Alcohol and drug addiction is a real problem in the United States. According to the US Department of Health and Human Services (2008), the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) administered by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) found that “8.5 percent of adults in the United States met the criteria for an alcohol use disorder, whereas 2 percent met the criteria for a drug use disorder and 1.1 percent met the criteria for both” (pp. 1). This survey ultimately observed the extent to which alcohol and other drugs are misused in the US. The NESARC survey found that individuals who exhibit drug dependency have a higher chance of developing disorders related to alcohol use. However, individuals who exhibit alcohol dependency are not as likely to develop issues with illicit drugs. The survey identified young adults ages eighteen to twenty-four as the population with the greatest issues related to concurrent alcohol and drug use disorders. Also, while examining specific populations, the survey showed that men are more likely to experience issues related to chemical dependency than women.
In terms of alcoholism specifically, the National Council on Alcoholism and Drug Dependence (NCADD) states that “17.6 million people, or one in every twelve adults, suffer from alcohol abuse or dependence along with several million more who engage in risky drinking patterns that could lead to alcohol problems” (n.d., p. 1). Clearly, alcohol is the most frequently abused chemical in the United States. Often times, alcohol use disorders can be traced throughout family histories. Over 50 percent of adults report some sort of family history of negative impacts related to alcohol use. Additionally, over seven million youth have been reported to reside in a home that also houses at least one parent who demonstrates difficulty with alcohol use. In reference to drug dependence, as cited by the NCADD website, the National Survey on Drug Use and Health (NSDUH) found that nearly “Twenty million Americans aged twelve or older used an illegal drug in the past thirty days” (n.d.). Such a value accounts for approximately eight percent of the population aged twelve and up. It was also found that the recreational use or misuse of prescription drugs is on the rise; so much so, that it was predicted that nearly forty-eight million adolescent and adult Americans aged twelve and over have used or are using prescription drugs for the unintended effects. The survey reported that this statistic characterizes almost 20 percent of the population. These numbers are staggering and speak to the increasing prevalence of substance related issues in the United States.
Onset of Use
Though alcohol and drug addiction may affect any individual at any age, “Addiction is a disease that in most cases begins in adolescence, so preventing or delaying teens from using alcohol, tobacco or other drugs for as long as possible is crucial to their health and safety” (US News, 2011). A study conducted by the National Center on Addiction and Substance Abuse (CASA) at Columbia University found that “90 percent of Americans who meet the medical criteria for addiction started smoking, drinking or using other drugs before age eighteen” (2011). The researchers also revealed that “One in four Americans who began using any addictive substance before age eighteen are addicted, compared to one in twenty-five who started using at age twenty-one or older” (CASA Columbia, 2011).
In another report by Hingson, Heeren, and Winter (2006), as cited by Hazelden (2010), it was indicated that “adolescents who begin drinking before age fourteen are significantly more likely to experience alcohol dependence at some point in their lives compared to individuals who begin drinking after twenty-one years of age” (Hingson, Heeren, & Winter, 2006; Hazelden, 2010).
Based on the current literature and research available, adolescent experimentation with alcohol and other drugs may lead to more serious use and increased risk for dependency. Because of this heightened susceptibility, more concentrated prevention efforts are necessary to help detract from these detrimental figures and unfortunate statistics.
The Importance of Prevention
Prevention against alcohol and drug abuse is important because addiction is harmful not only to the chemically dependent individual, but also to those that are close to them, and society at large. For underage individuals, developmental stages are greatly impacted by substance use and may lead to serious psychological and health concerns in later years. According to the National Highway Traffic Safety Administration, early onset of substance use is linked to a higher likelihood of developing an addiction, and there have also been reports that drinking among minors is linked to violence and crime (2001). Research has shown that early alcohol and drug use is more likely to contribute to risky behavior and result in negative consequences such as: injury, assault, impaired memory, decreased academic performance, altercations with the legal system, and compromised sexual health, including contraction of sexually transmitted diseases and unplanned pregnancy (Hazelden, 2010). With these considerable factors in mind, it is crucial to realize that prevention programs and procedures are absolutely necessary to help delay the onset of alcohol and drug use, which undoubtedly contributes to addiction problems later in life.
