Hi, my name is Julie Kmic and today I'm going to be talking about prevention. This is some information about me. I'm an addiction psychiatrist based out of Pittsburgh. I'm at the University of Pittsburgh School of Medicine. I have no conflicts of interest to disclose. So the objectives for today's lecture is to go over prevention as a public health measure, prevention strategies and principles, prevention programs for substance misuse and development of substance use disorders, risk and protective factors that can be targeted in prevention programs, as well as evidence-based prevention policies with regard to substance use. First I'm going to talk about prevention in public health. Substance use disorder prevention is very important in public health. It aims to prevent disease and injury before it occurs. It does this by preventing exposure to hazards that cause disease or injury and altering unhealthy or unsafe behaviors that can lead to disease and injury. And this can be done by legislation and enforcement to ban or control the use of illegal or hazardous products. So in the case of substance use disorders, this would be like banning heroin, fentanyl, cocaine. So the Controlled Substances Act. Also mandating safe and healthy practices. Some of the public health policies would be requiring seatbelts to be worn or helmets to be worn on bicycles or motorcycles. And you can also do education about safe and healthy habits. So eating well, not smoking, exercising, wearing condoms, and then immunizations. Now secondary prevention aims to reduce the impact of a disease or injury that has already occurred. And this is done by detecting and treating disease as soon as possible so it halts progression. Also encouraging personal strategies to prevent re-injury, loss of recovery, or recurrence of the disease. And also implementing programs to return people to their original health and function to prevent long-term problems. And an example of this would be prescribing buprenorphine for opioid use disorder. Tertiary prevention aims to minimize acute negative consequences in those with illness and injury and then promote recovery in the management of long-term effects of the disease or injury to improve their overall well-being. And this is done by helping an individual manage long-term, often complex health problems such as addiction to improve one's ability to function, their quality of life, as well as their life expectancy. So a tertiary prevention measure in addiction would be providing naloxone to people who use opioids to reduce the risk of death. Public health equals prevention. So public health is the science of preventing disease and injury and it promotes and protects the health of populations and communities. There are public health approaches that recognize the multifaceted nature of substance misuse and focus on addressing contributors to developing substance use disorders. These contributors are individual, environmental, and social factors. This is the health impact pyramid. Here we have a plan of attack or a means to effect change. This pyramid describes such a plan, the impact of different types of public health interventions. As we move down the pyramid, the public health impact grows greater. However, as we move up the pyramid, the amount of individual effort increases. Starting at the top, we can do counseling and education, perform clinical interventions, have longer-lasting preventive interventions, change the context in which people operate so default decisions they make are healthy, and lastly, positively influence socioeconomic factors. A point of emphasis here is that we have to have trade-offs. We have to sometimes give up resources in one area to have a larger impact in another. Let's take a look at some examples. This pyramid illustrates the impact of different types of public health interventions. Let's start at the top of the pyramid and work down. Counseling and education in clinical and other settings is regarded by some as the essence of public health action, but unfortunately, it's not as effective as we'd like. That being said, at times, counseling and education are the only forms of intervention available, and when applied consistently and repeatedly, they can have an impact. Examples include warning labels on cigarette packs and campaigns to promote tobacco cessation. Moving to clinical interventions, ongoing medical care for health condition is an example. In the case of cardiovascular disease, these interventions can have a considerable effect. However, we are limited by a lack of access to certain patients who need care and lack adherence to medical instructions in the real world. Long-lasting preventive medicine interventions, such as vaccines, can prevent deaths among children around the world every year. In this case, a single dose or an instance of an intervention can have a lifelong effect. We make health decisions by default by changing the context in which behaviors occur, making it difficult to avoid the intervention. For example, changing the laws to require seat belt use in cars and banning smoking in certain public places have had a sustained impact. At the base of the pyramid are public health interventions that affect socioeconomic factors. If we can improve quality of life by helping people out of poverty and providing basic sanitation and improving their access to education, healthy food, and medical care, we can greatly improve a population's chances for a healthy life. Now I'm going to shift to talk about some epidemiology terms. So data are collected and analyzed with respect to alcohol, tobacco, and drug use. This is done every year with the National Survey on Drug Use and Health. It's also done through the Monitoring the Future Survey. And when we do these surveys, we can calculate the incidence, the prevalence, and trends. And these data