Current Status of Prevention Efforts
New Connections - 3rd Annual Southern Oregon Educational Conference on Advances in Chemical Dependency and Mental Health Treatment, April 17-18, 2008, Medford, Oregon
This consistently brilliant symposium is hosted by the Genesis Recovery Center of Asante Health System, Central Point, Oregon. It was my third consecutive year of participation and I was again inspired by the content as well as the style of each presentation.
Dr. Cardwell (“CC”) Nuckols from Orlando, Florida presented on Neuroscience, Spirituality and 12 Step Facilitated Recovery. Dr. Chuck Jackson from Tulsa, Oklahoma gave a heartfelt address on compassion fatigue and the need for all recovery professionals to continuously self-monitor their healing energy. Dr. Andrea Barthwell, former Deputy Director for Demand Reduction in the Office of National Drug Control Policy traveled from Chicago to bring us up to date on Pharmacotherapy of Substance Dependence Disorders in Psychosocial Settings. I closed the conference with a presentation addressing the growing abuse of prescription and Over the Counter (OTC) medications. I can only hope that my presentation was at least half as well received by the audience as those of Drs. Barthwell, Jackson and Nuckols who gave some of the best talks I’ve ever heard and I attend several conferences each year.
The presenters shared so many “pearls” of knowledge and fascinating clinical experiences that I could write a number of blogs on what I learned. Dr. Barthwell’s discussion on current substance abuse prevention strategies struck me as the most interesting of the conference. She wove this topic into her talk on the science of addiction and treatment and it captivated my interest. Perhaps this is because I am continuously disappointed with what empirical longitudinal research reveals about prevention strategies or maybe it was because Dr. Barthwell described these activities from a new and challenging perspective.
In our book, Uppers, Downers, All Arounders, Bill Cohen and I explore three levels of substance abuse prevention, each with unique strategies and tools that focus on eliminating or minimizing the abuse of drugs in three target populations. Beginning with the first edition the three levels of prevention are described as Primary, Secondary and Tertiary - preventing first abuse of drugs or alcohol, preventing experimentation, social or recreational alcohol/drug abuse from progressing on to more serious problems, and providing intervention and/or treatment to those with problematic use or chemical dependency to get them into abstinence or “Recovery” lifestyles. In the most recent edition (the 6th), we recognize that some educators now use the terms: Universal, Selective and Indicated to describe the three levels of prevention strategies. This classification scheme recognizes the need to develop more intense strategies for those who have not used drugs (traditionally the target population of Primary Prevention) but who are at greater risk to develop problems because of parental drugs use, genetics, or environmental stressors. These and other risk factors, subject individuals who have never used drugs to Selective Prevention interventions that were previously employed in Secondary Prevention. Universal Prevention strategies are targeted at those with no or little risk factors who have never experimented with drugs. Indicated Preventions looks for early signs of abuse or behaviors and intervenes much earlier with traditional Tertiary Prevention techniques than previous models implemented those techniques. (Inaba, DS & Cohen, WE (2007), Uppers, Downers, All Arounders, 6th ED,CNS Pub, Inc., Medford Oregon, p. 375; Eggert, L. L. (1996). Reconnecting Youth: An Indicated Prevention Program. National Conference on Drug Abuse Prevention Research http://www.drugabuse.gov/MeetSum/CODA/Youth.html (accessed May 18, 2007).
As part of her presentation, Dr. Andrea Barthwell outlined a prevention classification scheme that she developed through research in her role as our nation’s Deputy Director of Demand Reduction. Dr. Barthwell looks at the three main targets for prevention strategies as:
“Non-Users consisting of Never Used, Not Using, and Never to Use Again”
“Non-Dependent Users”and
“Dependent Users”.
Research findings demonstrate ways certain risk factor variables can help sustain abstinence in Non-Use populations. These consist of decreasing drug/alcohol availability, reducing opportunities to use, limiting popularization of prior drug experiences, and diminished drug using behavior of peers. These variables also include increasing the perceived risk of use and bolstering respect for social norms. It is Dr. Barthwell’s belief that effective promotion of these variables will result in better prevention outcomes for Non-Users of drugs or alcohol.
Dr. Barthwell describes Non-Dependent Users (often referred to as “social” or “recreational drug users,” terms she strongly dismisses) as the population that fuels and promotes every drug epidemic experienced in our nation. This is the result of the false expectations this group projects about alcohol/drug use to other, more vulnerable populations. It is for this reason that Dr. Barthwell considers Non-Dependent Users the most important target group for intense prevention efforts. Drug prohibition, responsibility, and illegality are the elements of a strategy focused on Non-Dependent Drug Users. These individuals are more likely to respond to zero tolerance policies, detection and exposure activities. Stemming the flow or access of drugs to this population is also found to be effective. Unfortunately, the perception that Non-Dependent Drug Users are the force behind every drug epidemic is used to justify the government’s promotion of random drug testing of middle and high school students. Fortunately, most Americans still regard this strategy as too invasive of our civil liberties to seriously consider, though Drug Czar, John Walters estimates more than 1,000 U.S. high schools and middle schools conduct random drug testing. Mr. Walters also emphasizes that the U.S. Supreme Court has twice carved out exceptions to students’ privacy rights enabling schools to conduct random urine drug test within strict limits - either students for whom there is “reasonable suspicion” of drug use, or randomly testing athletes and students who participate in other extracurricular activities (USA Today Editorial Debate, http://blogs.usatoday.com/oped/2007/05/lede_ed.html, accessed 4/25/08).
