Strategy for Preventing Opioid Use Disorders in Communities

The majority of adolescents will engage in substance use (e.g., nicotine/tobacco, alcohol, cannabis) between the ages of 12-21. While most will not develop a substance use disorder (SUD), substance use of any kind during adolescence is concerning given the detrimental impact of substances on the developing brain. Moreover, for a subset of youth, substance use will become more frequent and problematic, leading to negative effects on their development, health, and well-being. The effects of substance use/misuse accumulate over time and significantly contribute to costly social, physical, mental, and public health problems. The development of SUDs, including opioid use disorders (OUDs) is often preceded by a variety of other problems including academic failure, antisocial behavior, anxiety, depression, and traumatic stress. These problems often arise due to environments within the home, school, or neighborhood that are unsafe, under-resourced, or otherwise harmful to social, academic, and behavioral development.

The three most important environments affecting young people’s development are families, schools, and neighborhoods, all of which offer opportunities for intervention. Effective programs shown to prevent teens from developing SUDs work within these environments to strengthen cognitive control over emotional and impulsive reactions, foster healthy relationships, teach effective ways of managing stress, reduce traumatic experiences, and provide nurturing settings for healthy development. One of the most effective prevention approaches involve the implementation of early intervention strategies that prevent problems from occurring or tackle them head-on when they do appear before problems worsen. It works by identifying and providing early supports and programs to children and adolescents who are at risk of a variety of poor outcomes that tend to be related to one another; e.g., substance misuse, delinquency, school drop-out, depression, and other mental and behavioral problems.
 
 Implementing these programs well through supportive infrastructure and policies can yield significantly more benefits than costs. Taxpayers benefit when investments are made in these successful research-based programs rather than waiting and reacting to already serious substance use problems that are much more difficult and costly to address. Prevention is increasingly recognized as an essential element for tackling pandemics, social and racial injustices, health disparities, and other adversities. As states are about to receive heavy infusions of money from the pharmaceutical settlements, they have the unique and urgent opportunity to promote the scaling up and scaling out of effective prevention.

1. Select and implement family and school programs shown to reduce behavioral problems and substance use.

The best available research evidence enables researchers, practitioners, and policymakers to determine whether or not a prevention program, practice, or policy is actually achieving the outcomes it aims to and in the way it intends.

2. Identify at-risk youth.

Use evidence-based screening tools to identify youth with a high probability for risky behaviors and train staff and practitioners in Youth Mental Health First Aid to learn strategies to help identify, understand, and respond to signs and symptoms of mental health and substance use challenges. [See below.]

3. Intervene early.

Early intervention can take different forms, such as home visiting programs, support for disadvantaged parents in the postnatal period, school-based programs shown to improve children’s social and emotional skills, brief motivational interventions to promote behavior change, and mentoring young people who are vulnerable to involvement in crime.

4. Focus on promoting evidence-based investments supported by technical assistance and a built-in plan for continuous quality improvement.

A shared measurement system—where multiple organizations use a common set of measures to evaluate performance and track progress toward goals—can account for how dollars are spent and can clearly attach to the outcomes of programs supported by opioid settlement funds.

5. Embed strong community-level support.

A continuum of resources, delivered by local organizations providing community-based prevention, treatment, aftercare/recovery, and ongoing maintenance, is vital for a community-driven response to local needs.

6. Use existing infrastructures when possible.

The Center for Medicare and Medicaid Services developedEPSDT (Early and Periodic Screening, Diagnostic and Treatment) in 2014 to guide the provision of an array of prevention, diagnostic and treatment services for children who are enrolled in the Medicaid program. Medicaid could oversee and coordinate statewide implementation of prevention policies by tying into federally supported prevention initiatives such as EPSDT and Bright Futures.

7. Engage an informed and capable workforce.

To achieve long lasting improvements, professionals who work with at-risk youth and families in communities with a high prevalence of risk conditions should be trained and equipped with the tools to carry out this work and certified that they meet standards demonstrating their knowledge, skills, and competencies to effectively deliver evidence-based prevention interventions. This workforce spans educational, justice, public health, primary care, child welfare, and other sectors/systems, each containing its own infrastructure, so it is important that all those who will deliver prevention programming have the same training and credentialling.