allow changes in use to be detected and provide information for policymakers to prioritize prevention and treatment. So let's talk a little bit about risk and frequency, incidence, and prevalence. Risk is the likelihood of an individual developing a disease or a problem. Epidemiology measures risk, either actual or absolute measures, and how this compares with other populations, and these would be relative risk measures. The principle that measures risk are incidence and prevalence rates. A risk factor is a characteristic associated with disease. So let's talk a little bit about prevention strategies and principles. So there are several different prevention strategies that we can have. The first is policy. So we develop policies to prevent substance use, such as a minimum drinking age, tobacco laws, enforcement of these policies and laws, such as enforcing underage drinking and making sure realtors aren't selling tobacco products to minors, and collaboration as part of prevention. So activities that include organizing, planning, and enhancing the effectiveness of the program, advocacy, and practice implementation. Communication is very important for prevention, and we need to communicate activities that provide awareness and knowledge of the nature, extent, and the effects of alcohol, tobacco, and drug use, and addiction on individuals in the community. Examples include social media, speaking engagements, television commercials. And education is also important, and these are activities that are aimed at affecting critical life and social skills, such as decision making, refusal skills, as well as clinical analysis and systematic judgment abilities. Policy intervention is done when people have started using substances. These are activities that aim at identification of people who have started to use illegal or age-inappropriate substances, such as tobacco, and the individuals who have used either illicit substances or tobacco or alcohol receive an intervention to assess if the behavior can be reversed by education. Lastly, alternatives are important. So activities that encourage participation of the target population, and activities that exclude alcohol, tobacco, and other drug use. So examples include alcohol-free drop-in activities or after prom events. So these are some general principles of prevention. So first off is prevention is on a continuum. So I already mentioned about primary, secondary, and tertiary prevention. So that's the continuum. And next concept is prevention is prevention. So what this means is that preventing substance use can go on to prevent other problems. So if you don't have somebody who develops a substance use disorder, such as opioid use disorder, when a person has opioid use disorder, they might start injecting, then that can put them at risk for developing HIV or hepatitis C. So by preventing the substance use in the first place, you're preventing them from developing the HIV or hepatitis C. Next concept is that prevention is not treatment. And then prevention decreases risk factors, and at the same time, increases protective factors. And another important concept is that we should utilize proven practices in prevention. So let's move on to talk about prevention of substance misuse and the development of substance use disorders. So over the last century, there's a new focus of prevention because of the shift in disease. So major illnesses that led to death shifted from infectious disease, like tuberculosis and infections in newborns, to non-communicable diseases in the 20th century, so things like heart disease, diabetes, and cancer. And at the end of the 20th century, that was the beginning of the current opioid epidemic. There was a shift that resulted from effective public health interventions, so improved sanitation as well as immunizations could be a couple of these things. At the same time, there was an increase in rates of unhealthy behaviors, so smoking, poor nutrition, physical inactivity, and substance use and misuse. So why try to prevent substance misuse? Now people generally start using and misusing substances during adolescence, but misuse can begin at any age and can continue to be a problem across the lifespan. Early substance misuse, including alcohol, is associated with a greater likelihood of developing a substance use disorder later in life. And substance use can result in harms even without a substance use disorder. So the vast majority of the people in the United States who use or misuse substances don't have a substance use disorder. Regardless, people who use substances put themselves and other people at risk. Early initiation, substance misuse, and substance use disorders are associated with a variety of negative consequences, such as deteriorating relationships, poor school performance, loss of employment, poor mental health, and increase in sickness and death. So especially related to substance use would be motor vehicle crashes, accidental deaths by poisoning, also violence and accidents when somebody's using substances. Substance use has a lot of cost to society. It's associated with a wide range of health and social problems, which significantly cost our society. So heart disease, strokes, high blood pressure, various cancers is associated with tobacco, alcohol. And then mental disorders is associated with substance use and substance use disorders, neonatal opioid withdrawal syndrome, DUIs and other transportation-related injuries. There's a higher incidence of sexual assault and rape when substances are being used, unintended pregnancies, sexually transmitted infections, and then intentional and unintentional injuries. There are evidence-based prevention interventions that are done before somebody needs treatment. The first thing you can do is delay early use of substances. The second thing would be to stop the progression