Transcript Comer, Abnormal Psychology, 8th edition

Chapter 12
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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Substance Use and Addictive
Disorders
Substance Use Disorders
– Any substance other than food that affects our bodies
or minds
– Current language uses the term “substance” rather
than “drug” to overtly include alcohol, tobacco, and
caffeine
– About 9% of all teens and adults in the U.S. display
substance abuse or dependence
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• What is a drug?
• Some substances can also lead to long-term
problems
• People who regularly ingest them may develop
substance use disorders
• Also called “addiction”
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Substance Use Disorders
• Tolerance: The adjustment that the brain and
the body make to the regular use of certain
drugs so that ever larger doses are needed to
achieve the earlier effects
• Withdrawal: Unpleasant, sometimes dangerous
reactions that may occur when people who use
a drug regularly stop taking or reduce their
dosage of the drug
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Substance Use Disorders
Substance Use Disorders
–
–
–
–
Depressants
Stimulants
Hallucinogens
Cannabis
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• There are several categories of substances
used and studied:
Depressants
• Depressants slow the activity of the central
nervous system (CNS)
• Three most widely used depressants:
– Alcohol
– Sedative-hypnotic drugs
– Opioids
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– Reduce tension and inhibitions
– May interfere with judgment, motor activity, and
concentration
Depressants: Alcohol
– Short-term: alcohol blocks messages between
neurons
– Alcohol helps GABA (an inhibitory messenger) shut
down neurons and relax the drinker
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• All alcoholic beverages contain ethyl alcohol
• It is absorbed into the blood through the
stomach lining and takes effect in the
bloodstream and CNS
Depressants: Alcohol
• The extent of the effect of ethyl alcohol is
determined by its concentration (proportion) in
the blood
• Gender also affects blood alcohol concentration
– Women have less alcohol dehydrogenase, an
enzyme in the stomach that metabolizes alcohol
before it enters the blood
– Women become more intoxicated than men on equal
doses of alcohol
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– A given amount of alcohol has a lesser effect on a
large person than on a small one
Depressants: Alcohol
– BAC = 0.06: Relaxation and comfort
– BAC = 0.09: Intoxication
– BAC > 0.55: Death
• Most people lose consciousness before they can drink this
much
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• Levels of impairment are closely tied to the
concentration of ethyl alcohol in the blood:
Depressants: Alcohol
• The effects of alcohol subside only after alcohol
is metabolized by the liver
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– The average rate of this metabolism is 25% of an
ounce per hour
– You can't increase the speed of this process!
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Depressants: Alcohol
• In any given year, 6.6% of the world's population
will fall into a pattern of abuse or dependence
• 7.4% of all adults in the U.S. display an alcohol
use disorder over a one-year period while over
13% display it at some point in their lives
– Men outnumber women 2:1
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– 13.2% experience one of the patterns sometime
during their life
• DSM-5 has combined two past disorders,
substance abuse (excessive and chronic
reliance on drugs) and substance dependence
(excessive reliance accompanied by tolerance
and withdrawal symptoms) into a single
category—substance use disorder. Critics worry
that clinicians may now fail to recognize and
address the different prognoses and treatment
needs of individuals who abuse substances and
those who depend on substances.
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Is All Drug Misuse the Same?
Depressants: Alcohol
• Alcohol use disorder
• Eventually the drinking interferes with social behavior and the
ability to think and work
– Individual patterns of alcohol abuse vary
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– In general, people who abuse alcohol drink large
amounts regularly and rely on it to enable them to do
things that would otherwise make them anxious
Depressants: Alcohol
• Alcohol dependence
• They build up a physiological tolerance and need to drink
greater amounts to feel its effects
• They may experience withdrawal, including nausea and
vomiting, when they stop drinking
• A small percentage of alcohol-dependent people experience
a dramatic and dangerous withdrawal syndrome known as
delirium tremens (“the DTs”)
– Alcohol withdrawal can be fatal
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– For many people, the pattern of alcohol misuse
includes dependence
What is the personal and social impact of
alcoholism?
