Alcohol and Substance Use Prevention and Early Intervention

CHAPTER 17
Alcohol and Substance Use Prevention and Early Intervention

Nicola C. Newton, Mark Deady and Maree Teesson

National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia

Introduction

The high prevalence of alcohol and other drug use by young people clearly highlights the need for effective prevention and early intervention [1–3]. The harms associated with substance use are significant and include accidental injury, disruption to educational and vocational paths and psychological problems [4, 5]. In addition, early initiation to substance use is a strong risk factor for the later development of full-blown substance use disorders [6–8]. To reduce the occurrence of such problems, interventions need to be initiated early before problems begin to cause disability, and vocational, educational and social harms.

What causes substance use problems?

Most adolescents begin to use substances as a result of social influences and rebellious behaviours that typically occur during the teenage years. Adolescence is a time when young people begin to experience increased social, emotional and educational challenges [9], and this developmental progression coincides with periods of enhanced risk for drug use and access to substances [10]. Numerous risk and protective factors have been implicated in the development of substance use and can generally be divided into three main categories: (1) genetic factors (predispositions to drug use), (2) individual (non-genetic) and interpersonal factors (characteristics within individuals and their interpersonal environments) and (3) environmental/contextual factors (broad societal and cultural factors) [11–15]. The risk and protective factors identified below are those which have strong evidence in the literature to suggest they precede alcohol and drug misuse in adolescence and are based on tables developed by Spooner et al. [16] and Vogl [17].

Genetic factors

Evidence (including twin studies) have shown robust genetic components in alcohol, cannabis, opiate, cocaine and tobacco addictions, suggesting that a genetic predisposition to substance use problems and addictions is probable [13, 16, 18–20]. Not all people who use drugs however will become addicted and it is therefore likely that drug and alcohol problems occur due to an interaction between genetic predisposition and social and environmental factors.

Individual and interpersonal factors

The non-genetic individual and interpersonal factors which influence drug use are associated with personality, attitudes, beliefs and early childhood characteristics [13, 14, 16, 18, 21]. These are outlined in Table 17.1.

Table 17.1 Individual risk and protective factors for drug use

Risk factors	Protective factors
Attitudes and beliefs – Favourable attitudes to drug use – Low perceived risks of drug use – Low religiosity Personality characteristics which reflect alienation from societal values such as – Rebelliousness – Nonconformity to traditional values and resistance to traditional authority – High tolerance for deviance – Strong need for independence Other personality characteristics – Sensation seeking – Adventurous personality – Low harm avoidance Behavioural and emotional issues – Early and persistent aggression – Early conduct problems – Adolescent delinquency – Frequent drug use in late adolescence	Easy temperament in childhood Social and emotional competence Religious involvement Shy and cautious temperament Belief in natural order Social problem-solving skills Belief in own self-efficacy

Risk factors

Protective factors

Attitudes and beliefs
- – Favourable attitudes to drug use
- – Low perceived risks of drug use
- – Low religiosity
Personality characteristics which reflect alienation from societal values such as
- – Rebelliousness
- – Nonconformity to traditional values and resistance to traditional authority
- – High tolerance for deviance
- – Strong need for independence
Other personality characteristics
- – Sensation seeking
- – Adventurous personality
- – Low harm avoidance
Behavioural and emotional issues
- – Early and persistent aggression
- – Early conduct problems
- – Adolescent delinquency
- – Frequent drug use in late adolescence

Easy temperament in childhood
Social and emotional competence
Religious involvement
Shy and cautious temperament
Belief in natural order
Social problem-solving skills
Belief in own self-efficacy

Environmental and contextual factors

The major environmental and contextual factors which influence drug use pertain to peers [22, 23], family and society [13, 14, 16, 18]. Social influence is recognized to have a strong effect in determining behaviours in adolescents, including initiation of drug use. In particular, the perception of drug use as a ‘normal’ behaviour is a good predictor of prevalence of use. Table 17.2 summarises the risk and protective factors associated with these environmental influences.

