See also: Substance use disorder
This article is about Drug abuse. For the Dice album, see Drug Abuse (album).
Substance abuse, also known as drug abuse, is a patterned use of a drug in which the user consumes the substance in amounts or with methods which are harmful to themselves or others, and is a form of substance-related disorder. Widely differing definitions of drug abuse are used in public health, medical and criminal justice contexts. In some cases criminal or anti-social behavior occurs when the person is under the influence of a drug, and long term personality changes in individuals may occur as well. In addition to possible physical, social, and psychological harm, use of some drugs may also lead to criminal penalties, although these vary widely depending on the local jurisdiction.
Drugs most often associated with this term include: alcohol, cannabis, barbiturates, benzodiazepines, cocaine, methaqualone, opioids and some substituted amphetamines. The exact cause of substance abuse is not clear, with the two predominant theories being: either a genetic disposition which is learned from others, or a habit which if addiction develops, manifests itself as a chronic debilitating disease.
In 2010 about 5% of people (230 million) used an illicit substance. Of these 27 million have high-risk drug use otherwise known as recurrent drug use causing harm to their health, psychological problems, or social problems that put them at risk of those dangers. In 2015 substance use disorders resulted in 307,400 deaths, up from 165,000 deaths in 1990. Of these, the highest numbers are from alcohol use disorders at 137,500, opioid use disorders at 122,100 deaths, amphetamine use disorders at 12,200 deaths, and cocaine use disorders at 11,100.
Public health definitions
Public health practitioners have attempted to look at substance use from a broader perspective than the individual, emphasizing the role of society, culture, and availability. Some health professionals choose to avoid the terms alcohol or drug "abuse" in favor of language they consider more objective, such as "substance and alcohol type problems" or "harmful/problematic use" of drugs. The Health Officers Council of British Columbia — in their 2005 policy discussion paper, A Public Health Approach to Drug Control in Canada] — has adopted a public health model of psychoactive substance use that challenges the simplistic black-and-white construction of the binary (or complementary) antonyms "use" vs. "abuse". This model explicitly recognizes a spectrum of use, ranging from beneficial use to chronic dependence.
'Drug abuse' is no longer a current medical diagnosis in either of the most used diagnostic tools in the world, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), and the World Health Organization's International Statistical Classification of Diseases (ICD).
Substance abuse has been adopted by the DSM as a blanket term to include 10 separate classes of drugs, including alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics, and anxiolytics; stimulants; tobacco; and other substances. The ICD uses the term Harmful use to cover physical or psychological harm to the user from use.
Physical dependence, abuse of, and withdrawal from drugs and other miscellaneous substances is outlined in the DSM a:
When an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed. Compulsive and repetitive use may result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped.
However, other definitions differ; they may entail psychological or physical dependence, and may focus on treatment and prevention in terms of the social consequences of substance uses.
Philip Jenkins suggests that there are two issues with the term "drug abuse". First, what constitutes a "drug" is debatable. For instance, GHB, a naturally occurring substance in the central nervous system is considered a drug, and is illegal in many countries, while nicotine is not officially considered a drug in most countries.
Second, the word "abuse" implies a recognized standard of use for any substance. Drinking an occasional glass of wine is considered acceptable in most Western countries, while drinking several bottles is seen as an abuse. Strict temperance advocates, who may or may not be religiously motivated, would see drinking even one glass as an abuse. Some groups even condemn caffeine use in any quantity. Similarly, adopting the view that any (recreational) use of cannabis or substituted amphetamines constitutes drug abuse implies a decision made that the substance is harmful, even in minute quantities. In the U.S., drugs have been legally classified into five categories, schedule I, II, III, IV, or V in the Controlled Substances Act. The drugs are classified on their deemed potential for abuse. Usage of some drugs is strongly correlated. For example, the consumption of seven illicit drugs (amphetamines, cannabis, cocaine, ecstasy, legal highs, LSD, and magic mushrooms) is correlated and the Pearson correlation coefficientr>0.4 in every pair of them; consumption of cannabis is strongly correlated (r>0.5) with usage of nicotine (tobacco), heroin is correlated with cocaine (r>0.4), methadone (r>0.45), and strongly correlated with crack (r>0.5)
Drug misuse is a term used commonly when prescription medication with sedative, anxiolytic, analgesic, or stimulant properties are used for mood alteration or intoxication ignoring the fact that overdose of such medicines can sometimes have serious adverse effects. It sometimes involves drug diversion from the individual for whom it was prescribed.
Prescription misuse has been defined differently and rather inconsistently based on status of drug prescription, the uses without a prescription, intentional use to achieve intoxicating effects, route of administration, co-ingestion with alcohol, and the presence or absence of dependence symptoms. Chronic use of certain substances leads to a change in the central nervous system known as a 'tolerance' to the medicine such that more of the substance is needed in order to produce desired effects. With some substances, stopping or reducing use can cause withdrawal symptoms to occur, but this is highly dependent on the specific substance in question.
The rate of prescription drug use is fast overtaking illegal drug use in the United States. According to the National Institute of Drug Abuse, 7 million people were taking prescription drugs for nonmedical use in 2010. Among 12th graders, nonmedical prescription drug use is now second only to cannabis. "Nearly 1 in 12 high school seniors reported nonmedical use of Vicodin; 1 in 20 reported such use of OxyContin." Both of these drugs contain opioids.
Avenues of obtaining prescription drugs for misuse are varied: sharing between family and friends, illegally buying medications at school or work, and often "doctor shopping" to find multiple physicians to prescribe the same medication, without knowledge of other prescribers.
Increasingly, law enforcement is holding physicians responsible for prescribing controlled substances without fully establishing patient controls, such as a patient "drug contract." Concerned physicians are educating themselves on how to identify medication-seeking behavior in their patients, and are becoming familiar with "red flags" that would alert them to potential prescription drug abuse.
Signs and symptoms
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Notes about the harm ratings
The Physical harm, Dependence liability, and Social harm scores were each computed from the average of three distinct ratings. The highest possible harm rating for each rating scale is 3.0.
Depending on the actual compound, drug abuse including alcohol may lead to health problems, social problems, morbidity, injuries, unprotected sex, violence, deaths, motor vehicle accidents, homicides, suicides, physical dependence or psychological addiction.
There is a high rate of suicide in alcoholics and other drug abusers. The reasons believed to cause the increased risk of suicide include the long-term abuse of alcohol and other drugs causing physiological distortion of brain chemistry as well as the social isolation. Another factor is the acute intoxicating effects of the drugs may make suicide more likely to occur. Suicide is also very common in adolescent alcohol abusers, with 1 in 4 suicides in adolescents being related to alcohol abuse. In the USA approximately 30% of suicides are related to alcohol abuse. Alcohol abuse is also associated with increased risks of committing criminal offences including child abuse, domestic violence, rapes, burglaries and assaults.
Drug abuse, including alcohol and prescription drugs, can induce symptomatology which resembles mental illness. This can occur both in the intoxicated state and also during the withdrawal state. In some cases these substance induced psychiatric disorders can persist long after detoxification, such as prolonged psychosis or depression after amphetamine or cocaine abuse. A protracted withdrawal syndrome can also occur with symptoms persisting for months after cessation of use. Benzodiazepines are the most notable drug for inducing prolonged withdrawal effects with symptoms sometimes persisting for years after cessation of use. Abuse of hallucinogens can trigger delusional and other psychotic phenomena long after cessation of use.