8. Enact policy change.

Changes to federal, state, and local policies affect the full range of institutions and structures in neighborhoods, communities, and society, including families, schools, churches, health care systems, community organizations, businesses, and corporations. The resulting characteristics and actions of those institutions and structures in turn affect the physical, economic, and social environments experienced by children and their families in their communities. Thus, policy can influence the distribution of wealth (e.g., EITC), employment (e.g., training programs), and the health care (e.g., Bright Futures), education (e.g., social-emotional learning), child welfare (e.g., child support), and juvenile justice systems (e.g., diversion) and will, thus, have more far reaching and sustainable impacts than any specific programs. See the National Academy of Sciences, Engineering and Medicine Report, 2019.

Evidence-Based School and Family Programs to Reduce Problem Behaviors & Substance Use

Each of the following programs are considered “evidence-based” and can be found on the Blueprints for Healthy Youth Development website along with additional background material, implementation advice, and resources. These programs are developmentally appropriate and have been shown to either prevent the initiation of substance use or escalation of use. The National Prevention Science Coalition to Improve Lives (NPSC) also offers subject matter experts and additional guidance around conducting needs assessments, selecting programs appropriate for the community, implementing and evaluating prevention programs, and leveraging existing infrastructure to support their delivery.

The following are evidence-based approaches that can be used to identify youth who need assistance to improve their outcomes.

1. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based framework used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. SBIRT is most frequently employed during well-child check-ups and school health and psychological services to reinforce healthy choices and support early identification, intervention, and referral to treatment. A highly adaptable framework, SBIRT can be implemented within a number of systems that encounter at-risk children, adolescents, and families (e.g., education, pediatric health care, criminal justice, child welfare). There are several well-validated tools that can aid in the identification of risk.

2. Youth Mental Health First Aid. This program teaches adults who work with youth, including teachers, school staff, coachers, parents, camp counselors, and youth group leaders, how to identify, understand, and respond to signs and symptoms of mental health and substance use challenges among children and adolescents and provides a basis for referral to services. Subjects covered include the common signs and symptoms of mental health and substance use challenges in youth, how to interact with a child or adolescent in crisis, and how to connect the youth with help. The training includes expanded content on trauma, substance use, self-care and the impact of social media and bullying, and use of the Mental Health First Aid Action Plan (ALGEE): Assess for risk of suicide or harm; Listen nonjudgmentally; Give reassurance and information; Encourage appropriate professional help; and Encourage self-help and other support strategies.

Building a Backbone Infrastructure to Achieve Successful Outcomes

A strong community-based infrastructure is needed to support delivery of preventive interventions made possible via the pharmaceutical settlement monies. We recommend a 5-phase process that results in a Substance Prevention Service Delivery System (see figure) for the effective and cost-efficient implementation of interventions known to reduce SUD/OUD. The phases include:

For further information, resources, trainings, and other guidance, please access the following websites:

Authors

Dr. Diana Fishbein (dfishbein@unc.edu)

Senior Scientist, FPG Child Development Institute,University of North Carolina-Chapel Hill, Part-Time Faculty at Penn State University, and Founder/Co-Director of the National Prevention Science Coalition to Improve Lives

Dr. Zili Sloboda (zili.sloboda@apsintl.org)

President, Applied Prevention Science International, Inc.

Dr. Melissa Clepper-Faith (mclepperfaith@unc.edu)

Translational Research Program and Policy Coordinator,FPG Child Development Institute, University of NorthCarolina-Chapel Hill

A Division for Advancing Prevention & Treatment (ADAPT)

Point of contact: Dr. Lora Peppard (lpeppard@wb.hidta.org)

Director of ADAPT, Washington/Baltimore HIDTA

And the national Consortium to Advance Prevention Solutions to the Opioid Crisis (CAPSOC)