Transcript Prevention - Peer Assistance Services

Prevention:
Moving from Science to Practice
A. Thomas McLellan
Treatment Research Institute
3/24/2017
©Treatment
©Treatment
Research
Research
Institute,
Institute,
20132012
The End
In Summary:
1. It is possible and cost effective to prevent
substance use and misuse
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Highly related to most other harms to our young
2. Adolescence is THE “at risk period”
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ALL of Adolescence – not just part
3. Policies that make substances harder to get are
the most effective form of prevention
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Costs, taxes, age restrictions, provider restrictions.
4. Many Prevention Programs Do work –
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MUCH better in Prevention Prepared Communities
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Size and Scope of the
Problem
Substance Use is related to:
28% of college rape and IPV
44% of injuries among 12-25
63% of disabilities among 12-25
74% of all deaths among 12-25
Figures even higher for minorities
Annual Costs of Substance Use
Related Harms:
$450 Billion
Annual
Costs Services
of
$270 Billion
in Soc/Crim
Iraq
andinAfghan
Wars
$120
Billion
Healthcare
$180 – $250 Billion
“Addiction”?
Addiction-Related Problems?
“Misuse”?
Substance “Use”?
Substance Use Among US Adults
Very
Serious
Use
In Treatment ~ 4,100,000
Addiction ~ 21,400,000
Prevention
Target
Little/No
Use
Misuse ~ 40,000,000
Little or No Use
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Addiction is not “just more partying”
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It is an acquired, progressive, often chronic
illness - cardinal symptom is loss of voluntary
control over use
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About 50% of risk is genetic; rest is
environment and age of onset.
Substance Use & Addiction
Addiction – like other chronic
illnesses has an “at risk” period
Adolescence
94% of all addictions initiate
between 12 - 25
National Institute on Alcohol Abuse and Alcoholism
Source: Grant and Dawson (1997) J. Substance Abuse
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1. Reduce Risk Factors
2. Enhance Protective Factors
Risk and Protective Factors
Environmental Risks
1. easy access to cheap substances,
2. heavy advertising of these products
(particularly to youth),
3. low parental monitoring, and
4. high levels of family conflict.
Environmental Protections
1. healthy recreational and social activities
2. regular supportive monitoring by parent
Personal Risk Factors
Personal Risks
1. family history of substance use or mental
illness,
2. a current mental disorder,
3. low involvement in school,
4. a history of abuse and neglect, and
5. family conflict and violence.
Personal Protective Factors
Personal Protections
1. involvement in school,
2. involvement in healthy recreational and
social activities, and
3. development of good coping skills
About Risk and Protective Factors:
1. NO Single factor is determinative
2. Adolescence is THE risk period (12 – 23)
3. Risk Factors can be Modified with proven
policies and programs
4. Same Factors Predict MANY Different
Harms - drop out, pregnancy, bullying,
drug use, suicide
Commonality of Risk Factors
Risk Factors
Adolescent/
Young Adult
Substance
Use
Delinquency
Teen
Pregnancy
School
Dropout
Violence
Depression
and Anxiety
Adult
Substance
Use
Excessive
Alcohol
Use
Community
Availability of substances
Price of substances
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Availability of firearms
Permissive community laws
and norms
Media portrayal of violence
Low neighborhood attachment
and disorganization
Extreme economic deprivation
Transitions and mobility
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School
Academic failure beginning in
late elementary school
Lack of commitment to school
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Family
Family management problems
Family conflict
Permissive parental attitudes
& low parent involvement
Family history of the problem
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Personal
Persistent antisocial behavior
Alienation and rebelliousness
Favorable attitudes toward the
problem behavior
Early initiation of the problem
behavior
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1. Prevention Policies
2. Prevention Programs
Delivered in Prevention
Prepared Communities
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• Alcohol Related Problems
– DWI, Violence, Injuries, Deaths
• Opioid Related Problems
– Overdose Incidents and Deaths
What Are Low-Risk Drinking Limits?
