Alcohol and Drug Problems: Prevention
- Flavio F. Marsiglia, Flavio F. MarsigliaArizona State University
- David BecerraDavid BecerraArizona State University
- and Jaime M. BoothJaime M. BoothArizona State University
Prevention is a proactive science-based process that aims to strengthen existing protective factors and to diminish or eliminate other factors that put individuals, families, and communities at risk for substance abuse. Prevention is important because alcohol and drug abuse are a leading cause of morbidity, mortality, and health expenditures in the United States. Alcohol and other drug abuse is also associated with infectious diseases, chronic diseases, emergency room visits, newborn health problems, family violence, and auto fatalities. The comorbidity of drug and alcohol abuse with mental health disorders and HIV adds urgency to the development, evaluation, and implementation of comprehensive and effective prevention interventions. The social work profession plays a key role in substance abuse prevention, as it not only targets the use and abuse of alcohol and other drugs but also aims at reducing the related negative health and psychosocial outcomes and economic burden they produce on individuals and society at large.
Updated in this version
Prevention programs and information on substance abuse updated. Bibliography and citations expanded to reflect recent research.
The Center for Substance Abuse Prevention (CSAP) provides the following working definition of prevention:
Prevention is an anticipatory process that prepares and supports individuals and systems in the creation and reinforcement of healthy behaviors and lifestyles. Alcohol, tobacco and other drug problem prevention focuses on risk and protective factors associated with the use of these substances, concentrating on areas in which research and experience suggest that success in reducing abuse and addiction is most likely (Center for Substance Abuse Prevention, 2007).
This definition highlights effectiveness and notes that prevention efforts are conducted in different contexts and settings such as the family, social service agencies, schools, and communities at large. Since most people who use alcohol, tobacco, and other drugs start before the age of 20 (Skara & Sussman, 2003; SAMHSA, 2013), the bulk of prevention efforts takes place with children and youth in schools. These efforts aim at addressing alcohol and drug problems before they emerge or as youth start to experiment with substances in order to avert the onset of addiction and other negative health consequences. By delaying the initiation of substance use, substance use prevention is more cost effective than treating substance abuse once it has occurred. Studies have demonstrated that if prevention programs were implemented nationwide, every $1 invested would save an estimated $18 (or over $30 billion total) in savings in future social costs (medical care, treatment, lost work productivity) (Caulkins, Paula, Paddock, & Chiesa, 2002; Miller & Hendrie, 2008). Specific types of service vary, but evidence-based prevention interventions are generally designed to reduce risk factors and increase the influence of protective factors in order to prevent the initiation of substance use (SAMHSA, 2009). In addition, evidence-based prevention interventions rely on problem-solving skills, drug resistance strategies, and linking youth and their families to existing support services.
Alcohol and drug prevention grew out of the public health field and has a strong interdisciplinary tradition in which social work plays a very important part. Social work practitioners conducting prevention collaborate with a wide array of professionals and paraprofessionals. Social workers provide community-based alcohol and drug prevention services across the life span to those of diverse socioeconomic status, race and ethnicity, gender, sexual orientations, and ability status (NASW, 2000).
The temperance movement of the early 1800s can be considered one of the first organized prevention efforts. It began in response to dramatic increases in the production and consumption of alcoholic beverages. Regardless of its actual success, 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, Hermann, & Heinz, 2000).
In the 1960s scare tactics became a popular prevention tool, later used by school-based programs such as Drug Abuse Resistance Education, known by the acronym DARE (Bikerland, Murphy-Graham, & Weiss, 2005). They 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 ineffective, as people did not change their behavior as a result of hearing such messages (Witte & Allen, 2000).
In the 1970s accurate information emerged in part as an attempt to address the shortcomings of scare tactics. These efforts were mostly atheoretical but were based on the idea that knowing the harmful consequences of alcohol and drugs will deter people from using regardless of their environmental conditions. However, providing detailed and accurate information about the consequences of using alcohol and other drugs was found to motivate some youth to experiment with drugs—or, in other words, selected members of the target population became educated consumers of drugs (Botvin, 2000; Flay, 2000).
The last two decades of the 20th century saw the emergence of a substance abuse prevention program labeled Life Skills Training, with an emphasis on the etiology of drug abuse or the behaviors that may lead to alcohol and drug use. Once behaviors are identified, alternative skills are taught in order to appropriately and competently resist drug offers (Botvin, 2000, 2002).
Interventions can take place at different levels, such as the individual, family, neighborhood, school, and larger society. The more levels the interventions target, or the more comprehensive the approach, the more promise it has to achieve effectiveness (Botvin & Griffin, 2002; Hawkins, Catalano, & Arthur, 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, Griffin, & Botvin, 2001). In the 2000s, prevention programs built upon the research of the Life Skills Training program to develop models that accounted for social, cultural, and neighborhood environments and incorporated parents and peers into the prevention programs in order to increase the effectiveness of the intervention.