Dr. Barthwell also outlined prevention strategies targeted at Dependent Users. Research shows an “Awareness Gap” (also called “Denial”) in this population, 76% of those who met DSM-IV-TR criteria for alcohol or drug problems, say they don’t have a problem. Of those who recognize that they have a problem with drugs or alcohol, only 5% will try to find treatment, a “Motivation Gap”. Two percent of those who desired and sought treatment could not access it, the “Treatment Gap” and 17% of those who met criteria for drug or alcohol problems had at least one admission to treatment in the preceding 12 month, a “Success Gap”. (SAMHSA, (2001), NHSDUH) Dr. Barthwell quoted another set of data that she used to develop her demand reduction strategies. Of those who do access treatment, only 25% to 31% will complete treatment with a positive discharge, another type of a “Motivation Gap” and only 50% of those who complete treatment will stay clean and sober for at least a year after being discharged, an “Outcome Gap” (SAMHSA, (2001), TEDS; SAMHSA, (2001), UFDS). Effective strategies targeted to address these gaps were identified as: increased Screening and Brief Interventions by health professionals that are buttressed by Case Management and a Continuum of Chemical Dependency Treatment Services that is actively supported by communities, labor, and faith-based resources.
Despite the meticulous research and careful development of the current spectrum of prevention strategies in America, Dr. Andrea Barthwell confessed that like me, she too is concerned that rigorous empirical research fails to document significant positive long-term outcomes from U.S. drug and alcohol prevention programs. She is especially disappointed by those activities targeted for Non-Users and Non-Dependent Users. I call this an “Efficacy Gap”. Dr. Barthwell described current drug and alcohol prevention efforts as a “blunt instrument”. She stated that we need to discover better tools to prevent drug and alcohol abuse in our communities but quickly added that at the moment we are using the best tools that our science can provide and that using these flawed tools is a lot better than not using any at all. Perhaps there is truth in Dr. Barthwell’s statement since the current prevention efforts were really developed to prevent alcohol and illicit drug abuse and every survey indicates a dramatic decline of these substances since 2001. The recent edition of NIDA Notes states that teen substance abuse continues to decline with current use (any use during the past month) declining by at least 24% for marijuana and any other illicit drug in 2007 as compared to 2001. Use of methamphetamine and ecstasy declined by 64% and 54% respectively and alcohol use had declined by 15% and cigarettes by 33% during that period of time. (NIDA Notes (2008), Teen substance abuse continues to decline. 21(5):15, March) This dramatic decline in teen abuse of alcohol and illicit drugs seems to indicate that prevention strategies are having a much greater impact than either of us had believed. Unfortunately, this illusion is quickly shattered when current data on teen or adult abuse of prescription and OTC drugs are examined.
The number of U.S. adults abusing prescription drugs (approximately 15-17 million) has doubled over the last decade. Abuse of these medications has risen even more rapidly among teens, tripling during the same period of time. By 2006, 9.2% of the U.S. population over the age of 12 (22.6 million people) were dependent on or abused alcohol and/or illicit drugs (Prescription drug misuse grows, but illicit drugs are less popular. Pharmacy Today, 13(10):2, 2007). Teen abuse of prescription opioid pain medications increased over 540% in the last few years alone (CASA, 2005). Non-medical use of all prescription drugs in young adults grew from 5.4% in 2002 to 6.4% in 2006 (Prescription drug misuse grows, but illicit drugs are less popular. Pharmacy Today, 13(10):2, 2007). Abuse of prescription and OTC medications by teens now exceed abuse levels for many of the media hyped street drugs like ecstasy and methamphetamine. By 2006, prescription drugs became the drugs of choice for abuse by 12- and 13-year olds in the U.S. (SAMHSA 2007, National Survey on Drug Use and Health, 2006; ONDCP 2007, Teens and Prescription Drugs: An Analysis of Recent Trends on the Emerging Drug Threat). Regrettable, prescription drugs are now involved in 30% of all hospital emergency room deaths and 80% of drug mentions during an emergency room visit (CASA, 2005).
This was a perfect segue for my conference presentation on the misuse and abuse of prescription and OTC drugs. Hopefully, Dr. Barthwell will now work on prevention strategies that target the abuse of prescription and OTC drugs as well as alcohol and illicit drug. If the current trend continues, these medications will clearly become the major drug problem of this decade. I am very grateful to Dr. Andrea Barthwell for participating in the New Connections - 3 Conference and especially for her continued contributions to our nation’s demand reduction strategies.
Darryl S. Inaba, PharmD., CADC III