Cannabis may trigger panic attacks during intoxication and with continued use, it may cause a state similar to dysthymia. Researchers have found that daily cannabis use and the use of high-potency cannabis are independently associated with a higher chance of developing schizophrenia and other psychotic disorders.
Severe anxiety and depression are commonly induced by sustained alcohol abuse, which in most cases abates with prolonged abstinence. Even sustained moderate alcohol use may increase anxiety and depression levels in some individuals. In most cases these drug induced psychiatric disorders fade away with prolonged abstinence.
Impulsivity is characterized by actions based on sudden desires, whims, or inclinations rather than careful thought. Individuals with substance abuse have higher levels of impulsivity, and individuals who use multiple drugs tend to be more impulsive. A number of studies using the Iowa gambling task as a measure for impulsive behavior found that drug using populations made more risky choices compared to healthy controls. There is a hypothesis that the loss of impulse control may be due to impaired inhibitory control resulting from drug induced changes that take place in the frontal cortex. The neurodevelopmental and hormonal changes that happen during adolescence may modulate impulse control that could possibly lead to the experimentation with drugs and may lead to the road of addiction. Impulsivity is thought to be a facet trait in the neuroticism personality domain (overindulgence/negative urgency) which is prospectively associated with the development of substance abuse.
Screening and assessment
There are several different screening tools that have been validated for use with adolescents such as the CRAFFT Screening Test and in adults the CAGE questionnaire.
Some recommendations for screening tools for substance misuse in pregnancy include that they take less than 10 minutes, should be used routinely, include an educational component. Tools suitable for pregnant women include i.a. 4Ps, T-ACE, TWEAK, TQDH (Ten-Question Drinking History), and AUDIT.
From the applied behavior analysis literature, behavioral psychology, and from randomized clinical trials, several evidenced based interventions have emerged: behavioral marital therapy, motivational Interviewing, community reinforcement approach, exposure therapy, contingency management They help suppress cravings and mental anxiety, improve focus on treatment and new learning behavioral skills, ease withdrawal symptoms and reduce the chances of relapse.
In children and adolescents, cognitive behavioral therapy (CBT) and family therapy currently has the most research evidence for the treatment of substance abuse problems. Well-established studies also include ecological family-based treatment and group CBT. These treatments can be administered in a variety of different formats, each of which has varying levels of research support Research has shown that what makes group CBT most effective is that it promotes the development of social skills, developmentally appropriate emotional regulatory skills and other interpersonal skills. A few integrated treatment models, which combines parts from various types of treatment, have also been seen as both well-established or probably effective. A study on maternal alcohol and drug use has shown that integrated treatment programs have produced significant results, resulting in higher negative results on toxicology screens. Additionally, brief school-based interventions have been found to be effective in reducing adolescent alcohol and cannabis use and abuse.Motivational interviewing can also be effective in treating substance use disorder in adolescents.
Alcoholics Anonymous and Narcotics Anonymous are one of the most widely known self-help organizations in which members support each other not to use alcohol.Social skills are significantly impaired in people suffering from alcoholism due to the neurotoxic effects of alcohol on the brain, especially the prefrontal cortex area of the brain. It has been suggested that social skills training adjunctive to inpatient treatment of alcohol dependence is probably efficacious, including managing the social environment.
A number of medications have been approved for the treatment of substance abuse. These include replacement therapies such as buprenorphine and methadone as well as antagonist medications like disulfiram and naltrexone in either short acting, or the newer long acting form. Several other medications, often ones originally used in other contexts, have also been shown to be effective including bupropion and modafinil. Methadone and buprenorphine are sometimes used to treat opiate addiction. These drugs are used as substitutes for other opioids and still cause withdrawal symptoms.
Antipsychotic medications have not been found to be useful. Acamprostate is a glutamatergic NMDA antagonist, which helps with alcohol withdrawal symptoms because alcohol withdrawal is associated with a hyperglutamatergic system.
Psychedelics, such as LSD and psilocin, may have anti-addictive properties.
Main article: Dual diagnosis
It is common for individuals with drugs use disorder to have other psychological problems. The terms “dual diagnosis” or “co-occurring disorders,” refer to having a mental health and substance use disorder at the same time. According to the British Association for Psychopharmacology (BAP), “symptoms of psychiatric disorders such as depression, anxiety and psychosis are the rule rather than the exception in patients misusing drugs and/or alcohol.”
Individuals who have a comorbid psychological disorder often have a poor prognosis if either disorder is untreated. Historically most individuals with dual diagnosis either received treatment only for one of their disorders or they didn’t receive any treatment all. However, since the 1980s, there has been a push towards integrating mental health and addiction treatment. In this method, neither condition is considered primary and both are treated simultaneously by the same provider.
The initiation of drug and alcohol use is most likely to occur during adolescence, and some experimentation with substances by older adolescents is common. For example, results from 2010 Monitoring the Future survey, a nationwide study on rates of substance use in the United States, show that 48.2% of 12th graders report having used an illicit drug at some point in their lives. In the 30 days prior to the survey, 41.2% of 12th graders had consumed alcohol and 19.2% of 12th graders had smoked tobacco cigarettes. In 2009 in the United States about 21% of high school students have taken prescription drugs without a prescription. And earlier in 2002, the World Health Organization estimated that around 140 million people were alcohol dependent and another 400 million with alcohol-related problems.
Studies have shown that the large majority of adolescents will phase out of drug use before it becomes problematic. Thus, although rates of overall use are high, the percentage of adolescents who meet criteria for substance abuse is significantly lower (close to 5%). According to BBC, "Worldwide, the UN estimates there are more than 50 million regular users of morphine diacetate (heroin), cocaine and synthetic drugs."
APA, AMA, and NCDA
In 1932, the American Psychiatric Association created a definition that used legality, social acceptability, and cultural familiarity as qualifying factors:
…as a general rule, we reserve the term drug abuse to apply to the illegal, nonmedical use of a limited number of substances, most of them drugs, which have properties of altering the mental state in ways that are considered by social norms and defined by statute to be inappropriate, undesirable, harmful, threatening, or, at minimum, culture-alien."
In 1966, the American Medical Association's Committee on Alcoholism and Addiction defined abuse of stimulants (amphetamines, primarily) in terms of 'medical supervision':
…'use' refers to the proper place of stimulants in medical practice; 'misuse' applies to the physician's role in initiating a potentially dangerous course of therapy; and 'abuse' refers to self-administration of these drugs without medical supervision and particularly in large doses that may lead to psychological dependency, tolerance and abnormal behavior.
In 1973, the National Commission on Marijuana and Drug Abuse stated:
...drug abuse may refer to any type of drug or chemical without regard to its pharmacologic actions. It is an eclectic concept having only one uniform connotation: societal disapproval. ... The Commission believes that the term drug abuse must be deleted from official pronouncements and public policy dialogue. The term has no functional utility and has become no more than an arbitrary codeword for that drug use which is presently considered wrong.