– Plays a role in suicides, homicides, assaults, rapes,
and accidents
– Long-term excessive drinking can seriously damage
physical health
– Long-term excessive drinking can cause major
nutritional problems
– Women who drink alcohol during pregnancy place
their fetuses at risk from fetal alcohol syndrome (FAS)
and increased risk of miscarriage
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• Alcoholism destroys families, social
relationships, and careers
• In the past few years, a popular new “game”—made
possible by the internet and social media— has taken
alcohol-related behaviors and the impact of peer
pressure to new heights.
• Online drinking game called neknominate (or
neknomination) in this game, a person records a video of
him or herself drinking an entire bottle of hard liquor and
then challenges (“nominates”) a friend by name to post
his or her own drinking video, one that will top the level
and danger of the initial drinking act, and to then pass
the challenge on to another person
• What psychological factors, besides peer pressure,
might induce a person to participate in an activity as
risky as Neknominate?
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Neknomination Goes Viral
Depressants: Sedative-Hypnotic Drugs
• Sedative-hypnotic (anxiolytic) drugs produce
feelings of relaxation and drowsiness
• Sedative-hypnotic drugs include barbiturates
and benzodiazepines
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– At low doses, they have a calming or sedative effect
– At high doses, they function as sleep inducers or
hypnotics
Depressants: Barbiturates
• Widely prescribed in the first half of the 20th
century to fight anxiety and to help people sleep
• At low doses, they reduce excitement in a
manner similar to alcohol by attaching to the
GABA receptors and helping GABA operate
• At too high a level, they can halt breathing, lower
blood pressure, and can lead to coma and death
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– They can cause many problems such as abuse,
dependence, and overdose
Depressants: Barbiturates
– A great danger of barbiturate dependence is that the
lethal dose of the drug remains the same, even while
the body is building a tolerance for the sedative
effects
– Barbiturate withdrawal is particularly dangerous
because it can cause convulsions
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• Repeated use of barbiturates can quickly result
in a pattern of abuse and/or dependence
Depressants: Benzodiazepines
Benzodiazepines are often prescribed to relieve
anxiety
Most popular sedative-hypnotics available
Benzodiazepines have a depressant effect on
the CNS by binding to GABA receptors and
increasing GABA activity
Benzodiazepines relieve anxiety without causing
drowsiness
 Less likely to slow breathing and lead to death by overdose
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 Class includes Xanax, Ativan, and Valium
Depressants: Opioids
– Each drug has a different strength, speed of action,
and tolerance level
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• This class of drug includes both natural (opium,
heroin, morphine, codeine) and synthetic
(methadone) compounds and is known
collectively as “narcotics”
Depressants: Opioids
– Injection seems to be the most common method of
use, although other techniques have been increasing
in recent years
– An injection quickly brings on a “rush” – a spasm of
warmth and ecstasy that is sometimes compared with
orgasm
– This spasm is followed by several hours of
pleasurable feelings (called a “high” or “nod”)
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• Narcotics are smoked, inhaled, injected by
needle just under the skin (“skin popped”), or
injected directly into the bloodstream
(“mainlined”)
Depressants: Opioids
– Opioids bind to the receptors in the brain that
ordinarily receive endorphins (NTs that naturally help
relieve pain and decrease emotional tension)
– When these sites receive opioids, they produce
pleasurable and calming feelings, just as endorphins
do
– In addition to reducing pain and tension, opioids can
cause nausea, narrowing of the pupils, and
constipation
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• Opioids create these effects by depressing the
CNS
Depressants: Opioids
– After just a few weeks, users may become caught in a
pattern of abuse (and often dependence)
– Users quickly build a tolerance for the drug and
experience withdrawal when they stop taking it
– Early withdrawal symptoms include anxiety and
restlessness; later symptoms include twitching,
aches, fever, vomiting, diarrhea, and weight loss from
dehydration
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• Heroin use exemplifies the problems posed by
opioids:
Depressants: Opioids
• What are the dangers of heroin abuse?
