1. ©Treatment Research Institute, 2012 11/16/2016 Prevention: Moving from Science to Practice ©Treatment Research Institute, 2013 A. Thomas McLellan Treatment Research Institute

2. 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

3. 1 Size and Scope of the Problem

4. 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

5. Annual Costs of Substance Use Related Harms: $450 Billion $270 Billion in Soc/Crim Services $120 Billion in Healthcare Annual Costs of Iraq and Afghan Wars $180 – $250 Billion

6. “Addiction”? Addiction-Related Problems? “Misuse”? Substance “Use”?

7. Substance Use Among US Adults Addiction ~ 21,400,000 Misuse ~ 40,000,000 Little or No Use Little/No Use Very Serious Use In Treatment ~ 4,100,000 Prevention Target

8. 1 Addiction is not “just more partying” It is an acquired, progressive, often chronic illness - cardinal symptom is loss of voluntary control over use About 50% of risk is genetic; rest is environment and age of onset.

9. Substance Use & Addiction Addiction – like other chronic illnesses has an “at risk” period Adolescence 94% of all addictions initiate between 12 - 25

10. N ational I nstitute on A lcohol A buse and A lcoholism Source: Grant and Dawson (1997) J. Substance Abuse

11. 1 1.Reduce Risk Factors 2.Enhance Protective Factors

12. 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

13. 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.

14. Personal Protective Factors Personal Protections 1.involvement in school, 2.involvement in healthy recreational and social activities, and 3.development of good coping skills

15. 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 About Risk and Protective Factors:

16. Commonality of Risk Factors

17. 1.Prevention Policies 2.Prevention Programs Delivered in Prevention Prepared Communities

18. 1 Alcohol Related Problems –DWI, Violence, Injuries, Deaths Opioid Related Problems –Overdose Incidents and Deaths

19. What Are Low-Risk Drinking Limits? Source: NIAAA, Rethinking Drinking: Alcohol and Your Health, 2009

20. 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

21. 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

22. 1 Does It Work? Results from Policies to Reduce Alcohol Problems

23. N ational I nstitute on A lcohol A buse and A lcoholism Alcohol-Related ↓64% Non-Alcohol-Related ↑17% Alcohol- vs. Non-Alcohol-Related Traffic Fatalities Per 100,000 Population, Ages 16-20, United States,1982-2007 25.58 (n=5,244) 9.27 (n=1,987) 15.64 (n=3,351) U.S. MLDA Age 21 lawMLDA 21 in all 50 states Sources: U.S. Fatality Analysis Reporting System, 2008; U.S. Census Bureau, 2009 13.36 (n=2,738)

24. 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

25. Alc/Drg Related Fatal Errors 1983 - 2005 P otential impact on Safety : Fatal Medical Errors Phillips, D. P. et al. 2008;168:1561-1566.

26. Pain Society and State Guidelines for Pain Management 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 CDC Final Guidelines very similar

27. 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

28. 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

29. 1 Evidence Based Programs Delivered in Prepared Communities

30. 1.Adolescence is THE risk period (12 – 23) 2.Same risk factors predict many problems – drop out, pregnancy, bullying, drug use –BUT – Reducing risk for ANY problem reduces risks for MANY problems 3. Many environments influence teens – home, school, work, parties, driving, etc. State of the Science

31. 1.The delivery system is the Community –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

32. Schools Parents Law Enforcement Local Policies 1012 15 18 21 AGE ENVIRONMENT 23 Healthcare

33. Schools Parents Law Enforcement Local Policies 1012 15 18 21 AGE ENVIRONMENT 23 Healthcare

34. N ational I nstitute on A lcohol A buse and A lcoholism 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

35. N ational I nstitute on A lcohol A buse and A lcoholism 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

36. N ational I nstitute on A lcohol A buse and A lcoholism 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

37. 1 Does It Work? Results from Community-Organized Prevention

38. N ational I nstitute on A lcohol A buse and A lcoholism Consolidated Results from Community Prevention Studies Compared with Control Communities – 12 th graders in Organized Prevention Communities showed 31% 31% Less tobacco, alc, other substance use –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

39. 1 Submitted by Research Reviewers to Forthcoming Surgeon General’s Report

40. 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.

41. 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

43. N ational I nstitute on A lcohol A buse and A lcoholism 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

44. N ational I nstitute on A lcohol A buse and A lcoholism 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 attempting alcohol purchase -17% decline in the proportion of older teens providing alcohol to younger 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

45. N ational I nstitute on A lcohol A buse and A lcoholism A Matter of Degree (AMOD) Weitzman et al. American Journal of Preventive Medicine. 2004  College/ Community Partnerships  Environmental strategies to reduce drinking problems: Keg registrationKeg registration Mandatory responsible beverage serviceMandatory responsible beverage service Police wild party enforcementPolice wild party enforcement Substance free residence hallsSubstance free residence halls Advertising bansAdvertising bans

46. N ational I nstitute on A lcohol A buse and A lcoholism A Matter of Degree (AMOD) Weitzman et al. American Journal of Preventive Medicine. 2004  AMOD achieved 10 – 25% reductions among college students in Binge drinkingBinge drinking Driving after drinkingDriving after drinking Alcohol related injuriesAlcohol related injuries Being assaulted by other drinking college studentsBeing assaulted by other drinking college students

47. 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

48. N ational I nstitute on A lcohol A buse and A lcoholism 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