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, Berglund, Ryan, Lonczak, & Hawkins, 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, Nieri, & Stiffman, 2006). Risk factors on the other hand are individual or environmental vulnerabilities associated with a higher likelihood that a negative outcome will occur (Arthur, Hawkins, Pollard, Catalano, & Baglioni, 2002; Mrazek & Haggerty, 1994). Prevention programs work to strengthen protective factors and weaken or eliminate risk factors (Hawkins, Catalano, & Arthur, 2002).
Although there is an ongoing debate about what constitutes a protective or a risk factor, some commonly identified protective factors for alcohol and other drugs at different ecosystemic levels that are reinforced by prevention interventions are listed below (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 & Haggerty, 1994). Selected risk factors commonly targeted by prevention interventions are as follows (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).
The Role of Biology
Although environmental variables play a key role in the availability of alcohol and other drugs and their consumption, biological vulnerabilities also appear to have some explanatory power in the etiology of drug use (De Bellis et al., 2000). Some youth drink in excess from an early age and using in excess leads them more rapidly to addiction. Brain research has shown that adolescents and children are more vulnerable to addiction than are adults because their brains are not yet fully developed and lack the same ability to control use as a fully developed adult brain (De Bellis et al., 2000).
Translational neuroscience research has identified the prefrontal cortex and ventral striatum as key areas of the brain related to impulsivity and motivational stimuli such as using or not using alcohol and other drugs (Chambers, Taylor, & Potenza, 2003). The neurotransmitter dopamine has been identified as a key player in these processes. Dopamine acts as a chemical messenger that affects the brain processes that control movement, emotional response, and the capacity to feel pleasure and pain. It is active in the frontal lobe and regulates the flow of information coming in from other areas of the brain. A shortage of, or problems with the flow of, dopamine can cause a person to lose the ability to think rationally while a sudden increase in dopamine may increase risk-taking. Neurodevelopmental changes during adolescence may lead to a sudden increase in dopamine, which can make adolescents more vulnerable to addiction (Greydanus & Patel, 2005).
This type of neurological research has provided more evidence about the importance of accounting for the biological aspects of drug use in combination with psychosocial factors. These findings are being integrated into different treatment modalities but much remains to be done to integrate them into prevention interventions with adolescents and preadolescents.
There is no consensus in the field about best practices, but some agreement has emerged about what not to do (Flay, 2000). For example, using scare tactics to convey prevention messages and using large school assemblies to deliver the prevention message have been found to be mostly ineffective. On the other hand, best practices tend to provide content on social influences and normative education, develop social skills, provide information on perceived harm, target protective factors, and teach refusal skills or strategies (Kulis et al., 2005). Interactive techniques have been identified as the preferred delivery modality because this approach is more conducive to behavioral and attitudinal changes than are lectures. The use of small group discussions and activities, role plays, the Socratic Method, hands-on projects, videos and stories portraying real life situations, as well as other techniques that facilitate self-reflection and participants' active involvement are also part of effective interventions that deliver desired prevention outcomes (Holleran, Dustman, Reeves, & Marsiglia, 2002). The addition of parenting components to primarily school-based prevention interventions has been shown to provide additional benefits (Pantin et al., 2009). Parenting programs typically include skills training that target communication, parenting strategies, and encourage the reinforcement of anti-drug norms in the home (Marsiglia et al., 2013; Williams et al., 2012).
If children and youths' drug use behaviors are assessed along a continuum, the majority would be at the nonuse end and a small minority would be somewhere between experimenting, heavy use, and the addiction end of the continuum. Existing epidemiological data continue to challenge professionals and policymakers with the question of where to place limited resources? Should the priority be on nonusers who may benefit the most from primary prevention, or should it be on prevention efforts that also reach higher risk youth or youth who are already experimenting? Primary prevention interventions are designed to enhance protective factors of all students in order to keep problems from emerging. Secondary prevention interventions are designed to reverse the harm from exposure to known risk factors for a selected group of students. Tertiary prevention interventions are designed to reduce instead of reverse harm among a select group of students who are most at risk (Walker & Shinn, 2002).
The Institute of Medicine's framework for disease prevention has been broadly adopted in the substance abuse field as a guide in determining when and with whom to intervene. The framework expands on the primary, secondary, and tertiary categories and offers three basic classifications of interventions based on the kind of population they target (Institute of Medicine, 1994; Offord, 2000).
Universal prevention targets all individuals regardless of their level of risk. Prevention in this case aims at deterring or delaying the onset of substance use: for example, addressing all seventh graders in a classroom, without tailoring the message to those at different levels of risk. Interventions using this kind of strategy combined with a zero tolerance or abstinence messages may come across as naïve and too basic for youth who are already experimenting.
