Introduction

Although much of what is covered in this article applies across the lifespan, the focus is on young people who are at higher risk for developing alcohol and drug use disorders later in life. Social work continues to be in a unique position to target alcohol and drug use among young people and to contribute to the amelioration of the negative health, psychosocial, and economic impacts on individuals, families, communities, and society at large. Building on its historic commitment to addressing disparities and economic and social justice, social work can continue to help reduce the burden of substance use and its related costs. Critical to these efforts will be developing innovative strategies to translate the expanding research supporting effective prevention programs and policies into culturally relevant practice to meet the needs of many who lack adequate access to care, particularly underserved and marginalized populations. It is important for social work to embrace and adapt to the changing service environment as programs shift to online platforms in response to COVID-19 restrictions.¹

This purpose of this article is to help define prevention relative to current paradigmatic shifts in the field and to briefly describe the history of prevention from the temperance movement to the current public health approaches; the role that neuroscience is playing in driving innovations in the field; foundational theories essential to the design and evaluation of practice.

Defining Prevention

Substance use, misuse, and addiction are preventable disorders that interfere with normal healthy functioning (Robertson et al., 2016). Healthy mental, emotional, and behavioral development is a critical foundation for a productive adulthood (NASEM, 2019). Prevention encompasses a range of proactive activities and policies that support individuals, families, and communities in establishing and reinforcing healthy behaviors and lifestyles (NASEM, 2019; Robertson et al., 2016; Substance Abuse and Mental Health Services Administration [SAMHSA], 2020). A report by the National Academies of Sciences, Engineering, and Medicine developed a model that emphasized the importance of a spectrum of prevention activities required to support healthy individuals and communities (NASEM, 2019). Promotion efforts actively support society, the whole community, and individuals and families to develop well-being and strengthen the ability to cope with adversity. Within prevention there are three major areas of activity. Universal prevention focuses on an entire community or group regardless of risk for substance use. Selective prevention concentrates on individuals who may be at risk for substance use. Indicated prevention focuses on individuals who are starting to show signs of substance use. Treatment and long-term support for recovery are also important elements to the health of a community and individuals.

Approaches to effective alcohol and drug use prevention have evolved over time. The field has experienced a substantial paradigm shift which incorporates advances in neuroscience in the development of interventions. There is also an increased emphasis on changing the community environment and the promotion of mental, emotional, and behavioral health across the entire population (National Academies of Sciences, Engineering, and Medicine [NASEM], 2017, 2019; National Research Council & Institute of Medicine, 2009).

Research has underscored that substance use prevention activities need to be interdisciplinary to be effective. Social work is, by its very nature, interdisciplinary. Its commitment to professional values and ethics and its emphasis on social and economic justice are important elements of its work to effect changes at the individual, family, and community levels. Social workers also understand the need for collaborating with a range of professionals and paraprofessionals across service systems and settings to achieve positive outcomes for their clients. Social workers also have a long history of translational work in the provision of evidenced-informed community-based alcohol and drug prevention and treatment services across the lifespan to those of diverse socioeconomic status, race and ethnicity, gender, sexual orientation, and ability status (National Association of Social Workers [NASW], 2018; Wells et al., 2014).

History: From Social Control to Public Health

The use and misuse of alcohol and other substances has been documented for more than 4,000 years (Howard et al., 2013). History reveals numerous health and social and problems associated with alcohol and other drugs in the United States (Begun, 2017); therefore, it is important to consider the historical context of substance use and misuse in this country. Anderson (n.d.) noted that many substances that are considered extremely dangerous today were once viewed favorably and were instrumental in terms of rituals, ceremonies, and leisure activities. Over time, as substances like alcohol, cocaine, and morphine were developed for use in the medical community and use became more widespread, unforeseen problems such as misuse and dependence emerged. What was initially seen as a social and cultural phenomenon was transformed into a public health and social problem that needed to be controlled. Early prevention efforts sought to address the health and economic consequences of drug use by controlling access to distribution and supply.

One of the earliest efforts to control substance abuse and its consequences emerged in the late 1800s in response to dramatic increases in distribution and consumption of alcohol. Groups like the Women’s Christian Temperance Movement and the Anti-Saloon League were effective in influencing the passage of several liquor laws leading up to the Eighteenth Amendment in 1919. While there was a decrease in legal consumption after passage, illegal consumption increased during the 1920s (Levine & Reinarman, 1991; Tyrell, 1997). Its repeal in 1933 was in part an acknowledgemnt of this increasingly unpopular measure and the need to address economic realities such as the need for the creation of jobs and for increased tax revenues during the Great Depression (Mann et al., 2000). The movement established the foundation for the development of prohibition laws and to some degree was the preamble to the abstinence-only prevention paradigm that inspires much of contemporary U.S. prevention policy (Mann et al., 2000).