The first edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (published in 1952) grouped alcohol and drug abuse under Sociopathic Personality Disturbances, which were thought to be symptoms of deeper psychological disorders or moral weakness. The third edition, published in 1980, was the first to recognize substance abuse (including drug abuse) and substance dependence as conditions separate from substance abuse alone, bringing in social and cultural factors. The definition of dependence emphasised tolerance to drugs, and withdrawal from them as key components to diagnosis, whereas abuse was defined as "problematic use with social or occupational impairment" but without withdrawal or tolerance.
In 1987, the DSM-IIIR category "psychoactive substance abuse," which includes former concepts of drug abuse is defined as "a maladaptive pattern of use indicated by...continued use despite knowledge of having a persistent or recurrent social, occupational, psychological or physical problem that is caused or exacerbated by the use (or by) recurrent use in situations in which it is physically hazardous." It is a residual category, with dependence taking precedence when applicable. It was the first definition to give equal weight to behavioural and physiological factors in diagnosis. By 1988, the DSM-IV defines substance dependence as "a syndrome involving compulsive use, with or without tolerance and withdrawal"; whereas substance abuse is "problematic use without compulsive use, significant tolerance, or withdrawal." Substance abuse can be harmful to your health and may even be deadly in certain scenarios. By 1994, The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) issued by the American Psychiatric Association, the DSM-IV-TR, defines substance dependence as "when an individual persists in use of alcohol or other drugs despite problems related to use of the substance, substance dependence may be diagnosed." followed by criteria for the diagnose
DSM-IV-TR defines substance abuse as:
- A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
- Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions or expulsions from school; neglect of children or household)
- Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
- Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
- Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
- B. The symptoms have never met the criteria for Substance Dependence for this class of substance.
The fifth edition of the DSM (DSM-5), planned for release in 2013, is likely to have this terminology revisited yet again. Under consideration is a transition from the abuse/dependence terminology. At the moment, abuse is seen as an early form or less hazardous form of the disease characterized with the dependence criteria. However, the APA's 'dependence' term, as noted above, does not mean that physiologic dependence is present but rather means that a disease state is present, one that most would likely refer to as an addicted state. Many involved recognize that the terminology has often led to confusion, both within the medical community and with the general public. The American Psychiatric Association requests input as to how the terminology of this illness should be altered as it moves forward with DSM-5 discussion.
Society and culture
- Related articles: Drug control law, Prohibition (drugs), Arguments for and against drug prohibition, Harm reduction
Most governments have designed legislation to criminalize certain types of drug use. These drugs are often called "illegal drugs" but generally what is illegal is their unlicensed production, distribution, and possession. These drugs are also called "controlled substances". Even for simple possession, legal punishment can be quite severe (including the death penalty in some countries). Laws vary across countries, and even within them, and have fluctuated widely throughout history.
Attempts by government-sponsored drug control policy to interdict drug supply and eliminate drug abuse have been largely unsuccessful. In spite of the huge efforts by the U.S., drug supply and purity has reached an all-time high, with the vast majority of resources spent on interdiction and law enforcement instead of public health. In the United States, the number of nonviolent drug offenders in prison exceeds by 100,000 the total incarcerated population in the EU, despite the fact that the EU has 100 million more citizens.
Despite drug legislation (or perhaps because of it), large, organized criminal drug cartels operate worldwide. Advocates of decriminalization argue that drug prohibition makes drug dealing a lucrative business, leading to much of the associated criminal activity.
Policymakers try to understand the relative costs of drug-related interventions. An appropriate drug policy relies on the assessment of drug-related public expenditure based on a classification system where costs are properly identified.
Labelled drug-related expenditures are defined as the direct planned spending that reflects the voluntary engagement of the state in the field of illicit drugs. Direct public expenditures explicitly labeled as drug-related can be easily traced back by exhaustively reviewing official accountancy documents such as national budgets and year-end reports. Unlabelled expenditure refers to unplanned spending and is estimated through modeling techniques, based on a top-down budgetary procedure. Starting from overall aggregated expenditures, this procedure estimates the proportion causally attributable to substance abuse (Unlabelled Drug-related Expenditure = Overall Expenditure × Attributable Proportion). For example, to estimate the prison drug-related expenditures in a given country, two elements would be necessary: the overall prison expenditures in the country for a given period, and the attributable proportion of inmates due to drug-related issues. The product of the two will give a rough estimate that can be compared across different countries.
As part of the reporting exercise corresponding to 2005, the European Monitoring Centre for Drugs and Drug Addiction's network of national focal points set up in the 27 European Union (EU) Member States, Norway, and the candidates countries to the EU, were requested to identify labeled drug-related public expenditure, at the country level.
This was reported by 10 countries categorized according to the functions of government, amounting to a total of EUR 2.17 billion. Overall, the highest proportion of this total came within the government functions of Health (66%) (e.g. medical services), and Public Order and Safety (POS) (20%) (e.g. police services, law courts, prisons). By country, the average share of GDP was 0.023% for Health, and 0.013% for POS. However, these shares varied considerably across countries, ranging from 0.00033% in Slovakia, up to 0.053% of GDP in Ireland in the case of Health, and from 0.003% in Portugal, to 0.02% in the UK, in the case of POS; almost a 161-fold difference between the highest and the lowest countries for Health, and a 6-fold difference for POS. Why do Ireland and the UK spend so much in Health and POS, or Slovakia and Portugal so little, in GDP terms?
To respond to this question and to make a comprehensive assessment of drug-related public expenditure across countries, this study compared Health and POS spending and GDP in the 10 reporting countries. Results found suggest GDP to be a major determinant of the Health and POS drug-related public expenditures of a country. Labelled drug-related public expenditure showed a positive association with the GDP across the countries considered: r = 0.81 in the case of Health, and r = 0.91 for POS. The percentage change in Health and POS expenditures due to a one percent increase in GDP (the income elasticity of demand) was estimated to be 1.78% and 1.23% respectively.
Being highly income elastic, Health and POS expenditures can be considered luxury goods; as a nation becomes wealthier it openly spends proportionately more on drug-related health and public order and safety interventions.
The UK Home Office estimated that the social and economic cost of drug abuse to the UK economy in terms of crime, absenteeism and sickness is in excess of £20 billion a year. However, the UK Home Office does not estimate what portion of those crimes are unintended consequences of drug prohibition (crimes to sustain expensive drug consumption, risky production and dangerous distribution), nor what is the cost of enforcement. Those aspects are necessary for a full analysis of the economics of prohibition.
(billions of dollars)
These figures represent overall economic costs, which can be divided in three major components: health costs, productivity losses and non-health direct expenditures.
- Health-related costs were projected to total $16 billion in 2002.
- Productivity losses were estimated at $128.6 billion. In contrast to the other costs of drug abuse (which involve direct expenditures for goods and services), this value reflects a loss of potential resources: work in the labor market and in household production that was never performed, but could reasonably be expected to have been performed absent the impact of drug abuse.
- Included are estimated productivity losses due to premature death ($24.6 billion), drug abuse-related illness ($33.4 billion), incarceration ($39.0 billion), crime careers ($27.6 billion) and productivity losses of victims of crime ($1.8 billion).