from use to becoming problematic use to developing into a substance use disorder. By doing this, you can reduce the cost of individual, social, and public health consequences from substance use or misuse. Prevention programs and policies are effective at different stages of the lifestand, from infancy to adulthood. And one thing that's important is it's never too early and it's never too late. So let's talk a little bit about risk and protective factors. Research has identified predictors of substance use and other behavioral health problems that are targets for preventative interventions. Risk and protective factors influence the likelihood that a person will use a substance as well as develop a substance use disorder. Here are some risk factors. And you can see on this table, it's a little bit complex. We have individual, family, school, and community. So some individual risk factors would be early initiation of substance use, having early and persistent behavior problems, being rebellious, having a favorable attitude towards substance use, peers using substances, and genetic predisposition. As far as family risk factors, family management problems or conflicts in the family, favorable parental attitudes towards substance use, and a family history of substance misuse. Some school risk factors are academic failure late in elementary school and a lack of commitment to school. And some risk factors regarding the community are having a low cost of alcohol and a high availability of substances, community norms that favor substance use, favorable portrayal of alcohol use, low attachment to the neighborhood, community disorganization, and low socioeconomic status. Here are some protective factors. So you can see there aren't as many as there were on the other slide for risk factors. So individual protective factors include social, emotional, cognitive, and behavioral, as well as moral competence. Having a high self-efficacy, spirituality, and resiliency can be protective factors. As far as family, school, and community protective factors, there should be an opportunity for positive social development, recognition for positive behavior, feeling bonded with your family, school, or community, being married or having a committed relationship, and then having healthy beliefs and standards of behavior. One thing that's been found is that most risk and protective factors that are associated with substance use also predict other problems. So in kids, that could be delinquency and also psychiatric conditions, violence, and school dropout. And so having programs and policies that address overlapping predictors of problems can simultaneously prevent substance misuse and other undesired outcomes. So let's switch gears to prevention programs. So prevention programs should enhance protective factors or reverse and reduce risk factors. So the number of risk or protective factors that an individual has can vary over time. And risk and protective factors can change with age. So as far as a young child, risk factors within the family may have a greater impact. With an adolescent, associating with peers who use substances may have a greater impact. Doing an early intervention with risk factors can have a greater impact than later intervention as it can change a child's path. So if you intervene in a child who has poor self-control or aggression early on, that can lead to a better outcome. Risk and protective factors can affect people of all groups, but can have different effect based on an individual's age or gender, ethnicity, culture, and the environment. So there's three different types of interventions that the Institute of Medicine has described as categories of prevention. So there's universal interventions, selective interventions, and indicated interventions. As far as universal interventions, they're aimed at all members of a given population. For example, all children of a certain age. Selective interventions are aimed at a subgroup determined to be high risk for substance use, like justice-involved youth. And indicated interventions are targeted to individuals who are already using substances, but have not developed a substance use disorder. So how do you choose between the three types of preventive interventions? Is it better to direct services to individuals at highest risk and have the lowest protective factors? Or is it better to direct services to those already misusing substances? Well, a relatively high percentage of substance misuse-related problems come from people at lower risk. That's a much larger group within the total population than those at high risk. This is known as the prevention paradox, where a large number of people are at a small risk may give rise to more cases of disease than a small number who are at high risk. So it's prudent to provide a mix of universal, selective, and indicated preventive interventions. Universal prevention interventions aim to reduce specific health problems across all people in a particular population by reducing a variety of risk factors and promoting a broad range of protective factors. So some examples of this include policies such as a minimum legal drinking age, reducing the availability of substances in the community, and school-based programs that promote social and emotional competencies to reduce stress, express emotion appropriately, and resist negative social influences. Selective prevention interventions are delivered to particular communities, families, or children who are at increased risk of substance misuse problems due to risk factors. So some targeted audiences for these selective interventions could include families who are living in poverty, children of parents who are depressed or using substances, children who have difficulties with social skills. The goal of selective interventions is to reduce identified risk factors, increase