– The most immediate danger is overdose
• The drug closes down the respiratory center in the brain,
paralyzing breathing and causing death
– Death is particularly likely during sleep
• About 2% of those dependent on heroin and other opioids die
under the influence of the drug each year
– Users run the risk of getting impure drugs
• Opioids are often “cut” with noxious chemicals
– Dirty needles and other equipment can spread
infection
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– Ignorance of tolerance is also a problem
Stimulants
• Stimulants are substances that increase the
activity of the central nervous system (CNS)
• The four most common stimulants are:
–
–
–
–
Cocaine
Amphetamines
Caffeine
Nicotine
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– Cause increases in blood pressure, heart rate, and
alertness
– Cause rapid behavior and thinking
• Most powerful natural stimulant known
• Cocaine produces a euphoric rush of well-being
• Produces this effect largely by increasing
supplies of dopamine at key neurons
throughout the brain
• Also appears to increase norepinephrine and
serotonin
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Stimulants: Cocaine
Stimulants: Cocaine
– Some people also experience hallucinations and/or
delusions, a condition known as cocaine-induced
psychotic disorder
• As the stimulant effects of the drug subside, the
user experiences a depression-like letdown,
popularly called “crashing”
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• High doses of cocaine can produce cocaine
intoxication, whose symptoms include mania,
paranoia, and impaired judgment
Stimulants: Cocaine
– Regular use may lead to a pattern of abuse in which
the person remains under the effect of cocaine for
much of each day and functions poorly in social
relationships and at work
– Dependence on the drug may also develop
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• Cocaine abuse and dependence
Stimulants: Cocaine
• Cocaine abuse and dependence
• A “freebase” form where the drug is heated and inhaled with
a pipe
• “Crack,” a powerful form of freebase that has been boiled
down for smoking in a pipe
– Currently, 0.5% of all people over the age of 11 in the
U.S. manifest cocaine abuse or dependence in a
given year
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– Cocaine use in the past was limited by the drug's high
cost
– Since 1984, cheaper, more powerful versions of the
drug have become available, including:
Stimulants: Cocaine
• What are the dangers of cocaine?
• Excessive doses depress the brain's respiratory function, and
stop breathing
• Cocaine use can also cause heart failure
• Pregnant women who use cocaine have an increased
likelihood of miscarriage and of having children with
abnormalities
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– Aside from its behavioral effects, cocaine poses
significant physical danger
– The greatest danger of use is the risk of overdose
Stimulants: Amphetamines
• Amphetamines: stimulant drugs manufactured
in the laboratory
– Most often taken in pill or capsule form
• Like cocaine, amphetamines:
– Increase energy and alertness and reduce appetite
when taken in small doses
– Produce a rush, intoxication, and psychosis in high
doses
– Cause an emotional letdown as they leave the body
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• Some people inject the drugs intravenously or smoke them
for a quicker, more powerful effect
Stimulants: Amphetamines
• One kind of amphetamine, methamphetamine,
has had a major surge in popularity in recent
years
• Most of the nonmedical meth is made in
“stovetop laboratories”
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– Almost 6% of all persons over the age of 11 in the US
have used this stimulant at least once
• Regular use of either cocaine or amphetamines
may lead to stimulant use disorder
• The stimulant dominates the individual’s life
• Leads to poor function in social relationships
and at work
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Stimulant Use Disorder
Stimulants: Caffeine
World’s most widely used stimulant
80% of the world's population consumes it daily
Caffeine acts as a stimulant in the CNS, producing a
release of dopamine, serotonin, and norepinephrine
in the brain
More than 2 to 3 cups of brewed coffee can lead to caffeine
intoxication
Seizures and respiratory failure can occur at doses greater
than 10 grams of caffeine (about 100 cups of coffee)
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 Most is in the form of coffee; the rest is in the form of tea, cola,
energy drinks, chocolate, and over-the-counter medications
 99% of ingested caffeine is absorbed by the body and reaches
its peak concentration within an hour
Stimulants: Caffeine
– Studies suggest correlations between high doses of
caffeine and heart rhythm irregularities, high
cholesterol levels, and risk of heart attacks
• High doses during pregnancy also increase the risk of
miscarriage
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• Many people who suddenly stop or cut back
their usual intake experience withdrawal
symptoms, including headaches, depression,
anxiety, and fatigue
Hallucinogens, Cannabis, and Combinations
of Substances
• Hallucinogens
– Produce delusions, hallucinations, and other sensory
changes
– Produce sensory changes, but have both depressant
and stimulant effects
• Combinations of substances
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• Cannabis substances
Hallucinogens
• Hallucinogens produce powerful changes in
sensory perceptions (sometimes called “trips”)
– Natural hallucinogens
– Laboratory-produced hallucinogens