Source: NIAAA, Rethinking Drinking: Alcohol and Your Health, 2009
Price of Alcohol
Finding: Higher prices or taxes
on alcohol reduce alcohol
consumption and alcohol-related
problems
20-30%.
Evidence: 112 separate studies;
over 1,000 examples
Availability of Alcohol
Finding: Policies to reduce
alcohol outlets reduce alcohol
consumption and alcohol-related
problems - 10
– 20%.
NOTE Privatizing INCREASES sales 40%
Evidence: 21 longitudinal
studies; over 100 case examples
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Does It Work?
Results from Policies to Reduce
Alcohol Problems
National Institute on Alcohol Abuse and Alcoholism
Alcohol- vs. Non-Alcohol-Related Traffic Fatalities Per
100,000 Population, Ages 16-20, United States,1982-2007
U.S. MLDA Age 21 law
MLDA 21 in all 50 states
30
25.58
(n=5,244)
Non-Alcohol-Related ↑17%
25
15.64
(n=3,351)
20
15
13.36
(n=2,738)
10
9.27
(n=1,987)
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Alcohol-Related ↓64%
0
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
Sources: U.S. Fatality Analysis Reporting System, 2008; U.S. Census Bureau, 2009
2006
Misuse of prescribed opioids has
increased over 400% in 10 years
Opioids are now the most
commonly prescribed class of
drugs – more than statins
Opioids VERY effective for acute
pain but NOT for chronic pain
Potential impact on Safety: Fatal Medical Errors
Alc/Drg Related
Fatal Errors
1983 - 2005
Phillips, D. P. et al. 2008;168:1561-1566.
CDC
Final
Guidelines
Pain Society and State Guidelines
for
Painsimilar
Management
very
Model policy for the use of opioids in the treatment of pain.
http://www.fsmb.org/pdf/2004_grpol_Controlled_Substance
s.pdf
Gilson AM, Joranson DE, Maurer MA. Improving state pain
policies: recent progress and continuing opportunities.
CA Cancer J Clin. 2007;57(6):341–353
1. Screening for & discussing substance use
2. Patient contract – Single doc & pharmacy
3. Patient & family education on safe storage
of medications
4. Urine Screening pre and during
prescribing (expanded test panel)
5. Naloxone prescription and training
Naloxone
Naloxone is an opioid antagonist – blocks or
reverses the effects of any opioid
Extremely effective – few side effects –
injectable or inhalable
Most states have expanded its availability to
“first responders”
Many states have made it available without
prescription
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• Evidence Based Programs
• Delivered in Prepared
Communities
State of the Science
1. Adolescence is THE risk period (12 – 23)
2. Same risk factors predict many problems –
drop out, pregnancy, bullying, drug use
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BUT – Reducing risk for ANY problem reduces risks for
MANY problems
3. Many environments influence teens – home,
school, work, parties, driving, etc.
1. The delivery system is the
Community
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Examples are Communities That Care,
PROSPER, Communities Mobilizing
for Change, CADCA
2. The active ingredients are
Evidence-Based Programs for
each part of the Community
AGE
10
ENVIRONMENT
Schools
Parents
Law Enforcement
Healthcare
Local Policies
12
15
18
21
23
AGE
10
ENVIRONMENT
Schools
Parents
Law Enforcement
Healthcare
Local Policies
12
15
18
21
23
National Institute on Alcohol Abuse and Alcoholism
Preventing Initiation of Use
for Ages 0 - 10
Evidence-Based Programs:
1. Nurse Family Partnership – health/family
2. The Good Behavior Game - school
3. Raising Healthy Children – health/family
4. Fast Track Program - school
National Institute on Alcohol Abuse and Alcoholism
Preventing Substance
Misuse for Ages 10 - 18
Evidence-Based Programs:
1. Strengthening Families Program – family
2. Life Skills Training Program – Jr High school
3. I Hear What You’re Saying – on-line
4. Coping Power – Jr High school
5. Project Toward No Drug – Jr & Sr High
6. Familias Unidas - family
National Institute on Alcohol Abuse and Alcoholism
Preventing Misuse &
Addiction in Young Adults
Evidence-Based Programs:
1. BASICS - college
2. The Parent Handbook – college parents
3. 60 more programs – most – on-line
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Does It Work?