- The non-health direct expenditures primarily concern costs associated with the criminal justice system and crime victim costs, but also include a modest level of expenses for administration of the social welfare system. The total for 2002 was estimated at $36.4 billion. The largest detailed component of these costs is for state and federal corrections at $14.2 billion, which is primarily for the operation of prisons. Another $9.8 billion was spent on state and local police protection, followed by $6.2 billion for federal supply reduction initiatives.
According to a report from the Agency for Healthcare Research and Quality (AHRQ), Medicaid was billed for a significantly higher number of hospitals stays for Opioid drug overuse than Medicare or private insurance in 1993. By 2012, the differences were diminished. Over the same time, Medicare had the most rapid growth in number of hospital stays.
Immigrants and refugees
Immigrant and refugees have often been under great stress, physical trauma and depression and anxiety due to separation from loved ones often characterize the pre-migration and transit phases, followed by "cultural dissonance," language barriers, racism, discrimination, economic adversity, overcrowding, social isolation, and loss of status and difficulty obtaining work and fears of deportation are common. Refugees frequently experience concerns about the health and safety of loved ones left behind and uncertainty regarding the possibility of returning to their country of origin. For some, substance abuse functions as a coping mechanism to attempt to deal with these stressors.
Immigrants and refugees may bring the substance use and abuse patterns and behaviors of their country of origin, or adopt the attitudes, behaviors, and norms regarding substance use and abuse that exist within the dominant culture into which they are entering.
Street children in many developing countries are a high risk group for substance misuse, in particular solvent abuse. Drawing on research in Kenya, Cottrell-Boyce argues that "drug use amongst street children is primarily functional – dulling the senses against the hardships of life on the street – but can also provide a link to the support structure of the ‘street family’ peer group as a potent symbol of shared experience."
In order to maintain high-quality performance, some musicians take chemical substances. Some musicians take drugs or alcohol to deal with the stress of performing. As a group they have a higher rate of substance abuse. The most common chemical substance which is abused by pop musicians is cocaine, because of its neurological effects. Stimulants like cocaine increase alertness and cause feelings of euphoria, and can therefore make the performer feel as though they in some ways ‘own the stage’. One way in which substance abuse is harmful for a performer (musicians especially) is if the substance being abused is aspirated. The lungs are an important organ used by singers, and addiction to cigarettes may seriously harm the quality of their performance. Smoking causes harm to alveoli, which are responsible for absorbing oxygen.
Substance abuse can be another contributing factor that affects physical and mental health of veterans. Substance abuse may also damage personal relationships families and lead to financial difficulty. There is evidence to suggest that substance abuse disproportionately affects the homeless veteran population. A 2015 Florida study compared causes of homelessness between veterans and non veteran populations in a self reporting questionnaire. The results from the study found that 17.8% of the homeless veteran participants attributed their homelessness to alcohol and drug related problems compared to just 3.7% of the non-veteran homeless group.
A 2003 study found that homelessness was associated with access to support from family/friends and services. However, this relationship was not true when comparing homeless participants who had a current substance-use disorders. The U.S. Department of Veterans Affairs provide a summary of treatment options for veterans with substance use disorder. For treatments that do not involve medication, they offer a therapeutic options that focused on finding outside support groups and “looking at how substance use problems may relate to other problems such as PTSD and depression”.
- ^ abcdefgNutt, D.; King, L. A.; Saulsbury, W.; Blakemore, C. (2007). "Development of a rational scale to assess the harm of drugs of potential misuse". The Lancet. 369 (9566): 1047–1053. doi:10.1016/S0140-6736(07)60464-4. PMID 17382831.
- ^ abc"World Drug Report 2012"(PDF). UNITED NATIONS. Retrieved 27 September 2016.
- ^ ab"EMCDDA | Information on the high-risk drug use (HRDU) (formerly 'problem drug use' (PDU)) key indicator". www.emcdda.europa.eu. Retrieved 2016-09-27.
- ^ abcGBD 2015 Mortality and Causes of Death, Collaborators. (8 October 2016). "Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet. 388 (10053): 1459–1544. doi:10.1016/S0140-6736(16)31012-1. PMC 5388903. PMID 27733281.
- ^Ksir, Oakley Ray; Charles (2002). Drugs, society, and human behavior (9th ed.). Boston [u.a.]: McGraw-Hill. ISBN 0072319631.
- ^(2002). Mosby's Medical, Nursing & Allied Health Dictionary. Sixth Edition. Drug abuse definition, p. 552. Nursing diagnoses, p. 2109. ISBN 0-323-01430-5.
- ^"Addiction is a Chronic Disease". Retrieved 2 July 2014.
Youth use of harmful legal products, including inhaling or ingesting everyday household products, prescription drugs, and over-the-counter drugs, constitutes a growing health problem for American society. As such, a single targeted approach to preventing such a drug problem in a community is unlikely to be sufficient to reduce use and abuse at the youth population level. Therefore, the primary focus of this article is on an innovative, comprehensive, community-based prevention intervention. The intervention described here is based upon prior research that has a potential of preventing youth use of alcohol and other legal products. It builds upon three evidence-based prevention interventions from the substance abuse field: community mobilization, environmental strategies, and school-based prevention education intervention. The results of a feasibility project are presented and the description of a planned efficacy trial is discussed.
The use of legal products to get high continues to be a serious problem among youth in the United States. The Monitoring the Future national student survey in 2004 indicates that inhalant use in the United States showed an upward turn from the prior year, while use of illicit drugs continued a gradual decline (Johnston, O’Malley, Bachman, & Schulenberg, 2005). Further, the lifetime prevalence rate for inhalant use among 8th graders exceeded the prevalence rate for marijuana, making inhalants the third most commonly used substance for this population, behind alcohol and cigarettes. In 2005, one in 15 students reported using cough or cold medicines to get high in the past year. Inhalant use remained stable (Johnston, O’Malley, Bachman, & Schulenberg, 2006).
Inhalable and ingestible legal products to get high do not constitute a specific type of substance, but rather a constellation of many types of substances found in various products readily available to children and adolescents. Most inhalable products are volatile solvents, comprising liquids that can dissolve a number of other substances including paint thinners, gasoline, and model airplane glue, as well as aerosols, nitrites (“poppers”), and anesthetics (Alberta Alcohol and Drug Abuse Commission, 2004; Center for Substance Abuse Treatment, 2003; Wu, Schlenger, & Ringwalt, 2005). Legal products that can be ingested include over-the-counter medications like cough syrup, antihistamines, and cold medications; prescription drugs like OxyContin; and common household products like cooking extracts, disinfectant liquids, mouthwash, and other products high in ethanol (Banerji & Anderson, 2001; Fleming, McElnay, & Hughes, 2004; Mazor, DesLauriers, & Mycyk, 2005; Pates, McBride, Li, & Ramadan, 2002; Steinman, 2006). Studies indicate that harmful legal products like inhalants are often the first category of substances to be abused by adolescents and thus can constitute a gateway drug (Anderson & Loomis, 2003).