• Lysergic acid diethylamide (LSD)
• MDMA (Ecstasy)
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• Mescaline
• Psilocybin
Hallucinogens
LSD is one of the most powerful hallucinogens
Brings on a state of hallucinogen intoxication
(hallucinosis)
Effects wear off in about six hours
LSD produces these symptoms by binding to
serotonin receptors
These neurons help control visual information and
emotions, thereby causing the various effects of the
drug on the user
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 Increased and altered sensory perception
 Hallucinations and/or synesthisia
Hallucinogens
• More than 14% of Americans have used
hallucinogens at some point in their lives
• Tolerance and withdrawal are rare
• Users may experience a “bad trip” – the experience of
enormous unpleasant perceptual, emotional, and behavioral
reactions
– Another danger is the risk of “flashbacks”
• Can occur days or months after last drug use
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– But the drugs do pose dangers
Cannabis
• The drugs produced from varieties of the hemp
plant are, as a group, called cannabis
• Hashish, the solidified resin of the cannabis plant
• Marijuana, a mixture of buds, crushed leaves, and flowering
tops
• The major active ingredient in cannabis is
tetrahydrocannabinol (THC)
– The greater the THC content, the more powerful the
drug
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– They include:
Cannabis
• When smoked, cannabis produces a mixture of
hallucinogenic, depressant, and stimulant effects
– At low doses, the user feels joy and relaxation
– At high doses, cannabis produces odd visual
experiences, changes in body image, and
hallucinations
• Most of the effects of cannabis last 2 to 6 hours
– Mood changes may continue longer
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• May become anxious, suspicious, or irritated
• This overall “high” is technically called cannabis intoxication
Cannabis abuse and Dependence
– The marijuana available today is significantly more
potent than the drug used in the early 1970s
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• Marijuana was once thought not to cause abuse
or dependence
• One theory about the increase in abuse and
dependence is the change in the drug itself
Is Marijuana Dangerous?
• May cause panic reactions similar to those caused by
hallucinogens
• Because of its sensorimotor effects, marijuana has been
implicated in accidents
• Marijuana use has been linked to poor concentration and
impaired memory
– Long-term use poses additional dangers
• May cause respiratory problems and lung cancer
• May affect reproduction
– In males, it may lower sperm count
– In women, abnormal ovulation has been found
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– As the strength and use of the drug has increased, so
have the risks of using it
Cannabis
For centuries, cannabis played a respected role in
medicine, but its use fell out of favor and was criminalized
In the late 1980s, several interest groups campaigned for
the medical legalization of marijuana
The U.S. Federal Government has continued to fight and
punish the production and distribution of marijuana for
medical purposes
 However, in 2009, the US Attorney General directed federal
prosecutors to not pursue cases against medical marijuana
users complying with state laws
 Both the Netherlands and Canada permit its use
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Cannabis and Society: A Rocky Relationship
Combinations of Substances
• People often take more than one drug at a time,
a pattern called polysubstance use
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– Researchers have studied the ways in which drugs
interact with one another, focusing on cross-tolerance
and synergistic effects
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Combinations of Substances
– Sometimes two or more drugs are so similar in their
actions on the brain and body that as people build a
tolerance for one drug, they are simultaneously
developing a tolerance for the other (even if they have
never taken it)
– Users who display this cross-tolerance can reduce
the symptoms of withdrawal from one drug by taking
the other
• Example: alcohol and benzodiazepines
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• Cross-tolerance
• Synergistic effects
– When different drugs are in the body at the
same time, they may multiply, or potentiate,
each other's effects
– This combined impact is called a synergistic
effect, and is often greater than the sum of the
effects of each drug taken alone
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Combinations of Substances
Combinations of Substances
• Synergistic effects
• Example: alcohol, barbiturates, benzodiazepines, and opioids
• All depressants, these drugs may severely depress the CNS
when mixed, leading to death
– A different kind of synergistic effect results when
drugs have opposite (antagonistic) effects
• Example: stimulants or cocaine with barbiturates or alcohol
– May build up lethal levels of the drugs because of metabolic
issues (stimulants impede the liver's processing of barbiturates
and alcohol)
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– One kind of synergistic effect occurs when two or
more drugs have similar actions
Combinations of Substances
• Each year tens of thousands of people are
admitted to hospitals because of polysubstance
use
• As many as 90% of people who use one illegal drug are also
using another to some extent
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– May be accidental or intentional
What Causes Substance Use Disorders?