Results from Community-Organized
Prevention
National Institute on Alcohol Abuse and Alcoholism
Consolidated Results from
Community Prevention Studies
Compared with Control Communities – 12th graders in
Organized Prevention Communities showed
31% Less tobacco, alc, other substance use
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Among users – longer time to first use
39% less school truancy and drop out
25% less delinquency
16% fewer substance related injuries & deaths
Also, less school violence, pregnancy, suicides
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• Submitted by Research
Reviewers to Forthcoming
Surgeon General’s Report
1. Consolidate and Coordinate Prevention
a) Single Prevention Department
b) E-B Prevention Policies to reduce availability
c) Community-Based Prevention Programs
2. Integrate SA & Mainstream Healthcare
a) Require Substance Use Education in Medical,
Nursing and Pharmacy Schools
b) Teach and disseminate screening practices
3. Enforce Parity Laws – end insur. discrim.
The End
In Summary:
1. It is possible and cost effective to prevent
substance use and misuse
–
Highly related to most other harms to our young
2. Adolescence is THE “at risk period”
–
ALL of Adolescence – not just part
3. Policies that make substances harder to get are
the most effective form of prevention
–
Costs, taxes, age restrictions, provider restrictions.
4. Many Prevention Programs Do work –
–
MUCH better in Prevention Prepared Communities
National Institute on Alcohol Abuse and Alcoholism
Communities Mobilizing for Change
 Interventions to Reduce Availability:
– Merchants record underage buy attempts
– Beer kegs prohibited at University
Homecoming
– Policies to discourage motels from permitting
underage drinking parties
– Security at high school dances
– Model local ordinances to restrict underage
access to alcohol
– Compliance checks
Source: Wagenaar et al., J. Studies on Alcohol, 2000
National Institute on Alcohol Abuse and Alcoholism
Communities Mobilizing for Change
Results:
-17% increase in outlets checking age ID
-25% decrease in the proportion of 18-20 year olds
attempting alcohol purchase
-17% decline in the proportion of older teens
providing alcohol to younger teens
-7% decrease in the percent under 21 who drank
-14% decline in alcohol traffic injuries, drivers 18-20
Source: Wagenaar et al., J. Studies on Alcohol, 2000
A Matter of Degree (AMOD)
National Institute on Alcohol Abuse and Alcoholism
Weitzman et al. American Journal of Preventive Medicine. 2004
 College/ Community Partnerships
 Environmental strategies to reduce
drinking problems:
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Keg registration
Mandatory responsible beverage service
Police wild party enforcement
Substance free residence halls
Advertising bans
A Matter of Degree (AMOD)
National Institute on Alcohol Abuse and Alcoholism
Weitzman et al. American Journal of Preventive Medicine. 2004
 AMOD achieved 10 – 25% reductions
among college students in
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Binge drinking
Driving after drinking
Alcohol related injuries
Being assaulted by other drinking college
students
Drinking and Driving
Finding: Laws raising the legal
drinking age to 21; and zero
tolerance for young drivers have
prevented over 300,000 deaths.
Evidence: 29 separate studies of
policies in all 50 states
National Institute on Alcohol Abuse and Alcoholism
Early Drinking Onset and Alcohol
Dependence: Twin Study Results
 Early age of starting to drink is related to
alcohol dependence – earlier drinking =
greater likelihood of alcohol addiction
 This is true even among “identical” twins,
(ie fully controlling for genetics)
J. Grant et al. Psychological Medicine, 2006