The National Highway Traffic Safety Administration outlines two main theoretical frameworks to help guide prevention strategies and speaks to the importance of their implementation. One framework is the “risk and protective factor” approach, which encompasses a biopsychosocial model (National Highway Traffic Safety Administration, 2001). This model looks at various and overlapping influential forces that may help assess why some people may turn to alcohol and other drugs and have a higher probability of becoming addicted, and why some may not. Another framework is the public health “agent/host/environment” model (National Highway Traffic Safety Administration, 2001). This model views the “agent” as the actual substance being used, the “host” as the person ingesting or using the substance, and the “environment” as the surrounding settings in which the person uses the substance. Environment can also include attitudes and norms associated with use. Previously, most views of prevention concentrated on the agent and the host with little consideration for the environment. Now, “the focus has shifted to how the agent and the host interact with the third element in the model—the environment” (National Highway Traffic Safety Administration, 2001).
Because of these complex and interlinking factors associated with the onset of alcohol and drug use, it is imperative that adequate programs, services, and resources be allocated to the development and implementation of concentrated efforts for preventing alcohol and drug addiction.
How to Begin
Prevention should begin early so as to delay the onset of alcohol and drug use. Ideally, intervention should occur in underage youth, at the entrance of middle school or before, where many individuals become increasingly exposed to alcohol and other drugs. With this focus on youth, prevention education should initially take place within schools. This strategy would help to establish a consistent and widespread campaign that is sure to reach a full demographic of students across the country. From here, prevention should develop throughout the community and contain comprehensive, wrap-around outreach programs. This may include stricter law enforcement efforts along with individually focused strategies encompassing family and peer group dynamics; each portion of this prevention strategy works together to examine the aforementioned risk and protective factors (National Highway Traffic Safety Administration, 2001). Beyond this, however, prevention efforts should also expand further to include public policies and national procedures. The National Highway Traffic Safety Administration suggests that this helps institute universal penalties and provides an overall reduction to access, guiding the community and home front efforts (2001).
To help explain the connection between adolescent substance use and the development of addiction, Manceaux, Maricq, Zdanowicz, and Reynaert (2013) conducted a study to highlight the role of the prefrontal cortex in the cognitive and behavioral aspects of addiction. Maturation of the prefrontal cortex occurs during adolescence, and is not fully developed until well into the mid-twenties and significant peaks in the expression of dopamine levels also occur in this phase of development (Manceaux et al., 2013). Additionally, Manceaux et al.’s (2013) results concluded that there is a parallel between addiction and the feeling of love relations in terms of neuroscience and brain imaging. This demonstrates that a greater emotional sensitivity might be a considerable factor in the higher rates of substance abuse during adolescence.
For these reasons, it is important for prevention efforts to be implemented early on in the school system, in order to provide psychoeducation for some of the underlying biological factors influencing the effects of alcohol and drug use in these key developmental stages. Some underage youth may not be equipped with the appropriate family or social environment to provide this level of support and encouragement for the delayed onset of use. Therefore, it is paramount that the school systems become a primary place for early prevention. Beyond this, however, it is important that within this educational component there be an element of discussion and interaction to enhance this instructive piece. Moreover, it is difficult to ascertain an exact location for prevention intervention to take place. Though schools may be a great start, comprehensive community involvement is essential to wrap-around preventative care.
Current Prevention Models
There are currently many approaches to substance abuse prevention in the United States. Most preventative efforts begin as educational programs in schools and target individuals during adolescents. These models of substance abuse prevention have continuously evolved throughout the years. Initially, Botvin found that original models of prevention relied more on “intuition than theory” (2000, p. 887). These original models were developed with three intentions: provide accurate knowledge, encourage emotional expression, and offer appropriate choices to using substances. It was found that these initial models of prevention might have had an influence on the understanding and comprehension of substance use. However, it was also found that these models were continually unable to actually effect individuals’ plan to use and abuse substances. Additionally, Botvin explains that over time research has identified a change in viewpoint when it comes to approaching prevention in academic setting (2000). Rather than concentrating on general education related to the devastating effects of substance use, prevention models implemented in school settings have transitioned their focus to the various risk and protective factors related to adolescent individuals. All factors considered, Botvin concludes that “the science-based prevention approaches developed and tested over the last two decades can be grouped into two general categories: (1) social influence approaches and (2) competence enhancement approaches” (2000, p. 888).