protective factors, or both. Interventions are more specifically designed for that particular audience. Now, indicated prevention interventions are directed to those who are already engaging in substance misuse, are beginning to have problems, but have not yet developed a substance use disorder. So these can be intensive and expensive, but are cost-effective compared to the cost of developing a substance use disorder or other related negative consequences. So here are some prevention interventions that can be conducted from zero to 10 years of age. Now, there are a few substance use prevention programs for children under 10 that have been evaluated due to the need for long-term follow-up and cost. So that's a long study that would, if you started this at age one or two. So these prevention efforts include general strategies to increase protective factors and to decrease risk factors. So these are universal prevention interventions for infants, preschoolers, and elementary schools students. They focus on building healthy parent-child relationships, decreasing aggressive behavior, building children's social, emotional, and cognitive competence for the transition to school. So some examples of these prevention programs are called the Nurse-Family Partnership, the Good Behavior Game, Classroom-Centered Intervention, Raising Healthy Children, and the Fast-Track Program. Now, adolescents are especially vulnerable. Their immaturity during critical development period results in vulnerability to developing a substance use disorder. Adolescents are prone to risky and impulsive behavior. They prefer excitement-seeking and low-effort activities. They have difficulty delaying gratification. They have poor executive function and inhibitory control, and they have difficulty in emotion regulation. So early substance use in these individuals results in higher risk for developing a substance use disorder. As far as adolescent substance use, if we look at high school students, by the time kids are seniors in high school, almost 60% will have tried alcohol, 47% will have used an illegal drug, 22% will have smoked a cigarette, and about 15% will have used a prescription drug for a non-medical purpose. So it's important to aim some prevention efforts to those 10 to 18 years of age. So universal interventions focused on this age category of 10 to 18 were shown to affect either the initiation or escalation of substance use. In general, school-based programs share a focus on building social, emotional, cognitive, and substance refusal skills. They also provide children with accurate information on rates and the amounts of peers who are using substances. So there are some school-based programs, and they're called Life Skills Training, Keeping It Real, Project Toward No Drug Abuse. There's some family-based programs that can occur during this age period. They're called Strengthening Families Program for Parents and Youth 10 to 14, Familias Unidas, and Coping Power. There are also internet-based programs, Coping Power, and Project Chill. There are some prevention programs also for college students. So there's the Brief Alcohol Screening and Intervention for College Students, which is abbreviated as BASICS. And students who use BASICS have shown reductions in drinking quantity. There's also the Parent Handbook. And what this does is it focuses on teaching parents how and when to intervene between high school graduation and college entry to disrupt the escalation of heavy drinking during the first year of college. So it's distributed to these parents during the summer before college. And if parents received it during that time, it reduced the odds of their child becoming a heavy drinker, but it wasn't effective if it was used after the transition to college. There are also evidence-based prevention programs for young adults, the workplace, and older adults, but I'm not gonna talk too much about those today. This is a slide on the economics of prevention. And what you see here is the benefit per dollar cost of these prevention programs that I mentioned. So you can remember when I was talking about zero to 10-year-olds, those are the first one, two, three, four skills. So you can see you get a lot of bang for your buck with that good behavior game. So the benefit per dollar cost is $64.18. Looking at the ones for teenagers, like Strengthening Families Program, 10 to 14, you get $5 on every dollar that's been invested. Basics, that's the one for the college students, that's $17.61 for individuals for every dollar. It's important to screen individuals so you can implement an intervention or refer somebody to treatment if a substance use disorder has already developed. The American Academy of Pediatrics recommends that screening and brief interventions be done for adolescents, screening for substance misuse or use disorders. And the United States Preventive Services Task Force has recommended screening and brief intervention for reducing alcohol and substance misuse among adults. The last part of this presentation, I'd like to talk about some evidence-based prevention policies. So policies that are focused on reducing alcohol misuse for the general population can reduce alcohol consumption amongst adults as well as youth, and also reduce alcohol-related problems, including alcohol-impaired driving. So there's some evidence for price and tax policies. The evidence indicates that prices that are higher on alcoholic beverages are associated with reductions in alcohol consumption and alcohol-related problems, including alcohol-impaired driving. There's also policies about reducing alcohol outlet density. And so what this means is that if there's an increased number of retail alcohol outlets in an area, that means higher alcohol outlet density. That's associated with an increase in alcohol-related problems in that area, such