The use of harmful but legal products presents a number of prevention challenges. Many products widely available in retail stores, homes, and schools can be abused and share many characteristics of availability in common with other abused but legal products, alcohol and tobacco, while subjected to few formal controls. The body of prevention research relating to inhalant use and ingesting of legal products is very small (Brouette & Anton, 2001; Delva, Spencer, & Lin, 2000), and notably, no rigorous prevention study that targets the abuse of harmful legal products has appeared in the published literature. Only a few reviews of interventions to prevent inhalant abuse (d’Abbs & Maclean, 2000; Maclean & d’Abbs, 2002) and little prevention effectiveness have been reported (Harwood, 1995).
This article seeks to present an integrated community-based prevention intervention for preventing the use of harmful legal products among youth based upon existing evidence-based prevention programs and strategies that have the potential to prevent youth use of legal products to get high.
CONCEPTUALIZING A COMMUNITY PREVENTION INTERVENTION
As with most abused legal substances, total elimination of the use of inhalants and other harmful legal products by youth is unrealistic. As the field of prevention has matured, it has been recognized that any single strategy is unlikely to succeed and a reinforcing set of strategies has the greatest potential to reduce use.
Figure 1 presents a conceptual framework that describes the causal connections among significant variables in the use of harmful legal products. These variables should be addressed by a combination of prevention interventions or recognized as contributing to the actual use of harmful legal products and associated negative consequences.
Conceptual framework for the Community Prevention Intervention.
Five variables are conceptualized as important in reducing youth use of harmful legal products (shown with italics in Figure 1), i.e., Community Readiness, Rules and Regulations, Anti-drug Norms, Social Influence, and Cultural Identity. Community Readiness concerns the extent to which a community can effectively respond to substance abuse problems—like youths’ use of harmful legal products—and act to reduce these problems (Edwards, Jumper-Thurman, Plested, Oetting, & Swanson, 2000; Oetting et al., 1995). Rules and Regulations refers to restrictions on the availability of legal abusable products in homes, retail stores, and schools (Edwards & Holder, 2000; Johnson, 1996; Massachusetts Inhalant Abuse Task Force, 2005). Anti-drug Norms refers to the level of concern among retailers, families, and school officials about the use of inhalants and other harmful legal products in the community and support for local actions to prevent use (Birckmayer, Holder, Yacoubian, & Friend, 2004; Commonwealth of Massachusetts Department of Public Health, 2006). Social Influence relates to social pressures from peers, parents, and community which increase or decrease use of harmful legal products (Botvin, Baker, Goldberg, Dusenbury, & Botvin, 1992; Botvin, Schinke, & Orlandi, 1989). Schinke, Tepavac, and Cole (2000) assumed that social influence and cultural relevance were important correlates in designing an effective prevention program for American Indian youth. Cultural identity is a sense of belonging based on a set of attitudes, beliefs, and actions that are shared among people that help to define them as a cohesive group (Cross, Bazron, Dennis, & Isaacs, 1989).
Consistent with these key variables (Figure 1), three evidence-based prevention intervention components are combined to form a comprehensive community prevention intervention to combat youth use of harmful legal products: 1) community mobilization; 2) environmental strategies; and 3) a school-based prevention education. These components are based upon the best available scientific evidence on effective prevention strategies.
This strategy is designed to increase community readiness and engage communities in prevention activities and actions to reduce use of harmful legal products among youth. Wagenaar et al. (1999), for example, demonstrated via efforts to prevent alcohol abuse that effective community mobilization can support prevention actions and engage more community members. Effective community mobilization is essential to implementing a mutually supportive mix of prevention approaches, i.e., environmental strategies and a school-based prevention curriculum as proposed here.
Environmental Strategies are intended to alter the larger social, physical, and economic environment of a community in order to reduce the harmful use of ATOD (see Babor et al., 2003). Scientific evidence to support the effectiveness of environmental strategies for the reduction of alcohol and drug abuse has developed over the past three decades (Gruenewald, Holder, & Treno, 2003; Holder et al., 1999; Wagenaar, Murray, & Gehan, 2000). In this framework, three environments are targeted: retail stores, homes, and schools. This component is designed to enable retailers, parents, and school officials to take actions intended to reduce the availability of harmful legal products to youth.
School-based education of youth has a long history as a strategy to reduce child and youth use and abuse of ATOD and is included in this conceptual framework. There is empirical evidence that the Life Skills Training (LST) increases cognitive-behavioral skills, decreases the motivations to use drugs, and decreases vulnerability to social influences that promote drug use (Botvin, Griffin, Diaz, & Ifill-Williams, 2001; Griffin, Botvin, Nichols, & Doyle, 2003). Gilchrist, Schinke, Trimble, and Cvetkovich (1987) found that LST for American Indian youth living in the Pacific Northwest significantly reduced usage of alcohol, marijuana, and inhalants at a six-month follow-up. Life Skills Training (LST) has been adapted for American Indian populations (Raghupathy & Peterson, 2002; Schinke, Moncher, Palleja, Zayas, & Schilling, 1988; Schinke et al., 2000) with demonstrated effectiveness in reducing substance use.
In summary, we assume that if the availability of harmful legal products is reduced and youths’ cognitive—behavioral skills are increased, then youth use of these products will decrease. Further, if consumption is reduced, it is hypothesized that there will be a decrease in negative consequences such as illegal activity and substandard school performance and health risks associated with use. Details of the community prevention intervention that we posit can produce positive outcomes are provided below. We also discuss experience and “lessons learned” from a feasibility study sponsored by the National Institute for Drug Abuse in four Alaska communities which regional hubs with populations ranging from 3,500 to 9,000. Two communities are the northern region and two in the southeastern regions of the state.
COMMUNITY PREVENTION INTERVENTION OMPONENTS
The community prevention framework shown in Figure 1 presents the underlying theoretical assumptions of the intervention to reduce the use of harmful legal products. A more detailed view includes the key activities of each component and summary results from the feasibility study mentioned above.
Wagenaar et al. (1999) have outlined seven steps that serve as a guide for community mobilization: 1) assessing community readiness; 2) building a base; 3) expanding the base; 4) developing a plan of action; 5) implementing the plan of action; 6) seeking feedback and disseminating results; and 7) sustaining the effort (Figure 1).
Community Readiness Assessment
The assessment focuses on readiness to combat youths’ use of harmful legal products that include inhaling and ingesting these products (Oetting et al., 1995). Nine stages of community readiness have been identified: 1) no awareness; 2) denial/resistance; 3) vague awareness; 4) preplanning; 5) preparation; 6) initiation; 7) stabilization; 8) confirmation/expansion; and 9) high level of community ownership (Plested, Edwards, Jumper-Thurman, 2005). The stage of community readiness can be assessed by asking a small number of knowledgeable members of a community about how a specific health or social issue has been understood and dealt with in the past, and what the prevailing norms surrounding that issue are in the community. The results of the assessment can then be presented to community representatives (including the interviewed stakeholders and relevant coalitions) in order to establish the realistic baseline from which they can move their community toward a position of actively maintaining successful prevention programs.
