Substance abuse prevention and control: Policies and interventions that work

Prevention  Three levels of prevention with respect to behavior Primary – health promotion Primary – health promotion Secondary – aimed at stopping at or near early signs of problem Secondary – aimed at stopping at or near early signs of problem Tertiary – rehabilitation or treatment Tertiary – rehabilitation or treatment

What is an intervention Activity aimed at primary, secondary or tertiary prevention of a behavior or condition. Best practices include: Theory basedTheory based Packaged in some wayPackaged in some way Book, video, web, cd-rom, etc Book, video, web, cd-rom, etc ReplicableReplicable Someone can take it and do it themselves Someone can take it and do it themselves TestableTestable Delivered with fidelity to the original planDelivered with fidelity to the original plan

Public health goals relevant to substance abuse  Criminal Justice?  Treatment?  Counseling?  Prevention. If prevention is the goal, where do you aim your efforts? If prevention is the goal, where do you aim your efforts?

SOURCE: Past Year Nonmedical Use of Pain Relievers, by Detailed Age Category: Annual Averages Based on

Interventions  Are driven by social psychological models  Posit that some set of variables (things that do or can change) influence risk or protective behaviors

Adolescents…  Make intervention complex because: It is when most people initiate risk behavior It is when most people initiate risk behavior However initiation of risk is not uniform nor does it follow a set pattern However initiation of risk is not uniform nor does it follow a set pattern Adolescent cognitive/coping/social abilities vary greatly Adolescent cognitive/coping/social abilities vary greatly Sometimes adolescent behavior is not truly volitional Sometimes adolescent behavior is not truly volitional

Examples of Risk and Protective Factors Risk Factors Domain Protective Factors Early Aggressive Behavior Individual Self-Control Poor Social Skills Individual Positive Relationships Lack of Parental Supervision Family Parental Monitoring/Support Substance Abuse Peer Academic Competence Drug Availability School Anti-Drug Use Policies Poverty Community Strong Neighborood Attachment

12 th Graders ’ Past Year Marijuana Use vs. Perceived Risk of Occasional Marijuana Use Percent

Sustaining and broadening intervention effect  Enhancing self efficacy  Changing perceptions of normative behavior  Boosters  Influencing other intrinsic and extrinisic rewards Peer approval Peer approval Parent norms Parent norms

Whats in a booster?  Some topic specific content  Done at intervals after the main intervention  Usually theory based and the punchiest content  Maybe goal setting

Parental Monitoring  Parents are: Authority figures Authority figures Role models Role models Guide social interactions of kids Guide social interactions of kids Impart values Impart values Both good and badBoth good and bad  Monitoring includes both supervision and communication

Research  Parent intervention alone Kids and parents increased in concordance of self-reported information about risk behavior Kids and parents increased in concordance of self-reported information about risk behavior  Parent intervention plus child intervention with 6 and 10 month boosters Protective for cigarette use, alcohol, marijuana, and risk intention Protective for cigarette use, alcohol, marijuana, and risk intention With boosters there was marginal extra effect With boosters there was marginal extra effect Only in crack use and drug traffickingOnly in crack use and drug trafficking Burns and Stanton 2005 Burns and Stanton 2005

So Parents:  Can both broaden and strengthen intervention effect

Project MAC Making Amazing Choices McDowell County, WV

Used Communities that Care® Youth Survey  Risk and Protective Factors in 4 domains Community Community Family Family School School Peer and Individual Peer and Individual

Project MAC  Surveyed over th and 6 th graders at 5 schools  Students currently wrapping up an intervention with high school mentors  Post-test survey will be done the end of May  Pre/post comparisons of skills, knowledge, and attitudes

Community Domain  Risk Factors Low Neighborhood Attachment Low Neighborhood Attachment Community Disorganization Community Disorganization Transitions and Mobility Transitions and Mobility Laws and Norms Favorable to Drug Use Laws and Norms Favorable to Drug Use Perceived Availability of Drugs Perceived Availability of Drugs  Protective Factors Community Rewards and opportunities for Prosocial Involvement Community Rewards and opportunities for Prosocial Involvement

Family Domain  Risk Factors Poor Family Management Poor Family Management Family Conflict or history of antisocial behavior Family Conflict or history of antisocial behavior Parental Attitudes Favorable toward Antisocial Behavior Parental Attitudes Favorable toward Antisocial Behavior Parental Attitudes Favorable toward Alcohol, Tobacco, and Other Drug Use Parental Attitudes Favorable toward Alcohol, Tobacco, and Other Drug Use  Protective Factors Family Attachment Family Attachment Family Opportunities and Rewards for Prosocial Involvement Family Opportunities and Rewards for Prosocial Involvement