The Social Influence Model
The social influence approach to prevention emphasizes “the importance of social and psychological factors in promoting the onset of drug use” (Botvin, 2000, p. 888). This prevention model primarily focuses on factors such as norms, commitment, and intention not to use (Cuijpers, 2002). The model strives to add community-based interventions to school-based interventions as an effort to provide wrap around care. Additionally, the social influence model utilizes peer leaders for education facilitation and provides life skills training to participants (Cuijpers, 2002).
The Competence Enhancement Model
The competence enhancement approach to prevention emphasizes the “teaching of generic self-management skills and social skills” (Botvin, 2000, p. 892). Botvin explains that according to this prevention approach, the use of illicit drugs is viewed as a behavior that is socialized and learned through modeling. For adolescents, this process of modeling occurs on two levels: interpersonal and intrapersonal, and is impacted by “prodrug cognitions, attitudes, and beliefs” (Botvin, 2000, p. 892). Such modeling and replication is consistently reinforced throughout society at many levels. These dynamics, along with undeveloped life skills, are thought to raise the risk of adolescents’ likelihood to concede to environmental influences related to drug use and abuse.
In summary, Botvin categorizes the recent evidence-based substance abuse prevention models into two categories, as was previously discussed. Substance abuse prevention models such as the social influence approach and competence enhancement approach are generally implemented throughout school-based settings. Thus far, based on the literature, it seems as though many school-based prevention approaches are turning out to be ineffective in the long term (Botvin, 2000).
According to Fisher and Harrison (2013), there are three distinct types of prevention strategies within the Institute of Medicine Classification System: universal, selective, and indicated. This specific classification system aims its prevention activities towards various targeted populations. First, the “universal prevention strategies are directed toward the entire population of a county, state, community, school, or neighborhood” (Fisher & Harrison, 2013, p. 316). Next, Fisher and Harrison state that “selective prevention strategies are targeted at subsets of a population who are considered at risk for substance abuse” (2013, p. 317). Finally, the “indicated prevention strategies are directed toward individuals who have demonstrated the potential for substance abuse based on their behavior” (Fisher & Harrison, 2013, p. 317).
In addition to the various populations that can be targeted for various substance abuse prevention efforts based on risk factors, there are also classifications specified by the Center for Substance Abuse Prevention (CSAP). CSAP is “the federal agency that coordinates prevention efforts throughout the country” and they currently use a prevention classification system based on six key strategies: information dissemination, education, alternatives, problem identification and referral, community-based processes, and environmental approaches (Fisher & Harrison, 2013).
For starters, Fisher and Harrison state that information dissemination “involves communication of the nature, extent, and effect of substance use, abuse, and addiction on individuals, families, and communities” (2013, p. 317). Next, education activities “are designed to build or change life and social skills—such as decision making, refusal skills, assertiveness, and making friends—that are usually thought to be associated with substance abuse prevention” and alternative strategies “involved the development of activities that are incompatible with substance use” (Fisher & Harrison, 2013, p. 317–8). Additionally, Fisher and Harrison write that problem identification and referral is a strategy that is “generally targeted to indicated populations who have been identified as using tobacco, alcohol or other drugs or who have engaged in other inappropriate behaviors” (2013, p. 318). Community-based processes “involve the mobilization of communities to more effectively provide prevention services” and environmental approaches are “written and unwritten standards, codes, laws, and attitudes that impact substance use and abuse in a community” (Fisher & Harrison, 2013, p. 318).