Table 17.2 Environmental risk and protective factors for drug use

Risk factors	Protective factors
PEERS Relationship with peers who are involved in drug use Perceived support for substance use by peers Increased perception of friends’ use of drugs Rewards for antisocial behaviour Gang involvement Poor peer relationships and peer rejection	PEERS Association with nondrug using peers
SCHOOL School failure Not completing secondary school – evidence is unclear as to whether this may be explained by earlier developmental influences Low commitment to school	SCHOOL Opportunities for prosocial involvement Rewards for prosocial involvement Antismoking school policies
FAMILY Attitude and drug behaviour – Favourable parental attitudes to drug use – Parental alcohol and drug problems – Family history of antisocial behaviour Poor family management and communication factors – Poor family management – Parental rules pertaining to drug use – Inconsistent discipline strategies – High use of harsh discipline – High use of physical punishment – Negative communication patterns (e.g. blaming and criticism) Family bonding and attachment factors – Low attachment to parents – Low family bonding – Family breakdown – Child abuse and neglect – Parent–adolescent conflict Family structure – Sole parent families – this factor appears to result from the association with lower economic status and high family conflict	FAMILY Good attachment to family in adolescence – i.e. high in caring and connectedness Good parental supervision – being aware and in charge of what children are doing Sharing of affection and communication with children Parental interest in child activities Minimal parental conflict Opportunities for prosocial involvement Rewards for prosocial involvement
SOCIETY Extreme social disadvantage Disorganisation and chaos in the community structure Perceived and actual level of community drug use Availability of drugs in the community Low involvement in activities with adults in adolescence Positive media portrayal of drug use Laws and norms favourable to drug use Low neighbourhood attachment Personal transitions and mobility Community transitions and mobility Society labelling someone as a substance user after initial use	SOCIETY Religious involvement Opportunity for prosocial involvement Rewards for prosocial involvement

Although we know that a greater risk of drug dependence is correlated to a greater number of risk factors that persist and influence an individual over time [13, 18], it is unclear which risk factors or combinations of risk factors are more pertinent in impacting on adolescents’ drug use. What we can conclude is that drug use initiation is determined by numerous interacting individual factors and social pressures, and cannot be solved by a single intervention.

In order to develop effective prevention and early intervention, it seems sensible to incorporate a multi-component approach aimed at reducing risks and enhancing protective factors at the individual and societal levels [13, 16]. It is also necessary to determine the appropriate time when programmes should be implemented.

When should we intervene?

The transition to adolescence and young adulthood is a time when individuals move towards independence and autonomy, decrease dependence on families and schools, and place more emphasis on acceptance by peers. For most young people, this progression to adulthood is positive. However, this transition is also the time when risk-taking behaviour is high and vulnerability to substance use disorders is at its peak [24]. Coinciding with these social and emotional influences is the ongoing development of the brain which continues well beyond childhood and adolescence [25, 26]. In particular, the prefrontal cortex (involved in judgment, decision making and control of emotional responses) is one of the last areas of the brain to mature during late adolescence [27]. This can reduce an adolescents’ ability to carry out intended and planned choices [28], and can exaggerate the brain’s responses to immediate rewards [29].

In light of this research, it is important that prevention and early intervention be introduced in the adolescent years to provide young people with the knowledge and skills they need to make responsible and informed decisions regarding their substance use [30]. There are three periods during early years when the effects of prevention and early intervention can be optimised: the inoculation phase, the early relevance phase and the late relevance phase [31, 32]. The inoculation phase is the phase prior to initial drug experimentation, the early relevance phase occurs when most students are experiencing initial exposure to drugs and the late relevance phase is when the prevalence of drug use increases and the context of use changes. As the goal of prevention is to decrease the uptake of drugs and prevent the establishment of harmful patterns of use, the inoculation phase is considered the most appropriate phase to intervene. Early intervention on the other hand is best implemented during the early relevance and late relevance phases to target youth who have already started to use substances and experiences related harms [33].

The remainder of this chapter will review the evidence around effective prevention and early intervention of substance use in young people.

School-based prevention for substance use

Although prevention is best delivered through school, community and family interventions, such a holistic approach is resource intensive and not easily achievable. School-based drug education is achievable and is the most favoured approach to prevention of substance use due to the advantages it offers. Firstly, school is a location where educators are able to reach large audiences at one time whilst keeping costs low as attendance is a mandatory requirement in most Western countries and young people spend over a quarter of their waking lives at school [34–36]. Not only is school a place where peer interaction (a significant risk factor for drug use) is high, it also coincides with a time when young people are beginning to experiment or are exposed to drugs [37]. Therefore, schools provide a context to deliver preventive interventions before harmful use begins [38].

Historically, approaches to school-based prevention can be divided into four main categories: (1) information dissemination approaches, (2) affective education approaches, (3) social influence approaches and (4) comprehensive approaches [37, 39]. The least effective of these are the information and affective approaches and the most effective appear to be the social influence and comprehensive approaches. As well as the different approaches to school-based prevention, there are certain components that have been identified in the literature as contributing to programme effectiveness. Table 17.3 summarises the principles that have consistently been associated with effective prevention in schools [35, 40–43].

Table 17.3 Effective principles of school-based prevention of substance use

Be evidence based and theory driven
Acknowledge and target risk factors for substance use and psychopathology
Present developmentally appropriate information
Be implemented before harmful patterns of use are established
Be part of a comprehensive health education curriculum
Adopt a social influence or comprehensive approach to prevention; and
- Provide resistance skills training and
- Incorporate normative education
Make content of immediate relevance to students
Make use of peer leadership, but keep teacher as the central role
Address values, attitudes and behaviours of the individual and community
Be sensitive to cultural characteristics of target audience
Provide adequate initial coverage and continued follow-up in booster sessions
Employ interactive teaching approaches
Can be delivered within an overall framework of harm minimization.

