Chapter 48. Prevention of Substance Abuse

Richard R. Clayton, Ph.D.; Melissa J. H. Segress, M.S.; Crystal A. Caudill, M.P.H.
DOI: 10.1176/appi.books.9781585623440.359197



Prevention is usually thought of as relevant primarily for children and youths, not adults. For every drug, several potential targets exist in trajectories of drug use for prevention activities. These include 1) initiation; 2) continuation; 3) progression within a drug class to more extensive, intensive use patterns; 4) progression across drug classes; 5) progression to dependence; 6) regression to cessation; and 7) lapse and relapse. The preponderance of research on substance abuse prevention to date has focused on two targets: 1) attempts to reduce the likelihood of initiation (or at least delay onset) and prevalence of use among youths and 2) reducing the likelihood of relapse among adult drug abusers. In this chapter, we concentrate on primarily youth-focused prevention.

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Table Reference Number

Prevention science is still a relatively new area of scientific investigation. Even so, tremendous progress has been made in conducting rigorous research on efficacy and effectiveness, and research on dissemination has ramped up in recent years.

Prevention requires a focus on malleable risk and protective factors that exist at numerous levels. If something cannot be changed, it is not a legitimate target of prevention. To date, more attention has been paid to intraindividual factors that may be malleable than to environmental factors that could be changed and, if changed, could affect many individuals.

Prevention has focused largely on children and youths rather than adults; on initiation of drug use rather than other transition points (continuation, progression within and across drug classes, regression to cessation, and relapse); and on school-based prevention that is curriculum-driven, televised media messages, and the formation and sustenance of community-based coalitions. Little has been done to make prevention more comprehensive and integrated and to parse out the effects of various prevention strategies considered together rather than independently.

Substance abuse is complex. Large individual differences in substance abuse patterns exist, but the biggest return on investment in prevention will focus on covering large segments of the population and accepting a relatively small percentage change rather than having a large effect on a small number of individuals. Prevention as it currently exists does not lend itself well to individual tailoring.

Accumulating evidence indicates that school-based, curriculum-driven prevention programming can be efficacious, but a host of substantive and research issues remain to be solved.

Evidence indicates that media-based prevention strategies can be efficacious, but the knowledge base is suggesting that there are many issues and problems that need to be examined rigorously.

Evidence suggests that community coalitions can have an efficacious effect on substance abuse at the community level, but significantly more work is needed to have an algorithm that seems to work across communities.

Documentation that a prevention effort is efficacious in a controlled setting does not in any way guarantee that it will be effective when disseminated. Studies of effectiveness and dissemination are needed to show compellingly how to take a prevention program to scale.

Those involved in substance abuse prevention are often hard on themselves for not reporting large effects from interventions. A lesson may be learned from the prevention of cardiovascular disease. As many as 20% of the people who receive prescriptions do not even get them filled, and about 50% of the people taking routine medicines take them inconsistently (Miller 1997Miller 1997). After a major national push on hypertension, fewer than 60% of those receiving treatment had the condition "controlled" (Hajjar and Kotchen 2003Hajjar and Kotchen 2003).

The question that has driven the substance abuse prevention field to date is "Does prevention work?" In the coming decades, the question driving the field will be "Prevention works, but for whom, when, where, under what circumstances, why, and how?"


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CME Activity

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Sample questions:
For every drug, several potential targets exist in trajectories of drug use for prevention activities. The preponderance of research on substance abuse prevention has focused on which of the following targets?
Significant prevention efforts have been devoted to one of the so-called gateway drugs. Which of the following is a gateway drug?
There are several taxonomies of prevention. Which of the following terms refers to prevention in which the focus is on the individual and his or her lifestyle or behavior?
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