Creating Sustainable Homes for Prevention Services
The addiction and overdose crisis in the U.S. continues unabated, with more than 46 million people having a substance use disorder (SUD) in 2021 and more than 100,000 people dying from drug overdose annually. And the crisis is increasingly hitting adolescents. Fentanyl, the main driver of overdose deaths, is now contaminating other illicit drugs including methamphetamine, cocaine, and counterfeit prescription pills, which may be taken by people, including young people, who have no prior exposure to opioids. Adolescent overdose deaths more than doubled from 2019 to 2021 (and deaths from fentanyl nearly tripled) after having held steady at relatively low levels for years.
The urgency of this public health crisis and the escalating danger of the illicit drug supply point to a need for a greatly expanded focus on prevention. Thanks to decades of research, we understand the environmental factors in childhood and adolescence that raise the risk for later substance use as well as the modifiable factors that can help protect against that risk and promote resilience. Effective interventions built on this knowledge range from nurse home visitation of disadvantaged first-time parents and pregnant women to various kinds of family- and school-based programs to build emotional regulation and self-control skills in preadolescents, teens, and young adults.
Many of these interventions have proven very effective in randomized trials—reducing later drug use, even in some cases by the children of the children who received the intervention. In fact, prevention interventions in childhood address risk factors for various psychiatric problems, not just SUD. Some interventions have been shown capable of mitigating the impacts of adverse social environments like poverty on brain development. Moreover, studies have shown that some evidence-supported prevention programs are extraordinarily cost-effective, an outstanding investment for communities over the long term.
The problem is, prevention interventions don’t get used enough. Important reasons include lack of will, as well as fiscal shortsightedness, since the benefits from prevention interventions are delayed from the time of implementation. But another major impediment is a lack of dedicated infrastructure and workforce for prevention. For example, school systems that wish to implement prevention programs turn to teachers who likely have not had any prior training in substance use prevention, and already have numerous competing needs. This is further exacerbated by other educational curriculum requirements taking precedence in time allocation over prevention.
And unlike substance use treatment, which may be covered by private insurance or Medicaid, there is little in the way of dedicated funding for prevention. A prevention program may need to be paid for by cobbling together funds redirected from other priorities. It severely limits the reach of potentially effective interventions and means they are unlikely to be sustained over time if they are ever taken up in the first place.
Policy changes that would place increased priority on preventing substance use and its consequences and increase public funding for it could help increase the reach of prevention and help mitigate drug crises like the one our country is currently experiencing. But as my NIDA colleagues Drs. Amy Goldstein, Barbara Oudekerk, and Carlos Blanco highlight this month in Psychiatric Services, prevention researchers can also do more to ensure that interventions they design can find a home in the various systems that could implement or pay for them. That means developing and testing interventions in the settings where they are intended to be delivered and designing prevention programs that meet criteria that would qualify them for funding under the Patient Protection and Affordable Care Act (ACA), child welfare, or federal prevention dollars administered by the Substance Abuse and Mental Health Services Administration.
For instance, the ACA requires that preventive services be completely covered by insurance as long as they meet certain standards of evidence set by the U.S. Preventive Services Task Force (USPSTF), but those standards are currently only met by a small handful of prevention interventions. The USPSTF identifies gap areas in the evidence, so NIDA’s prevention research is now funding research that could generate the evidence needed to redress those gaps.
Greater collaboration between prevention researchers and those in a position to fund prevention programs could facilitate developing interventions that have greater promise of being paid for and sustained and that are more responsive to community needs. It could also spur innovation and even the development of new interventions in less traditional settings like justice systems and new strategies that take advantages of virtual tools and wireless devices.
As a society, we must do much more to foster mental health and resilience in young people as well as screen patients at all ages for potential or emerging drug problems before addiction becomes their reality, and before drug experimentation escalates, creating havoc in a person’s life or even claiming it. Prevention, if properly implemented in universal and tailored settings, could play a much larger role in reducing the numbers of Americans with drug addiction and stemming the tide of overdoses. For that to happen, the science of prevention should tackle strategies that address the challenges of paying for and delivering prevention services in a world with competing public health priorities.