Building and Expanding the Base
Coalitions or partnerships consisting of key leaders, agencies, and organizations provide a substantial base to mobilize the entire community to address a health or social problem (Lewis et al., 1996; MacLean et al., 2003). Coalition capacity-building training and technical assistance should also be provided to strengthen or build coalitions where they are in the early stages of organizing or reorganizing (Florin, Mitchell, & Stevenson, 1993; Mitchell, Florin, & Stevenson, 2002). The base can be expanded by hiring a part-time local community prevention organizer (CPO) who follows a written work plan organized by tasks and due dates to mobilize community members beyond the base. Even a part-time CPO can identify key leaders/supporters to endorse and support the project. Further, each CPO can coordinate the implementation of a variety of environmental strategies described below that target retailers, parents, and schools.
Developing and Implementing a Plan of Action
A community prevention action plan should provide concrete steps and strategies. Media advocacy is an essential aspect of this plan to motivate community policy makers, police, parents, neighborhood members, teachers at local schools, and retail merchants to be involved with community prevention interventions (Holder & Treno, 1997). Media advocacy refers to the strategic use of news media and other local forms of public communication to advance a social or public policy initiative. Unlike specifically designed public information campaigns, which use media to change behavior directly, media advocacy works with local news outlets (radio, television, newspapers, and magazines) and other information sources to increase local news attention to a specific public health problem and solutions.
Seeking Feedback, Disseminating Results, and Sustaining Effort
Evaluating and disseminating results are essential to support mobilization and determine whether community change is taking place (Johnson et al., 2003). Moreover, an essential element of a sustainability plan is to share evaluation results with key community leaders and prevention champions (Johnson, Hays, Center, & Daley, 2004). Baseline results on community readiness and capacity-building disseminated to coalitions or partnership members can guide training and technical assistance provided to the coalitions, alliances, and CPOs. Further, baseline results on youth use of harmful legal products can stimulate local interest and, later, evaluation impact results provide information on success (or failure) and whether the intervention components are worth sustaining. Finally, a sustainability strategy that highlights stable interagency structures, formal linkages, resources, prevention, champions, and prevention expertise to continue addressing youths’ use of harmful legal products is essential.
Feasibility Study Results
Community readiness in-person interviews showed the four Alaska communities in a status of denial or vague awareness of the problem of youth’s use of legal products to get high. While some community members acknowledged there might be a problem, most did not identify it as a local problem and did not feel anything needed to be done. Post-test readiness results showed significant improvement in community readiness in all four communities suggesting that the mobilization strategy worked (Ogilvie, Moore, Ogilvie, Johnson, Collins, & Shamblen, in review).
Under a public health perspective, environmental factors, such as the availability of substances, are important determinants of youth substance use and abuse. Birckmayer et al. (2004) suggest that many of the same environmental factors that contribute to alcohol and tobacco use, such as retail availability and price, also affect drug use including legal products which are used to get high. Zimring and Nelson (1995), in reviewing existing econometric studies, found that increasing the tax on cigarettes has been an important method of reducing the prevalence of adolescent tobacco use. Collins et al. (in review) found that the community-level risk factor of “perceived availability of drugs” had the strongest association with inhalant prevalence.
Environmental strategies complement more traditional individualistic approaches in several ways: a) focus on changing community systems rather than individual behavior; b) use the local news media to target community leaders or organizations rather than attempt to change individual behavior through media messages; c) view the community as a resource to mobilize for system change rather than the target group of information disseminators and receivers; and d) seek either to reduce supply or associated risk rather than reduce demand for drugs (Gruenewald et al., 2003).
Retail Environmental Strategy
The retail-focused strategy includes practical actions for retailers to take in partnership with their community. These actions include: 1) identifying and inventorying high-risk products; 2) developing written store policies regarding sales of harmful legal products; 3) posting warning labels or signs; 4) controlling display and availability; 5) substituting lower-risk products; and 6) restricting sales to youth.
Identify and inventory high risk products and how they are stored and displayed. Informing retailers is essential to increase the concern among retailers about products they sell which can be abused by youth and lead to serious health and social problems. An inventory achieves several objectives: 1) it provides data on actual legal products available in the community that can be abused by youth; 2) it increases community awareness of substances that are risky; 3) it increases retailers’ awareness of products that can be abused by youth; and 4) it establishes a locally unique profile of potentially harmful retail products.
Develop written store policies about sales of harmful legal products to children and youth. But increased knowledge and concern are not sufficient to actually reduce availability of such products through retail markets. Research indicates that retail establishments with firm and clear policies are more likely to limit sales of harmful legal products (Holder et al., 2000). For example, staff working in an establishment selling alcohol with a written policy of checking ID for all patrons who appear under the age of 30, and a system for monitoring staff compliance, are less likely to sell alcohol to minors. Written policies that are posted for all employees and customers ensure that employees have guidelines for responsible sales practices and understand that they need to be consistent in carrying out this policy. A written policy also establishes a public and written commitment by the retail store to take positive action to reduce abuse of legal products in their community and provides a clear set of guidelines for restricting sale (see Saltz, 1997a, 1997b; Saltz & Stanghetta, 1997).
Post warning or sale restrictions labels or signs near harmful legal products. Warning messages convey that the store wishes to limit sales of harmful legal products to and informs adults about potential risks and a justification to customer inconveniences that may occur when they purchase these products. However, the labels or signs must not be such as to discourage purchase altogether and deprive retailers of a sale. On the other hand, such signs (if too specific) can actually help youth identify products with the potential to be used to get “high” and thus actually increase the attractiveness of specific products. Display signs also can state the retailer’s support for the responsible sale of these products, along with the store’s right to refuse sales of harmful legal products.
Control display and availability of harmful legal products. The retailer can display frequently abused products in sight of shop staff, near checkouts, on high shelves, under the counter, or in locked display cabinets. Retailers can even use dummy containers for display purposes. Controlling access is an established strategy for reducing consumption of substances harmful to health—especially tobacco and alcohol—as well as for harmful legal products. By relocating harmful legal products so that minors do not have easy access to them, retailers reduce the likelihood of sales to minors and shoplifting. Very young buyers, in particular, are less likely to shop for legal products to get high in stores where they have to call attention to themselves by asking a clerk for the product. Many stores commonly relocate to reduce shoplifting.
Substitute products that cannot be abused for harmful but legal products. A comprehensive community project involving retailers has the potential to make product substitutions of the products themselves without decreasing sales. For example, low-odor dry-erase markers, water-based correction fluid, white glues or glue sticks, and latex paints are common substitutions for solvent-based products. Examples of retailer-focused substitution strategies that have been used in programs in Australia include: 1) substituting gasoline with Avgas/Comgas; 2) using unleaded gasoline to reduce potential brain damage; and 3) adding skunk odor and other deterrents to gasoline (Burns, Currie, Clough, & Wuridjal, 1995). Burns (1996), for example, found that using aviation gasoline (Avgas) for petrol as an aversion strategy was critical in combating inhalant abuse among Aboriginal youth in one Australian community because Avgas caused severe headaches and stomach cramps.