School Domain Results  Risk Factors Poor Academic Performance Poor Academic Performance Low School Commitment Low School Commitment  Protective Factors School Opportunities for Prosocial Involvement School Opportunities for Prosocial Involvement School Rewards for Prosocial Involvement School Rewards for Prosocial Involvement

Peer & Individual Domain  Risk Factors Low Perceived Risk of Drug Use Low Perceived Risk of Drug Use Early Initiation of Drug Use Early Initiation of Drug Use Sensation Seeking Sensation Seeking Rebelliousness Rebelliousness  Protective Factors Religiosity Religiosity Social Skills Social Skills Belief in the Moral Order Belief in the Moral Order Interaction with Prosocial Peers Interaction with Prosocial Peers

Intervention Study  School-based Aimed at 5th and 6th grade youth in school Aimed at 5th and 6th grade youth in school Mentored by Health Sciences and Technology Academy (HSTA) youth from the high schoolsMentored by Health Sciences and Technology Academy (HSTA) youth from the high schools Pretest-Intervention-Posttest (1 and 2) design Pretest-Intervention-Posttest (1 and 2) design SAMHSA approved programming SAMHSA approved programming  Community focused Works in concert with organic prevention efforts Works in concert with organic prevention efforts ONE VoiceONE Voice  Parent training COPA and Family Matters COPA and Family Matters  Local media and community-supported Funded by WV State Oxycontin settlement dollarsFunded by WV State Oxycontin settlement dollars

Project MAC results  Surveyed th and 6 th graders at 5 schools  126 students completed pretest, intervention and both post tests 106 in 5 th and 6 th 106 in 5 th and 6 th 20 HSTA students 20 HSTA students  Pre/post (2) comparisons of behaviors, skills, knowledge, and attitudes  Family component is still underway 22 dyads recruited and 4 have completed all follow ups 22 dyads recruited and 4 have completed all follow ups

Quick demographics  5th graders = 41% 6th graders = 59%  White = 69% African Amer. = 16% Native Amer. = 3% Other = 12%  Female = 42% Male = 58%  10 yrs old = 14% 11 yrs old = 41% 12 yrs old = 37% 13 yrs old = 7% 14 yrs old = 1 %

Poor self-esteem & antisocial attitudes Lower scores = emphatic NO!

How wrong is it for your peers to: Lower scores = Very wrong!

How wrong would your parents think that it was if you: Lower scores = Very wrong!

Summary  Positive findings: No increase in substance use No increase in substance use Might expect to see this with increased ageMight expect to see this with increased age Increases in negative attitudes about drugs and future drug use Increases in negative attitudes about drugs and future drug use Increases in negative attitudes about peer drug use Increases in negative attitudes about peer drug use Increases in self esteem Increases in self esteem  No positive changes in school connectedness, parental norms/involvement, or neighborhood attachment

Scale  Taking the intervention all the way to the national level  Disseminating broadly

Sustain?  Who makes interventions Creative motivated clinicians Creative motivated clinicians Public Health professionals Public Health professionals  Who makes them go to scale? ONLY the most focused, motivated, and lucky ONLY the most focused, motivated, and lucky  There is a trend in the direction of scale 14 in 1985 vs 200 today. 14 in 1985 vs 200 today.

Fidelity vs Evolution  Fidelity is doing the program as close to the manner intended by the developer as possible  Researchers endorse fidelity because so much care is taken in development  Practitioners argue for evolution

To take programs to scale:  Researchers often are entrepreneurial without training Takes creativity and skill to develop programs Takes creativity and skill to develop programs  We do want the public to accept our programs because that means there is a greater chance of health for all  But we are usually not very market- oriented

Alternate models for dissemination  Quasi-governmental DARE and DARE + DARE and DARE +  Faith community organizations  Self-Help books  Men’s and women’s civic organizations Elks, Lions etc Elks, Lions etc  Straight for-profit programs like Weight Watchers

Programs must be acceptable to multiple audiences  Often developed in clinic  Too often for small segments of population  Very academic  There could be a model from marketing wherein the data is centralized by national survey  Researchers cant do it alone

Programs must evolve over time Programs are usually thought to be static, but  There are design features for any intervention that could be changed Delivery setting, number of sessions, change agents, interventionists, timing of sessions, key skills, rhythm, delivery format, etc. Delivery setting, number of sessions, change agents, interventionists, timing of sessions, key skills, rhythm, delivery format, etc.  Continuous quality improvement principles must be applied

Recognizing efficacious interventions  Need credentialing bodies  Need better, more nimble new research designs

Dissemination  Begin with dissemination in mind  Adopt marketing techniques to thrive  There are examples in the US: Life skills Life skills Communities that care Communities that care