Fisher and Harrison (2013) also present various risk and protective factors that could be related to a higher or lower chance that individuals will or will not abuse alcohol and other drugs (AOD). Such risk and protection factors should be considered when it comes to discussing the concept of prevention. These risk and protective factors are separated into five categories including: community, family, school, individual, and protective (Fisher & Harrison, 2013). Fisher and Harrison state that community risk factors include the “availability of AOD, laws and norms, mobility, neighborhood attachment, [and] economic deprivation” and that family risk factors include “history of problem behavior, management problems, conflict, [and] involvement with AOD” (Fisher & Harrison, 2013, p. 320). School risk factors include “antisocial behavior, academic failure, [and] lack of commitment” while individual risk factors include “alienation and rebelliousness, peers who use AOD, favorable attitudes toward AOD, [and] early problem behaviors” (Fisher & Harrison, 2013, p. 320). Finally, Fisher and Harrison write that overall protective factors include “bonding and healthy beliefs and clear standards” (2013, p. 320).
As was previously discussed, substance abuse prevention models that are generally implemented through school-based settings, such as the social influence approach and competence enhancement approach have been found to be somewhat ineffective over longer periods of time (Botvin, 2000). However, according to a study by Botvin et al., “drug abuse prevention efforts targeting adolescents during junior high school in general, and the prevention approach tested in this study in particular, can produce prevention effects that last beyond the end of high school” (2000, p. 773). Furthermore, the “data also provide[s] additional support for the long-term effectiveness of a broad-spectrum, cognitive-behavioral, universal prevention approach called Life Skills Training (LST)” (Botvin et al., 2000, p. 773).
Ultimately, because prevention efforts are designed in research settings, they are not always fit for actual use in the environment for which they were designed—most specifically schools (Cuijpers, 2002). In addition, Cuijpers explains that it seems as though school-based prevention efforts have been researched most extensively, and it has been discovered that they serve only as a short-term delay in the initial use of substances among adolescents (2002). Furthermore, Cuijpers shares that some preventative interventions have been found to be more effective than others (2002). For example, interactive methods are more effective than educational methods- meaning, there needs to be a discussion as opposed to a lecture. Cuijpers also found that life-training skills are important when it comes to substance abuse prevention efforts with adolescents (2002).
According to Fisher and Harrison, prevention efforts are a “long-term process involving public policy (legislation) and public awareness” and “the effectiveness of prevention efforts would be enhanced if the contradictory messages [in the media] were less pervasive” (2013, p. 320–1). The aforementioned CSAP prevention classification system presented by Fisher and Harrison has been evaluated for effectiveness based on each of the separate categories.
First, when it comes to information dissemination, it was found that prevention efforts that solely offered information did “increase knowledge of participants but had no effect on attitudes and drug use” (Fisher & Harrison, 2013, p. 321). Second, when evaluating the effectiveness of education prevention strategies, it was found that some school-based programs were effective. When it came to alternatives, it was found that “entertainment, vocational, and social alternatives programs have been associated with more rather than less substance use, although academic, religious, and sports activities are associated with less use” (Fisher & Harrison, 2013, p. 324). When evaluating the effectiveness of problem identification and referral prevention strategies, it was found that these programs must have “valid procedures and trained personnel to determine where the individual is on the use continuum” (Fisher & Harrison, 2013, p. 325). Similarly, Fisher and Harrison found that “appropriate organization, leadership, and evaluation have been shown to be important components in successful community partnerships” (2013, p. 326). Finally, environmental approaches were found to have “demonstrated a direct impact on the use of tobacco and alcohol and on the problems associated with the use of these substances. However, environmental strategies have not been as effective with regard to illicit drugs” (Fisher & Harrison, 2013, p. 326).
According to the National Registry of Evidence-based Programs and Practices (NREPP), as of April 2014, there are 115 evidence-based substance abuse prevention models (2014). Fisher and Harrison mention that the NREPP website currently contains a list of “prevention, intervention, and treatment programs, [but] it was initially started as a process to determine which prevention programs could be called ‘model programs’” (2013, p. 327). Moreover, because the NREPP website lists all evidence-based substance abuse prevention programs, it can be used as a tool so that “states can ensure that the prevention programs they fund have evidence to support their effectiveness” (Fisher & Harrison, 2013, p. 327).