Over the next 50 years, several acts were passed, including the Marijuana Stamp Act of 1937 and the Controlled Substances Act of 1970. These acts tended to increase regulation, either through taxation or criminal penalties. Musto (1999) suggested that many of these laws were not supported by the American public as there was a shift toward a more medical approach for drug control. Tolerance was short-lived, however, as the United States saw increasing experimentation with drugs in the context of an unpopular war and massive social change (Anderson, n.d.). In response, the Nixon administration implemented new policies, often referred to as the War on Drugs (Begun, 2017). Originally framed as a strategy to stop the use, distribution, and trade of illegal drugs, its reliance on harsh prison sentences for dealers and users continue to raise significant policy and ethical questions in terms of the racial and gender disparities in sentencing (Radosh, 2008). The Carter administration deemphasized criminal penalties for drug use, particularly marijuana use. By 1977, 11 states had chosen to decriminalize its use (Martin, 2016). In the early 1980s, as the Regan administration expanded the War on Drugs, and First Lady Nancy Regan launched the Just Say No initiative, a campaign focused on discouraging young people from engaging in illegal drug use and offering strategies to say no when offered drugs. From this initiative, the Drug Abuse Resistance Education (DARE) program gained some prominence in the United States (Joseph, 2017). Joseph (2017) noted that this program was designed to be taught by police and relied on graphic and often exaggerated depictions of the consequences of alcohol and other drug use on the body and mind. The approach was found to be ineffective, as people did not change their behavior because of hearing such messages. In fact, many young people expressed increased interest in substance use (Bikerland et al., 2005; West & O’Neal, 2004; Witte & Allen, 2000).

Contemporary evidence-based prevention interventions can take place at different levels, such as the individual, family, neighborhood, school, and larger society. They tend to minimize the burden of substance use and associated harms by delaying the onset of use and reducing problematic use leading to improved health in the community. The more levels the interventions target, or the more comprehensive the approach, the more effective the programs are (Botvin et al., 2000; Hawkins et al., 2002). Effective prevention interventions are sensitive to social and cultural environments, integrate existing assets, and address unique contextual risks. Although they may differ in their specific content, effective prevention interventions tend to be grounded in ecological perspectives familiar to social workers (Botvin et al., 2000; Epstein et al., 2001).

The Role of Neuroscience and the Environment

The risk for developing an addiction is the result of complex interactions between environmental factors, such as social and cultural systems, stress, and trauma, and biological factors, such as genetics and epigenetics, development, and neurocircuitry (De Bellis et al., 2000; Volkow & Boyle, 2018). Recent advances in addictions research have significantly enhanced our understanding of

how psychological traits, emotions, and behaviors are encoded on the brain; how environmental factors influence brain circuits and subsequent behavior; and how genetic and epigenetic factors influence the development and function of the brain, all of which are of relevance to addiction risk and resilience.

(Volkow & Boyle, 2018, p. 730)

Neuroscience has shown that adolescents and children are more vulnerable to addiction than adults because their brains are not yet fully developed and have greater neuroplasticity. During adolescence, the neuronal circuits associated with reward and motivation develop much faster than the circuits in the prefrontal cortex, and they are in a heightened state that can lead to greater emotional reactivity leading to pleasure and thrill-seeking behaviors (Giedd, 2008; Volkow & Boyle, 2018). The later development of the prefrontal cortex means that adolescents do not have the same ability to self-regulate their behavior as a fully developed adult does (De Bellis et al., 2000; Jordan & Andersen, 2017). Greater neuroplasticity and sensitivity help to explain why addiction develops faster among adolescents and why this population may be more susceptible to environmental factors such as stress and trauma that can influence drug-taking behavior (Giedd, 2008; Lewis & Olive, 2014; Whitaker et al., 2013).

This type of neurological research has provided evidence about the importance of accounting for the biological factors associated with drug use in combination with psychosocial and environmental factors. More recently, Volkow and Boyle (2018) suggested that increased understanding of the effects of substance use on normal brain development, the harmful effects of adverse environments, and the role of innate vulnerabilities may lead to the development of personalized prevention interventions to reverse or mitigate some of these susceptibilities.

Many findings from the field of neuroscience are currently integrated into treatment and prevention modalities, but much remains to be done to fully exploit this work for prevention interventions with adolescents and preadolescents. For example, we know that when an individual initiates substance use, changes occur in the neurocircuitry of the brain. Therefore, delaying the onset of alcohol and other drug use can prevent or reduce substance use and reduce or deter progression to substance use disorders and related conditions (Spoth et al., 2009). Volkow and Boyle (2018) highlighted the need to develop strategies that mitigate or reduce the harm related to adverse social environments, particularly social isolation and poor social support. Research has shown that social isolation and poor social support can delay prefrontal limbic connectivity, which is related to impulsivity (Eiland & Romeo, 2013; Ozbay et al., 2007), a significant risk factor in substance use in children and adolescents.