– No single explanation has gained broad support
– Best explanation: a COMBINATION of factors
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• Clinical theorists have developed sociocultural,
psychological, and biological explanations for
substance abuse and dependence
• Some theorists propose that people are more
likely to develop patterns of substance abuse or
dependence when living in stressful
socioeconomic conditions
• Others propose that substance abuse and
dependence are more likely to appear in families
and social environments where substance use is
valued or accepted
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Causes of Substance Use Disorders:
Sociocultural Views
Causes of Substance Use Disorders:
Psychodynamic Views
• Psychodynamic theorists believe that people
who abuse substances have powerful
dependency needs that can be traced to their
early years
• Some people may develop a “substance abuse personality”
as a result
– Limited research does link early impulsivity to later
substance use, but the findings are correlational and
researchers cannot presently conclude that any one
personality trait or group of traits stands out in
substance use disorders
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– Caused by a lack of parental nurturing
Causes of Substance Use Disorders:
Cognitive-Behavioral Views
– They argue that the temporary reduction of tension
produced by a drug has a rewarding effect, thus
increasing the likelihood that the user will seek this
reaction again
– Similarly, the rewarding effects may also lead users to
try higher doses or more powerful methods of
ingestion
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• According to behaviorists, operant conditioning
may play a key role in substance abuse
Causes of Substance Use Disorders:
Cognitive-Behavioral Views
– Objects present at the time drugs are taken may act
as classically conditioned stimuli and come to
produce some of the pleasure brought on by the
drugs themselves
– Although classical conditioning may be at work, it has
not received widespread research support as the key
factor in such patterns
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• Other behaviorists have proposed that classical
conditioning may play a role in substance abuse
and dependence
• In recent years, researchers have come to
suspect that drug misuse may have biological
causes
• Studies on genetic predisposition and specific
biochemical processes have provided some
support for this model
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Causes of Substance Use Disorders:
Biological Views
Causes of Substance Use Disorders:
Biological Views
– Research with “alcohol-preferring” animals has
demonstrated that their offspring have similar alcohol
preferences
– Research with human twins has suggested that people
may inherit a predisposition to abuse substances
– Clearer support for a genetic model may come from
adoption studies
• Studies compared adoptees whose biological parents were
dependent on alcohol with adoptees whose biological parents
were not dependent
– By adulthood, those whose biological parents were dependent
showed higher rates of alcohol use themselves
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• Genetic predisposition
Causes of Substance Use Disorders:
Biological Views
– Recent brain imaging studies have suggested that
many (perhaps all) drugs eventually activate a reward
center or “pleasure pathway” in the brain
– The reward center apparently extends from the
ventral tegmental area of the brain to the nucleus
accumbens and on to the frontal cortex
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• Biochemical factors
Causes of Substance Use Disorders:
Biological Views
• Biochemical factors
• This theory, called the incentive-sensitization theory – has
received considerable support in animal studies
– Other theorists believe that people who abuse
substances suffer from a reward-deficiency syndrome
• Their reward center is not readily activated by “normal” life
events so they turn to drugs to stimulate this pleasure
pathway, particularly in times of stress
– Defects in D2 receptors have been cited as a possible cause
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– A number of theorists believe that when substances
repeatedly stimulate the reward center, the center
develops a hypersensitivity to the substances
• Many approaches have been used to treat
substance use disorders, including
psychodynamic, behavioral, cognitivebehavioral, and biological, along with
sociocultural therapies
• Although these treatments sometimes meet with
great success, more often they are only
moderately helpful
• Today treatments are typically used in
combination on both an outpatient and inpatient
basis
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How Are Substance Use Disorders Treated?
How Are Substance Use Disorders Treated?