Over the past few decades, the development and evaluation of school-based prevention substance use prevention programmes has significantly increased as has the number of systematic reviews and meta-analyses examining their effectiveness. These reviews have consistently established that school-based prevention can result in significant increases in knowledge about substances and improved attitudes towards substance use [44–48]. However, they have not been able to consistently demonstrate the effectiveness of school-based drug prevention in reducing actual substance use [44]. This is most likely a result of the many barriers or ‘obstacles’ which can impede on programme effectiveness [49–52]. Arguably, the greatest obstacles to effective school-based drug prevention can be attributed to issues regarding implementation and dissemination of programmes [53].

Disseminating drug prevention programmes into schools is not always entirely successful [36, 37, 44]. For example Ennett et al. [54] found that only 14% of schools in the United States implemented programmes which incorporate the correct content and delivery as identified in the literature as having the largest effect sizes in reducing drug use [48]. It is possible that because evidence-based programmes are rarely designed and packaged in ways that are competitive with commercial programmes and, once funded trials of prevention cease, schools do not have the motivation or sufficient resources to continue using such programmes [35]. It could also be a result of the many challenges that arise when implementing prevention programmes into the classroom. This is known as ‘implementation fidelity’ which refers to adhering to, and implementing, a programme in the exact way it was designed to be [55]. A study examining the implementation fidelity of substance use prevention programmes indicated that one-fifth of teachers reported not using a curriculum/programme guide at all, and only 15% reported following one very closely [56]. This is of great concern because research shows that programmes delivered with high fidelity lead to superior outcomes for students, and programmes delivered with poor fidelity lead to poorer outcomes for students [51, 55]. In schools, there are a number of potential barriers to fidelity which compromise program efficacy. These relate predominately to inconsistent or incompetent delivery of programmes and include insufficient ongoing teacher training, inadequate resources, problems with adherence to existing guidelines, lack of support for teachers, insufficient time, classroom overcrowding and management, transient student populations and curriculum changes [44, 49, 53, 54, 56]. Internet-based technology offers a way to overcome barriers to implementation and ensure complete and consistent delivery of programmes.

Internet- and computer-based prevention

Internet- and computer-based technology offers many advantages over traditional methods of delivering prevention and are both feasible and scalable to meet the needs of large audiences. Promising research has been conducted into the development and evaluation of interventions delivered by computers or over the internet to reduce substance use in adolescents. From the evidence that exists, it appears that such programmes are both feasible and acceptable. In terms of efficacy, computerised drug prevention programmes for youth have been shown to increase knowledge [17, 57–61], decrease prodrug attitudes [57, 62–64], increase drug resistance [65] and decrease reported intention to use drugs [65, 66]. The evidence for behavioural change is more limited as most studies which have evaluated the efficacy of computer-based drug prevention programmes for youth have failed to collect behavioural measures [57, 65, 66]. From those that have collected measures of behavioural change, the results are promising.

A study conducted by the Body Awareness Resource Network (BARN) group, found their programme to be effective in slowing the progression of drug use from non-use to problem use in a high-risk population [67]. A study by Schinke et al. [62], found youth who completed a 10-session CD-ROM drug prevention programme to have lower monthly rates of alcohol, tobacco and cannabis use than young people who did not receive the intervention up to 3 years following the intervention. A computerised smoking prevention programme for school students was found to be effective in encouraging cessation in existing smokers and delaying onset in non-smokers [68], and the internet-based Climate Schools programmes for drug prevention have been found to decrease average alcohol consumption, decrease frequency of binge drinking and decrease frequency of cannabis use up to 2 years following the interventions [59–61, 63].

In summary, research has demonstrated that computerised interventions can give rise to equivalent or even greater changes in desired outcomes than traditional drug intervention programmes can. This coupled with the numerous implementation advantages and high fidelity associated with computers, the internet offers a new and promising delivery method for substance use prevention and potentially early intervention as well.

Early intervention for substance use disorders

Early intervention is a style of therapy aimed at reducing the risk of harm and progression to dependence in ‘hazardous users’, whose substance use is at an early or mild stage. It seeks to provide a combination of both screening and brief therapy to individuals before they would normally present for treatment [69]. The therapy usually consists of one to three sessions and is focussed around techniques to educate, encourage and motivate at-risk individuals to consider behaviour change to reduce harm associated with substance use [70–73].

Early intervention programmes stem from the assumption that most substance use disorders do not occur immediately upon initial exposure, but rather, abuse and dependence begins with less pathological, but nonetheless, risky patterns of use [74]. Early work undertaken by Kristenson et al. [75] first demonstrated the efficacy of these programmes for problem drinking, subsequent studies have supported these findings [76, 77].

Traditionally, these programmes have focussed primarily on alcohol misuse, therefore, much less is known about the role and effectiveness of early intervention in illicit substance use. Nevertheless, limited findings suggest that such programmes may have similar utility [77–79].

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