Many current prevention interventions are designed to help individuals improve self-regulation and delay immediate gratification. Social work’s efforts to increase attention on social and cultural systems and create less stressful and traumatic environments through strengthening family ties and social connectedness may lead to long-term changes across generational cohorts (Lubben et al., 2015).

Ecological Theory and Prevention

Ecological perspectives, and in particular risk and resiliency approaches, provide the appropriate theoretical foundation for prevention. The premise behind this theoretical approach is that there are factors or conditions that protect individuals against alcohol and drug abuse while other factors and contextual conditions may make them more vulnerable to alcohol and drug abuse (Catalano et al., 2004).

Protective factors are individual or environmental assets or safeguards that increase or boost a person’s ability to cope with stressful events or risky situations and help them to adapt and be competent in resisting those risks (Marsiglia et al., 2006). Risk factors on the other hand are individual or environmental vulnerabilities associated with a higher likelihood that a negative outcome will occur (Arthur et al., 2002; Mrazek et al., 1994). Prevention programs work to strengthen protective factors and weaken or eliminate risk factors (Hawkins et al., 2002).

There is an ongoing debate about what constitutes a protective or a risk factor for alcohol and other drugs at different ecosystemic levels. The following are the risk and preventive or protective factors that have been reinforced by prevention interventions (Hawkins et al., 2002):

Community protective factors: social cohesion, caring adults, shared norms, and ethnic or cultural identity

Family protective factors: effective and horizontal parent-child communication, clear rules, consistent consequences, religiosity and spirituality, intergenerational shared fun time

School protective factors: positive school climate, welcoming and caring environment, clear rules and expectations, academic excellence

Individual and peer protective factors: high academic achievement, involvement in extracurricular activities, problem-solving and critical thinking skills, adult role models, antidrug norms

Risk factors are individual or environmental vulnerabilities that are associated with a higher probability that an undesired or negative outcome will occur (Arthur et al., 2002; Mrazek et al., 1994). Selected risk factors commonly targeted by prevention interventions include the following (Arthur et al., 2002; Hawkins et al., 2002):

Community risk factors: social disorganization, low neighborhood attachment, easy access to alcohol, tobacco, and other drugs

Family risk factors: lack of communication or poor communication, lack of parental monitoring, lack of or inconsistent rules and expectations, family history of addiction

School risk factors: low or inconsistent academic standards and support, lack of discipline and chaotic environment, unclear policies regarding alcohol and other drugs

Individual and peer risk factors: antisocial behaviors, sensation seeking, peer and individual pro-drug norms, susceptibility to peer influence, acculturation stress, low school achievement, and young age of initiation (Marsiglia et al., 2012; Sobeck et al., 2000).

Principles and Effective Macro Prevention Practices

Ethical Issues and Other Challenges for Social Workers Providing Prevention Services

Social Justice and Prevention Services Issues

Nissen (2014) claimed that “substance [use] problems, addictions, and addictions treatment and the related preparation of professionals to fill its treatment ranks exist within an ideological and political infrastructure” (p. 1). This applies equally to the field of substance use prevention. Discussions of social justice issues are noticeably lacking as a fundamental concern of people who seek substance use services, communities that want to address addiction, and the national discussion on the current epidemic of drug use (NASW, 2013; Nissen, 2014). Barker (2003) conceptualized social justice as a

state in which equity, fairness, opportunity and success for all diverse members of a society are commonplace and expected in which there is acknowledgement that personal and structural success and struggles are intertwined, and that inequities of the past are acknowledged and redressed.

(Nissen, 2014, p. 3)

Enduring structural, social, and cultural factors tend to limit access to evidence-based preventions among ethnic and other minority youth and affect whether these youth choose to access or participate in prevention services and how they experience and respond to prevention interventions that may be successful in nonminority populations (Backinger et al., 2003; Blume, 2016; Noonan et al., 2016; U.S. Department of Health and Human Services, 1985). These same factors create barriers to comprehensive health and social services that may help support engagement with minority youth and their families in prevention services. As a result, many minority youth and their families experience disparities in access to care and substance use prevention services, and they often find themselves involved in the criminal justice system, which creates new challenges. As a profession, social work can take the next step to expand the role of racial, ethnic, cultural, sexual minority and other marginalized youth in the development and selection of strategies to address substance use risk and prevention and how services are designed and prioritized within their communities (NASW, 2013; Noonan et al., 2016).

