the IOM definition of prevention.
  2. In order for states and communities to build, strengthen and maintain the infrastructure for substance use prevention, it is imperative to educate, train and provide technical assistance for a substance use prevention professional workforce as well as others in ancillary fields that are participating in sectors and settings aligning with the implementation of the strategic prevention framework.
  3. The comprehensive infrastructure for state and community-based substance use prevention must be taken to scale with adequate investments of Federal, state and local resources allocated to fully implement it at all levels of government. Funding should reach communities in an equitable manner, ensuring that all populations receive the benefits of prevention.