Restrict the sale of harmful legal products to youth purchasers, especially if there is reason to believe that the products are being purchased in order to get high. Retailers can monitor purchases of harmful legal products and be prepared to refuse sale of these products to youth purchasers. Communities can provide retailers with information regarding common signs of customer solvent use, tips and suggested responses to customers, and a flow chart for dealing with customers suspected of abusing legal products to get high. Of course, individual communities may establish formal restrictions on the sale of inhalants to adolescents or require locking devices for gasoline. Such formal laws have been criticized as either unworkable (because there are frequent cases of legitimate purchase of these products) or confusing to implement and enforce (Kerner, 1988), but there is evidence in Esmail et al. (1992) that the laws are effective.
Feasibility Study Results
A retailer guide was provided to all retailers as well as personal visits were used to ensure that retailers were aware of the problem of youth abusing legal products in order to get high, along with training about practical actions that can be taken to limit access to these products by youth. Face-to-face meetings often involving parents and other community leaders were found critically important to engaging retailers as project partners especially when communities are small and team members were generally personally known by the retailer. Baseline and follow-up youth purchase attempts, in which youth aged 12 to 17 years attempted to purchase conspicuous amounts of harmful legal products targeted by the intervention, demonstrated a statistically significant reduction in the ability of children and youth to purchase harmful products (Courser, Collins, Holder, Johnson, & Ogilvie, 2007). A pre/post retailer telephone survey found changes self-reported actions which retailers were taking to reduce the retail availability of harmful legal products (Courser et al., 2007).
Home Environmental Strategy
Evidence suggests that parental communications about ATOD use are an important component of the prevention strategy within communities (Miller-Day, 2002). Within the home environment, youth may access harmful legal products (Brook et al., 2001; Swahn, Hammig, & Ikeda, 2002) and/or the home may provide a “safe” environment to use these products. This strategy is intended to involve parents and encourage parents to restrict access to harmful legal products, to reinforce parental norms against use, and to strengthen parental strategies for controlling use and access. Overall parental readiness to change may mirror that of the key community leaders but parents may represent a greater diversity regarding readiness to change. Parents who responded to the Parent Nights hosted in the community most likely represent those parents who are most ready to take on the change effort in their community and represent the “early adopters” of change strategies.
On the community level, parents might be encouraged to adopt more changes within their individual households by community support such as making available locking gas caps or other products that might restrict youth access to legal abusable products. The success of parental involvement in community-wide action strategies has been demonstrated with other public safety issues. For example, when communities support centers where parents can have infant and child car seat installation checked, automobile safety for children improves. Less structured community support for parental action can be found as well. For example, if groups of parents discuss their strategies for maintaining an environmentally “safe” home, the informal support from parent-to-parent regarding strategies, tips, and established norms, can create a supportive environment for parents to become more active and engaged in protecting their youth. Specific important parental actions include the following.
Parents communicate clearly with their children regarding the dangers and problems of using harmful legal substances. Related to the control over the availability of harmful legal products (Action 3) is the need to have clear family rules about using substances to attain a high, and the ability to monitor compliance with these rules (Barnes, Reifman, Farrell, & Dintcheff, 2000; Shillington et al., 2005).
Parents were encouraged to provide clear messages about their own values and beliefs regarding youth use of legal products to get high. In addition, parents were encouraged to establish clear rules and consequences regarding youth use of these substances. During the course of working with families, parents indicated that it is also important to provide rewards or reinforcement when youth adhere to the family rules regarding substance use. This focus was introduced into the family sessions.
Identify and inventory high-risk products within the home. Legal products that can be abused by youth are commonly found in the home. Inhalants such as gasoline, glue, and solvents are readily available. Over-the-counter and prescription drugs are readily available and parents need to be aware of the potential for abuse if there is to be appropriate monitoring or product substitution. To assist parents in monitoring the availability of these products, a home inventory checklist was created that families may use to assess where products might be in their homes. This inventory could then be used as a practical guide for action step 3.
Control the availability of harmful legal products in the home and encourage product substitution where feasible. Making parents aware of the variety of legal products that youth can use to get high and encouraging them to do an inventory of the products in their home are part of building “readiness for change.” Parental action is then needed to exercise control over the harmful legal products present within their own home environment. Product substitution can be encouraged as a strategy for controlling availability in the home for some products. For example, instead of purchasing markers or glues that can be sniffed for a high, non-toxic products can be purchased. Locks and secured access are other methods for controlling availability. For products that are essential to the home, such as gasoline, gas cap locks can be purchased to reduce the risk of youth inhaling the products. For over-the-counter and prescription drugs or alcohol, locked cabinets can be used.
Advocate the prevention of harmful legal product use among parents in the community. Identifying committed parents who are willing to engage in community-level action to control the use of harmful legal substances is another important step of engaging families in the environmental strategies. Prior examination of the parental role-modeling suggests that parental actions and behavior regarding ATOD use can influence how youth perceive the acceptability of the use of substances (Brody, Ge, Katz, & Arias, 2000). Parental involvement in the larger community actions has not been examined in prior studies. However, parents can provide additional support for environmental strategies and have a vested interest for doing so. For example, parental involvement in working with retailers may be a stronger motivator for retailer involvement than using community organizers alone. Also, parents can support other parents who are working to control the availability of legal products in the home and create solidarity around norms and expectations for their youth. Social availability of legal substances used to attain a high can be reduced by parents agreeing to restrict access in their own homes and ensuring that their youth cannot access these substances in their friends’ homes.
Feasibility Study Results
Two to three family-nights events were convened in each of the four communities. Both didactic materials about key concepts as well as exercises and parent discussions about their perspectives and experiences were incorporated into the parent sessions. Parents were separated from the youth so that parents could engage in discussions without youth present. Follow-up surveys with family-night participants suggest participating parents had increased awareness of this issue and did adopt strategies suggested in the training (Miller, Johnson, Keagy, & Shepherd, in review).
School Environmental Strategy
Schools use a wide range of supplies which have the potential to be inhaled and thus abused including paints, glues, correction fluid, other solvents, concentrated alcohol products (including cleaners) and many others. Some potentially abusable products can be found in typical classrooms, while others in specialized classes (e.g., shop or vocational classes, art classes, and others) as well as cafeterias, storage closets, or janitorial areas. Potentially harmful legal products at school have a wide range, from vanilla extract to Lysol to dusting sprays.
While there is little scientific literature specifically related to the restriction of abusable products within the school environment, that is evidence that substance abuse at school may be correlated with individual inhalant prevalence (see Collins et al., 2006, in review). Commonwealth of Massachusetts Department of Public Health (2006) notes that schools should (among other things): review purchases of school supplies; substitute safer products where possible; institute policies that ban materials that may be inhaled; and provide information to faculty, staff, and school nurses via in-service trainings and printed material about the dangers of inhalants. School policy and other changes in the school environment to prevent inhalant abuse (as well as, presumably, abuse of other harmful yet legal products) are consistent with a trend recently noted by Weiss (2005). A baseline student survey data from four Alaska communities showed that between 48% and 91% of students responded that it would be “sort of easy” or “very easy” to obtain four different types of products in the school setting (if they wanted to obtain them for the purpose of getting high) (Saylor, Fair, Deike-Sims, Johnson, & Ogilvie, in press).
The school environmental strategy parallels and supports the home and retail environmental strategies and is designed to promote practical actions to restrict availability of legal but potentially abusable products at school.