Selective prevention targets those at risk for substance abuse because of their membership in a subgroup of the population that is known to be vulnerable. For example, selective prevention strategies have been designed for dropouts, children of adult alcoholics, or victims of family violence. Although not all individuals identified as part of a selective group may be at risk with a presumption of alcohol or drug use or abuse, they receive the intervention because of their group membership. This approach risks alienating or inappropriately labeling some individuals.
Indicated prevention targets those already using or engaged in behaviors known to lead to drug use. These individuals do not meet criteria for addiction but show early signs such as using gateway drugs (tobacco, alcohol) and underperforming in school. These interventions aim at cessation or reducing the severity of use. Indicated interventions tend to focus more on the individual and less on community variables than the other two classifications. Sometimes there is no clear distinction between indicated prevention and treatment, which can lead to overemphasizing the risk factors over the protective factors needed for success.
Although the IOM classification system is useful, the boundaries between the three classifications may not be clear. For example, a model universal prevention program implemented in middle schools was found to have a significant effect on the reduction and discontinuation of use of high numbers of participants who were already experimenting with alcohol and other drugs at the time of their participation (Kulis, Yabiku, Marsiglia, Nieri, & Crossman, 2007). It was also found that the addition of a small group component designed for youth at elevated risk of substance use provided additional benefit to the universal prevention intervention, combining primary and secondary prevention strategies (Marsiglia et al., 2012).
A rich array of universal, selective, and indicated interventions have been developed, “manualized,” and tested since the mid-1980s. The Substance Abuse and Mental Health Services Administration (SAMHSA) National Registry of Evidence-Based Programs and Practices (http://nrepp.samhsa.gov/) provides a comprehensive list of evidence-based prevention interventions. These model programs are very diverse but tend to provide content on normative education, social skills, social influences, perceived harm, protective factors, and refusal skills.
Substance abuse prevention shares many of the same ethical dilemmas as alcohol and other drug treatment. Confidentiality is paramount, but since most prevention interventions target youth, confidentiality could present an ethical dilemma. Children and youth participating in a prevention intervention often disclose to the social worker or other preventionist their activities or situations they experience at home. If the students are minors and make known that they are engaging in an unlawful behavior, such as purchasing and consuming alcohol and other drugs, the social worker or preventionist has an ethical obligation to follow school or agency policy about addressing the behavior. The same procedures need to be applied if minors report drug use by their parents or other adults that may be associated with child abuse or neglect. Although law enforcement is meant to deter the illegal or dangerous behavior of parents, their involvement may also negatively affect the child. Involving law enforcement is often necessary to ensure the safety of a child, such as when reporting a parent or other adult for providing alcohol or drugs to a minor or because the parents abuse drugs, but reporting it to the police may lead to the arrest of the parents or the removal of the child from the parents' home.
On the other hand, social workers conducting research must ensure confidentiality in order to protect the participants. The participants must feel comfortable and confident that their responses will not be associated with their names when the results of the study are reported. Therefore, as interventions are evaluated, strict confidentiality needs to be assured in order to attain reliable data from the participants. The use of unique identifiers instead of any personal identifiers is recommended.
Challenges and Dilemmas
Although studies have shown prevention programs to be efficacious, each community has its own unique demographics, strengths, and challenges, and implementing or adapting an identified model program, while maintaining fidelity, may be difficult (Kulis et al., 2007). Social workers, educators, and researchers also need to increase their effectiveness in promoting proven programs and convincing policymakers to adopt policies and provide funding for implementation of programs.
Cultural, Racial, Ethnic, and Other Populations
Alcohol use rates vary among racial, ethnic, and cultural groups. Within each group there are also differences in consumption based on gender, sexual orientation, and socioeconomic status. Studies indicate, for instance, that Latino gay males are less likely than Whites to use methamphetamines or cocaine (Colfax et al., 2005), but they report higher rates of alcohol use than do heterosexual Latinos (Tori, 1989). African American lesbians report higher rates of alcohol use than do heterosexual African American women (Hughes & Eliason, 2002). “Culturally neutral” prevention has been questioned, as it does not allow for an integration of unique characteristics, including assets, coming from culture of origin (Marsiglia, 2002). Adaptation of standard prevention intervention to serve the needs of members of ethnic minority groups has also been challenged.
There is a movement to recognize multiple factors as part of the clients' holistic experience, and as such, prevention aims at reaching the clients at the intersection of these factors (Kulis et al., 2007). From this perspective, prevention programs recognize the unique needs and strengths of each diverse population and ensure that programs provide culturally competent and effective services (Resnicow, Soler, Braithwaite, Ahluwalia, & Butler, 2000; Sale et al., 2005).