The overall outcomes of the various substance abuse prevention models are mixed. Therefore, it is difficult to rely on one model to have the best-proven outcomes. Instead, there are 115 substance abuse prevention models that are all considered to be evidence-based and effective according to the NREPP (2014). It may be important to remember that prevention models should be individualized to the targeted population to some extent so that they can be compatible and effective based on the specific population’s risk and protective factors.
According to Castro & Alarcón, “in the past, substance abuse prevention and treatment programs have given limited or no attention to cultural variables as potential determinants of substance use and/or as integral components of programs for substance abuse prevention and treatment” (2002, p. 783). However, over time, it has been seen that there are in fact cultural issues related to prevention efforts.
For example, drug and alcohol use is extremely normalized in American culture—so much so that use is almost expected with age. Research on drug and alcohol marketing indicated that marketing cues could act as environmental triggers for individuals who are in the “preaddiction phase” (Martin et al., 2012). The research described how marketing cues might facilitate dysfunctional consumption based on the consumption continuum from non-use to addiction. Newcomb and Bentler explained that, “even though child or teenage drug use is an individual behavior, it is embedded in a sociocultural context that strongly determines its character and manifestations” (1989, p. 242).
When it comes to other cultural issues related to prevention efforts, research conducted by Griffin, Botvin, Nichols, and Doyle indicated “that a universal drug abuse prevention program is effective for minority, economically disadvantaged, inner-city youth who are at higher than average risk of substance use initiation” (2003, p. 1). Griffin et al. also concluded that such universal drug abuse prevention programs could in fact be effective for a range of youth along a continuum of risk (2003).
As a whole, when it comes to cultural issues related to substance abuse prevention efforts, there are many factors that should be considered. According to Resnicow, Soler, Braithwaite, Ahluwalia, and Butler (2000), the procedure of creating chemical dependency services that are culturally appropriate should start with an in-depth assessment of chemical use patterns, while also examining risk and protective factors relevant for the specific population.
As noted by the 115 different prevention strategies that are currently considered evidence-based (NREPP, 2014), there are many ways in which prevention efforts can be designed, implemented, and measured, but still be effective. However, there are important factors that still warrant considerable attention when designing, implementing, and measuring substance abuse prevention strategies.
To begin, Foxcroft, Ireland, Lister-Sharp, Lowe, and Breen (2002) sought out to explore various long-term prevention interventions for younger individuals, meaning those aged twenty-five years and below. Foxcroft et al. (2002) discovered that there are five main factors that need to be considered for longevity and that four of these are potentially applicable to other prevention strategies. These factors are as follows:
- Extensive research linked to specific desired outcomes
- More accurate evaluation procedures
- The advancement of interventions designed for diverse populations
- More standardized and easily assessable means of obtaining information related to prevention strategies.
With regard to the last factor, Foxcroft et al. specifically suggests “an international register of alcohol and drug misuse prevention interventions should be established and criteria agreed for rating prevention interventions in terms of safety, efficacy and effectiveness” (2002, p. 397).
Next, Allamani identified that, “in any case, prevention intervention is based on the individual decision to change one’s own behavior mediated by collective health messages” (2007, p. 430). Additionally, Allamani identified several significant abilities or skills the substance abuse prevention provider should possess; these skills include proficiency and capacity related to communication, and the ability to inspire motivation. Allamani also suggested that substance abuse prevention providers should also be able to demonstrate exceptional listening and attending skills, with the capability to absorb what was heard before attempting to reframe them within the confines of an appropriate prevention strategy. Other skills include the ability to facilitate healthy connections among a range of participants, ensure a relevant relationship between program objectives and prevention strategies, and function within a group that is team-oriented and supportive, as to foster collaboration. With these considerations in mind, it may be important to remember that effective prevention models should be individualized to the targeted population to some extent, so that they can be compatible and effective based on the specific population’s risk and protective factors.
All things considered, prevention is a team effort between individuals, professionals, community partnerships, and family and social supports. An open dialogue that flows between the pieces of this delicately intricate puzzle is essential. One “best approach” to substance abuse prevention may not currently exist. Nevertheless, it is vital to realize that successful substance abuse prevention is not solely determined by each individual part, but is rather accomplished by all of the parts working together as a whole.
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