As with the retail environment, it is critical to identify high-risk products within the school environment as well as determining how they are stored and may be accessed, In the school environment, however (more than in the retail store environment), staff must also be aware of products that may be brought onto school grounds for the purpose of getting high.
Guidelines for the appropriate and safe use of harmful legal products within the school environment are essential. Examples of guidelines might be that student use of potentially abusable products used in art classes (such as spray adhesives or spray paints) or in general classes (e.g., correction fluid) be restricted to specific class projects or situations where their use is appropriately monitored by the teacher or other responsible school staff person.
Placing limits on availability of legal products within the school environment that youth may use to get high can occur through enforcement of safe use of products, the careful placement of products within the classroom or other school location (e.g., cafeteria, janitorial closet) to deter use to get high, and the monitoring of use of products. For example, an art teacher might work to: 1) develop guidelines appropriate to the products used in his or her classroom; 2) place the products so that student access is limited; and 3) monitor on a regularly scheduled basis what quantity of a given harmful product is in the art classroom.
Substitution of safer alternative products has been mentioned earlier in the context of retail availability. Substitution of safer alternative products is particularly important among school staff who are responsible for ordering classroom supplies for the school or the school district. For example, safer non-toxic correction fluid or odorless markers may be ordered as a matter of policy. In shop or mechanical classes (in which many potentially abusable products are typically available, including propane, gasoline, varnishes, rubber cement, wood stains, and many others), substituting products or using additives may play an role in deterring abuse of school products.
Feasibility Study Results
In-service training was used to educate school staff and consisted of an approximately 90-minute training module that focused on increasing knowledge about harmful products, changes norms, and identify specific actions that will restrict students’ access to harmful products. One lesson learned was that a routine school inventory of potentially harmful products is needed. Follow-up technical assistance by a third party agency is also needed to help reinforce messages of the in-service training. Pre- and post-surveys of staff found that one-third reported taking three or more new actions; one-fifth, one or two new actions; and one-quarter, no new actions. On average, respondents reported taking two new actions, suggesting school personnel did adopt some the strategies discussed in the in-service.
School-Based Youth Prevention Education
This component of a community prevention intervention is concerned with demand reduction involving the host, i.e., the reduction of youth desire for/use of harmful legal products (Figure 1). The primary means of intervention is school-based education concerned with information about risks and local norms, as well as life skills, for resisting social influences to inhale or ingest harmful legal products. These skills are taught using a combination of didactic techniques including demonstration, behavioral rehearsal, feedback and reinforcement, and behavioral homework assignments. Information is also imparted to reinforce non-drug-use norms and to lessen pro-drug normative expectations (Botvin et al., 2001; Griffin et al., 2003).
Think Smart Curriculum
Think Smart (Ogilvie, Coulehan, Ogilvie, & Johnson, 2006) is a modified form of the Personal Intervention Curriculum (Schinke, Tepavac, & Cole, 2000) as adapted from LST for rural populations in the Pacific Northwest. The curriculum addresses risk factors associated with youth substance abuse and builds protective factors in pre-adolescents (Hawkins, Catalano, & Arthur, 2002). The risk factors associated with substance abuse that are addressed in this curriculum include social influences (peer pressure), interpersonal factors (i.e., poor communication or social skills), and intrapersonal factors (i.e., poor decision-making skills or low self-esteem). Bicultural competence is also addressed, primarily by discussing values and beliefs that help the students make decisions. Some studies have identified biculturalism as a risk factor (Epstein, Botvin, & Diaz, 2001), and others as a protective factor (Carvajal, Photiades, Evans, & Nash, 1997; Farver, Bhadha, & Narang, 2002). Schinke, Tepavac, and Cole (2000) and Raghupathy and Peterson (2002) found that bicultural competence skills led to the reduction of substance use among American-Indian adolescents.
This curriculum involves 10 core lessons, with an introductory lesson and a celebratory lesson to complete in the fall semester. Three booster lessons are designed to be completed three months after completion of the core content. Lessons are 60 minutes in duration and can be taught once or twice a week. The inclusion of boosters extends and further reinforces the learning to increase the effects. Lessons are didactic, teaching information about the effects of drug and alcohol use, as well as interactive, affording frequent opportunities for interaction between students. Role-plays, games, and other interactions allow students to apply the new information and practice new skills
Feasibility Study Results
The teachers’ self-reports of implementation fidelity via two observers ranged from 63% to 95% implemented as designed (content and delivery). Observer reports ranged from 69% to 98%. These results provide evidence of moderate to high fidelity in the implementation of the Think Smart curriculum. Comparing pre- and post-proximal outcomes of the Think Smart curriculum, we found positive change in the cognitive skills but not behavioral skills among students (5th and 6th graders) who participated in the Think Smart curriculum. Lessons learned have led to revisions in the curriculum for an anticipated efficacy trial described below.
CONCLUSIONS AND FUTURE RESEARCH
To combat youth’s use of everyday retail products to get high, an integrated community prevention intervention is needed. This intervention must integrate the key elements of community mobilization, environmental intervention in retail shops, home, and school, as well as classroom education. This community-focused prevention intervention, unlike single-targeted prevention programs, is designed to increase community involvement, to stimulate the implementation of environmental strategies to reduce the availability of potentially abusable legal products, and to increase cognitive and behavioral skills among students. Both reduced availability and students’ increased cognitive and behavioral skills are expected to decrease the intent to and actual use of harmful legal products, which will decrease negative consequences. In some respects, the community intervention addresses both the supply and demand side of the abuse problem in complementary fashion.
The intervention described is rooted in evidenced-based substance abuse prevention interventions that have been developed and tested in a variety of community settings. Further, the intervention is based on lessons learned in the on-going that is described above. The next step is to empirically test this community prevention intervention under controlled conditions as an efficacy trial. In such a trial, the distal outcomes should include youth’s use of legal products to get high, and related problems which derive from legal product abuse. The proximal outcomes should include: a) availability of potentially harmful legal products in retail stores (based upon actual youth purchase attempts) in homes (based upon parent interviews about family actions to reduce availability) and in schools (based upon school product inventories and school staff interviews about actions taken to reduce student access); b) youth perceived availability of harmful legal products in retail stores, home, and school (based upon student self report surveys); and c) and cognitive and behavioral skills of youth to deal with the pressures to use harmful legal products.
The community prevention intervention described in this article provides, to our knowledge, the first detailed design of a prevention effort to reduce youth abuse of legal products which is based upon evidence-based strategies. The feasibility test of this design in Alaskan communities has demonstrated the practical and potential effectiveness of such a comprehensive and mutually supporting strategy set which should next be tested for efficacy using the standards described above.
Preparation of this article was supported by National Institute for Drug Abuse under grant (1 R01 DA015966), A Community Trial to Prevent Inhalant Use in Alaska (2004–2007), K. Johnson, P.I.
We wish to thank Michael Garza, Susan Squires, Chris Bayer, and Jude Vanderhoff for their assistance in preparing this article which was based on the project, A Community Trial to Prevent Inhalant Use in Alaska (2004–2007), K. Johnson, P.I.
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