– Different substance use disorders pose different
problems
– Many people with substance abuse patterns drop out
of treatment early
– Some people recover without any intervention at all
– Different criteria are used by different clinical
researchers
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• The value of treatment for substance abuse or
dependence can be difficult to determine
• Psychodynamic therapists first guide clients to
uncover and work through the underlying needs
and conflicts that they believe led to the disorder
then try to help them change their styles of living
• Research has not found this model to be very
effective
– Tends to be of greater help when combined with other
approaches in a multidimensional treatment program
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Psychodynamic Therapies
Behavioral Therapies
– Individuals are repeatedly presented with an
unpleasant stimulus at the very moment they are
taking a drug
– After repeated pairings, they are expected to react
negatively to the substance itself and to lose their
craving for it
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• A widely used behavioral treatment is aversion
therapy, an approach based on classical
conditioning principles
Behavioral Therapies
– In one version, drinking behavior is paired with druginduced nausea and vomiting
– Another version of this approach requires people with
alcoholism to imagine extremely upsetting, repulsive,
or frightening scenes while they are drinking
• A behavioral approach that has been successful
in the short-term is contingency management
– This procedure makes incentives contingent on the
submission of drug-free urine specimens
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• Aversion therapy is most commonly applied to
alcohol abuse/dependence
Cognitive-Behavioral Therapies
– The overall goal is for clients to gain control over their
substance-related behaviors
• Clients are taught to identify and plan ahead for high-risk
situations and to learn from mistakes and lapses
– This approach is used particularly to treat alcohol use;
also used to treat cocaine and marijuana abuse
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• These treatments help clients identify and
change the patterns and cognitions contributing
to their patterns of use
• Relapse-prevention training
Biological Treatments
– These approaches have limited long-term success
when used alone, but can be helpful when combined
with other approaches
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• Biological approaches may be used to help
people withdraw from substances, abstain from
them, or simply maintain their level of use
without further increases
Biological Treatments
Detoxification
Systematic and medically supervised withdrawal from
a drug
 Can be outpatient or inpatient
 Gradual withdrawal by tapering doses of the substance
 Induce withdrawal but give additional medication to block
symptoms
Detoxification programs seem to help motivated
people withdraw from drugs
 For people who fail to receive psychotherapy after
withdrawal, however, relapse rates tend to be high
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Two strategies:
Biological Treatments
• Antagonist drugs
• Example: disulfiram (Antabuse) for alcohol
• Example: naloxone for narcotics, naltrexone for alcohol
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– As an aid to resist falling back into a pattern of
substance abuse or dependence, antagonist drugs
block or change the effects of the addictive substance
Biological Treatments
• Drug maintenance therapy
– A drug-related lifestyle may be a greater problem than
the drug's direct effects
– Methadone maintenance programs are designed to
provide a safe substitute for heroin
• Methadone is a laboratory opioid with a long half-life, taken
orally once a day
• Programs were roundly criticized as “substituting addictions”
but are regaining popularity, partly because of the spread of
HIV/AIDS
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• Example: heroin addiction
Sociocultural Therapies
– Self-help programs
– Culture- and gender-sensitive programs
– Community prevention programs
Abnormal Psychology | Ronald J. Comer | Ninth Edition
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• Three sociocultural approaches have been
applied to substance use disorders:
Sociocultural Therapies
• Self-help and residential treatment programs
• Offers peer support along with moral and spiritual guidelines to
help people overcome alcoholism
• It is worth noting that the abstinence goal of AA directly opposes
the controlled-drinking goal of relapse prevention training and
several other interventions for substance misuse – this issue
has been debated for years
– Many self-help programs have expanded into residential
treatment centers or therapeutic communities
• People formerly dependent on drugs live, work, and socialize in
a drug-free environment while undergoing individual, group, and
family therapies
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– Most common: Alcoholics Anonymous (AA)
Sociocultural Therapies
– A growing number of treatment programs try to be
sensitive to the special sociocultural pressures and
problems faced by drug abusers who are poor,
homeless, or members of ethnic minority groups
– Similarly, therapists have become more aware that
women often require treatment methods different from
those designed for men
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
• Culture- and gender-sensitive programs
Sociocultural Therapies
– Perhaps the most effective approach to substance
use disorders is to prevent them
– Some prevention programs argue for total abstinence
from drugs, while others teach responsible use
– Prevention programs may focus on the individual, the
family, the peer group, the school, or the community
at large
• The most effective of these prevention efforts focuses on
multiple areas to provide a consistent message about drug
use in all areas of life
Abnormal Psychology | Ronald J. Comer | Ninth Edition
Copyright © 2015 by Worth Publishers. All rights reserved
• Community prevention programs