Cultural adaptations of effective prevention programs range from minor to major adaptations of the interventions in order to tailor the prevention program to a cultural group which differs from the group for which the intervention was originally designed. While cultural adaptations may be helpful in certain situations, a more effective and authentic strategy is to develop culturally grounded or culturally specific interventions. These interventions are designed with the language, culture, values, beliefs, behaviors, and norms of the population the prevention program is intended to serve (Okamoto et al., 2014). Culturally grounded or culturally specific interventions are being developed and evaluated by social workers in order to better integrate cultural strengths as part of the design of the intervention and not as an afterthought (Marsiglia et al., 2013; Marsiglia, Kulis, Wagstaff, Elek, & Dran, 2005; Okamoto et al., 2014).
Substance use in rural areas has increasingly become a concern. Poverty combined with an influx of drugs from drug dealers searching for new markets, and the lack of resources, has created a high-risk environment for rural youth. Youth in rural areas are more likely to binge drink than youth in urban areas. Easy-to-manufacture drugs such as methamphetamines have become prevalent in rural communities (Clay, 2007). Unfortunately, not only are there limited resources for prevention programs in rural communities, but prevention programs are not being developed to account for the geography, lifestyle, and culture of rural communities. Social work researchers can take the lead in developing much-needed substance abuse prevention programs to address the unique needs of rural communities.
Compared with Whites, people of color are more likely to have low incomes, and low-income communities are disproportionally affected by alcohol and other drug use (Resnicow et al., 2000). Children residing in low-income communities are at a greater risk for consuming alcohol and other drugs (Arthur & Blitz, 2000). Poor living conditions, violence at home or in the community, high dropout rates, and the availability and accessibility of drugs and alcohol must be addressed comprehensively. Ethnic minority youth tend to have less access to evidence-based prevention interventions (Backinger, Fagan, Matthews, & Grana, 2003). Prevention programs must assess the strengths and assets as well as the vulnerabilities of communities in order to build more positive environments.
Substance abuse is a global problem. Worldwide, alcohol use accounts for 2.5 million death annually and is the leading risk factor for men ages 15 to 59 (WHO, 2011). In Europe, alcohol-related deaths account for 36% of all deaths among males 15 to 29 years of age (WHO, 2011). Although men in developed countries continue to use alcohol at the highest rates worldwide, alcohol use in developing countries and among women is on the rise (Malbergier, Cardoso, do Amaral, & Santos, 2012). In response to the global health need, prevention programs originating in one country are being utilized in other countries, and prevention researchers are actively collaborating in developing and adapting effective programs. Social work researchers are participating in the design and implementation of international prevention adaptation trials and in multisite international prevention interventions through randomized trials and pilot exploratory studies (Marsiglia et al., 2013; Marsiglia, Kulis, Martínez-Rodríguez, Becerra, & Castillo, 2009).
Roles and Implications for Social Work
Social workers provide essential preventive services to diverse communities at the micro, mezzo, and macro levels. They are often responsible for developing as well as implementing prevention programs in schools and other community settings and evaluating their effectiveness. A prevention program cannot be developed or implemented without funding, and to secure funding from federal, state, county, and municipal levels, prevention programs must often be selected from an evidence-based list such as SAMHSA's National Registry of Evidence-Based Programs and Practices. Social workers must therefore utilize existing research or conduct new research in order to secure funding for programs that would best meet the needs of the communities or individuals they work with. The connection that social workers have to the community allows for research on substance abuse and prevention to be more culturally grounded, relevant, and applicable to the communities they work with (Kulis et al., 2005; Parsai et al., 2011). As a result, social workers are valued members of the community and are able to develop collaborations with educators, representatives of community-based organizations, and community members at large in order to provide not only alcohol and other drug prevention programs, but also the most effective and efficient services possible to address a variety of social and behavioral health issues.
In clinical settings social workers have unique opportunities to conduct alcohol and drug prevention by including key screening questions with all clients regardless of their age or other demographics. As a result of the high comorbidity of substance abuse with other behavioral and mental health conditions, social workers play a significant role in early detection and prevention regardless of the presenting problem. Including a few validated screening items in the intake form can assist practitioners with this integration (Brown, Leonard, Saunders, & Papasouliotis, 2001) by triggering a conversation and making an appropriate referral when necessary. Social workers are uniquely positioned to intervene throughout the prevention-to-treatment continuum as they practice in different fields and use different practice modalities. Not only do social workers provide services in the community, but they are mandated by the NASW Code of Ethics to promote social justice and advocate for social change on behalf of clients (NASW, 2008). As a result, social workers also play key roles in advocating for social policies and developing substance use and prevention programs that are evidence-based and meet the needs of diverse populations (NASW, 2008). The combination of research, clinical, community organization, and social advocacy skills allows social work professionals to be effective at working with individuals, groups, or communities to promote positive outcomes.
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