as violence, crime, and injuries. There were four longitudinal studies that found significant reductions in alcohol-related crimes when the alcohol outlet density was reduced compared to communities that had not reduced alcohol outlet density. So there are commercial host liability policies, also called DRAM shop liability policies. So an alcohol retailer, so this could be an owner or a server at a bar or restaurant, they can be held legally liable for harms resulting from illegal beverage service to intoxicated or underage customers. A systematic review found that there was a median reduction of 6.4% in alcohol-related motor vehicle fatalities associated with these policies. Policies to reduce the days and the hours of alcohol sales have also been shown to be effective. So there was a review of 11 studies on changing the days of sale at restaurants and bars, grocery, liquor, and convenience stores. And this review found that increasing the number of days alcohol could be sold was associated with increases in alcohol misuse and alcohol-related harms. And it also found that reducing the days that alcohol was sold was associated with decreases in alcohol-related harms. In one state, lifting a ban on Sunday sales of alcohol led to an estimated 41.6% increase in alcohol-related fatalities on Sundays from the period of 1995 to 2000. And that equated to an additional cost of more than $6 million in medical care and lost productivity per year in that state. So some policy and law enforcement approaches to reduce drinking and driving include the legal limit is under 0.08%. Also, you might see on weekends or holidays a variety of checkpoints set up to ensure that people aren't driving under the influence. There are also specific indicated interventions that target people who have a history of DUI. They might be having a lower blood alcohol concentration for people who have already had a DUI, having mandatory ignition interlock laws for anybody who's been convicted of DUI, mandatory assessment and treatment of persons convicted of DUI, having specific DUI courts. There's also continuous alcohol monitoring of people who have DUIs. And then lastly, they could do vehicle impoundment or immobilization for people with DUI. So this is looking at alcohol versus non-alcohol related traffic deaths, the rate per 100,000 people of all ages in the United States from 1982 to 2013. And what you can see is that the rate of alcohol related deaths went down. You can see it starts in 1982 and it starts the slope of this, starts getting really low in like 1990, 91, and then goes down over the years, whereas the non-alcohol related deaths kind of stays stable over time. Maybe it goes down a little bit in around 2009. So the declines in traffic deaths due to reductions in drinking and driving exceeded declines from the combined effects of seatbelts, airbags, and motorcycle and bicycle. And I just wanted to mention a little bit about BIC limits. So these started all the way back in 1930 and 1940. Most states initially set the limit at 0.15%. In 1982, Congress encouraged states to adopt stricter driving while impaired laws. In 1983, Utah became the first state to implement a 0.08% BIC limit. In the 1990s, the National Highway Traffic Safety Administration and President Clinton worked to establish a consistent 0.08% BIC limit across the country. In 2000, Congress adopted the 0.08 BIC limit as the national standard. And by 2004, every state had adopted that 0.08% BIC limit, with Delaware being the last state to do so. So that's about the time where you see the reduction in drinking and driving fatalities really started going down with that more steep slope. So policies are also in place to reduce underage drinking. So one of those things was raising the minimum legal drinking age. So before 1984, only 22 states had a minimum legal drinking age of 21. And there was the National Minimum Drinking Age Act, which threatened to withhold a portion of the state's federal highway construction funds if the states made the purchase or public possession of alcoholic beverages legal for people that were under 21. By 1988, all states had adopted that 21 years old as the minimum legal drinking age. There are also policies to reduce underage drinking. So first we have zero tolerance laws, which makes it illegal for persons younger than 21 years of age to drive with any measurable BIC. And there's also some use it, you lose it laws, which allows states to suspend a person's driver's license for underage alcohol violations, even if they weren't driving when they were found to be violating this. So I just wanna talk about other examples of prevention policies or programs. So we have laws regarding impaired driving. So not only alcohol, but there's also about impairment with cannabis and other drugs. There's laws regarding minimum age to purchase tobacco, alcohol, and cannabis. There are syringe service programs. This is for people who are injecting drugs so they can get clean syringes to prevent infection. Could be soft tissue infections, also could be hepatitis C or HIV transmission because using sharing syringes. There's also a requirement to check the PDMP prior to prescribing controlled substances. So this is a prevention policy that states have adopted. And then there's also overdose education and naloxone distribution for people who are using opioids to prevent opioid overdose deaths. Here's some references and resources for you. A majority of the information here came from the US Department of Health and Human Services, so the Office of the Surgeon General, the Surgeon General's Report on Alcohol, Drugs, and Health. So thank you so much for attending this presentation and best of luck.

substance use disorder

prevention strategies

public health

risk factors

prevention programs

evidence-based policies

Health Impact Pyramid