International Connections

Substance use, misuse, and abuse is a global problem. Worldwide, approximately 269 million people used drugs in 2018, which is 30% more than in 2009. Some 35.6 million people suffer from drug use disorders globally but only one of eight people who need drug-related treatment receive it (United Nations Office on Drugs and Crime, 2020). Drug markets are increasingly complex, and more types of drugs are available. Nations across the globe are seeking to address the devastating impact of drug use on their citizens by advancing research; supporting effective prevention, treatment, and recovery programs; and collecting data to better understand drug use patterns (Das & Horton, 2019). Social work has an important role to play in helping disseminate and implement evidence-based practices with the international community. Further, they can be influential in advancing prevention science through translational research efforts that are rooted in what DiNitto (2005) defined as social work’s “distinctive strength-based, culturally relevant practice and social justice frame” (Wells et al., 2014).

Emerging Trends: Opportunities and Challenges for Social Work

Substance use and misuse imposes enormous physical, social, emotional, and monetary costs on young people, their families, and the communities in which they live. There have been significant reductions in alcohol use, including binge alcohol use, among adolescents and young adults aged 18–25 since 2010 (Center for Behavioral Health Statistics and Quality, 2020; Kulak & Griswold, 2019). However, researchers and practitioners have seen a concerning increase in the use of electronic cigarettes (nicotine, marijuana, and flavored), marijuana, and opioid use (Kulak & Griswold, 2019; National Institute on Drug Abuse, 2020). The use of e-cigarettes, or vaping, is used to deliver nicotine and increasingly marijuana, often at higher doses than combustible cigarettes, which increases the risk of addiction (CDC, 2016, 2020b; Jankowski et al., 2019). Recent research by Garcί‎a and his colleagues (2016) suggests that marketing practices for e-cigarettes vary by ethnic community, which may require new community-based interventions to mitigate these practices such as peer-crowd messaging based on authentic and realistic portrayals (Kim et al., 2020).

Recent research by Dumas et al. (2020) highlighted a potentially problematic challenge for social work involved in prevention with the movement to online school and telehealth strategies in response to risks associated with the COVID-19 pandemic. Young people are suffering from significant stressors that can and do lead to declines in mental health and the ability to cope. The break from daily routines, limited access to friends, and missing significant life events including birthdays, graduations, and vacations contribute to a sense of social isolation. Additionally, many adolescents and young adults are at greater risk of exposure to abuse and neglect, intimate partner violence, and sexual violence (CDC, 2020a). It is not surprising then, that although Dumas and her colleagues (2020) found that the percentage of users decreased among their sample, the frequency of alcohol and cannabis use increased among those who did use. Perhaps the greatest challenge for all social workers working with adolescents and young adults is the need to help them achieve a sense of stability and security in the face of rapid and often confusing changes in their environment. Creating support structures that help empower individuals, families, and communities will be central to enhancing coping skills and building resilience for young people, their support structures, and the community.

In the post-pandemic world, social workers will continue to encounter adolescents and young adults who are at risk for substance use disorders wherever they practice. Those involved in providing prevention services within communities may find themselves in a new and complex service environment that may require changes to how and where prevention services are delivered. Social workers will continue to play an important role in the early identification and intervention with individuals who are at risk for substance abuse or misuse. There are several scientifically valid screening instruments, such as the Screening to Brief Intervention (S2BI) and Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD), which are both available online on the National Institute on Drug Abuse website (see Screening Tools for Adolescent Substance Use). These and these and other instruments can be easily integrated into everyday practice irrespective of how and where social workers connect with clients. Information gained from these instruments can help spark important conversations with the young person, and when necessary, provide a basis for referral for additional treatment. As more interactions move to online telemedicine portals, social workers will need to continue to update their skills with telemedicine and the application of technology to help coordinate care between provider organizations, providers, support staff, and funders. The shift to online care has led to deficiencies in access to preventive and treatment services for many individuals, families, and communities (Barney et al., 2020; Oesterle et al., 2020). Social work can take a leadership role in substance use prevention by helping to identify creative solutions that help manage issues of confidentiality and quality of care.

Changing patterns of drug use among adolescents and young adults over the past 20 years, especially over the last decade, and the rapid shift to telehealth to provide services in response to the COVID-19 pandemic will require additional research to develop innovative prevention interventions that are both developmentally and culturally appropriate; new strategies to implement programs with fidelity; and evaluation research to determine which prevention services can be provided safely and equitably across diverse and vulnerable populations (Wood et al., 2020). By advancing this work, social work can promote social justice and advocate for social change on behalf of clients (NASW, 2018).