Expand School-Based Prevention Programs

Introductory Paragraph

With fatal drug overdoses reaching the highest levels recorded in history, more and more schools are recognizing that students' overall health and wellbeing are of paramount importance as children are often the silent victims of the addiction disease which knows no boundaries. Schools are in a unique position of having the ability to systematically reach a large portion of youth at all stages of development from preschool to late adolescence. Because attending school is a major part of a young person’s life, schools can serve as a leading protective factor from the adverse effects of substance use, misuse, and abuse.

The school campus provides a learning environment and an opportunity to provide education on lifelong healthy skill and behavior development. Choosing curricula which reach all students aligns to a public health approach. School-based prevention programs which focus on broad-based skill building (e.g., psychosocial development, life-skills development, and social-emotional learning, and connectedness) have greater promise than substance-specific programs.

Research shows that school health programs reduce the prevalence of health risk behaviors among youth and have a positive effect on academic performance. Preventing the onset of substance use during the critical years of youth development can have positive lifelong results. Therefore, in addition to providing quality education and social learning environments, schools are taking a proactive health approach with a keen focus on substance prevention. Research has shown that young people who feel connected to their school are less likely to engage in many risk behaviors, including early sexual initiation, alcohol, tobacco, and other drug use, as well as violence and gang involvement. Students who feel connected to their school are also more likely to have better academic achievement, including higher grades and test scores, have better school attendance, and stay in school longer.

There is a vast offering of school-based prevention programs that can enhance and create a whole school approach to youth development which can serve to prevent substance use before it starts. Such a proactive upstream strategy is needed to prevent the devastating consequences of substance use.

Key Information

Behaviors established during adolescence often continue into adulthood, and young people’s experiences during this critical time have long-lasting impacts on their future health and well-being. The Center for Disease Control has established an evidence-based approach to school-based HIV and STD prevention. These evidence-based strategies benefit all students. Further, activities related to health education can be tailored to address health outcomes other than sexual behaviors, including high-risk substance use, violence, and mental health. Promoting safe and supportive environments, which includes increasing school connectedness and engaging parents, can impact all of these health outcomes. Schools, families, and communities can work together to provide more intentional messages, skills, and mental health support for adolescents so that encouraging trends can continue and troubling trends can be reversed. Most kids believe that a majority of students use substances when, in reality, only a very small percentage does. Changing social norms of a school by educating students on the reality of substance use leads to a changed perspective of drug use as deviant rather than something that "everyone is doing."

What Is a Drug Prevention Program? The most effective prevention programs require a commitment of time, priority standing (curriculum inclusion), and are recurring and consistent. Prevention is NOT as simple as just showing up once and telling individuals to “Just Say No.” As with drug treatment, a “one-size-fits-all” approach to drug prevention is not effective. Many of the most common strategies being used by well-meaning parents, schools, and communities have been shown by careful research to be ineffective. Some have even caused harm by unintentionally reinforcing pro-use attitudes, behaviors, or norms. Knowing what works in prevention, and what doesn’t, is vital to keeping young people from developing serious and life-long issues with addiction, as alcohol and other drug abuse remain the problem behaviors contributing to the most serious problems facing our communities today.

Features of the highest quality and most effective drug prevention programs are listed below:

• Contains evidence-informed and evidence-based strategy.
• Intentional focus on all substances of use, misuse, and abuse (alcohol, nicotine, marijuana, prescription drugs, illicit drugs, over-the-counter drugs/medications).
• Designed to address problems and their root causes as indicated by local data.
• Reduce risk factors and enhance protective factors.
• Appropriately timed - students receive accurate information and skill development in advance of age of onset of use.
• Delivered by teachers/prevention professionals who have achieved a high level of training in the field of substance prevention, intervention, treatment, and recovery.
• Recurring in nature with follow-up booster lessons at subsequent grade levels.
• Utilizes multiple teaching techniques to engage all students -- behavior rehearsal, interactivity, and open communication.
• Teaches skill development which includes: self-control, emotional awareness, communication, problem-solving, and advanced capacity for learning.
• Enhances school connectedness with a whole-school approach which includes healthy alternative activities.
• Provides accurate and real-life information that corrects misperceptions versus fabricated scare tactics.
• Enhances family bonding and communication.
• Reinforced at the community sector level (policies, laws, media)
• Inclusive and compassionate, taking into account that some youth will have used and/or have close friends and family members who are actively using, living in recovery, or have passed away from a substance use disorder.

The core goal of prevention programs is the development of lifelong attitudes, beliefs, and behaviors that supports healthy choices and open the door for youth to reach their fullest potential. Specifics include:

• Delaying the onset of substance use
• Decreasing overall substance use
• Reducing the loss of life due to overdose

Types of Prevention Programming. Evidence-based programs are structured for three different audiences:

• Universal curricula provide all students in the school, or within select grade levels, with the substance use information and prevention skills.
• Selective programs target an entire subgroup that has higher risk, regardless of the degree of risk of any individual within the group.
• Indicated curricula prevent the onset of additional substance use in individuals who have used a substance but who do not meet the medical criteria for addiction.

Evidence-Based Drug Prevention Program Registries. There are many strategies that have been confirmed by research to show a positive impact on youth choices and healthy behaviors. Meticulous evaluation has proven evidence-based strategies to be effective over time. Registries of evidence-based prevention programming are an invaluable resources in the selection of suitable programs that fit with the local landscape.

It is very important to note that even the best-designed programs can be ineffective if the fidelity of the implementation process or content is added to or subtracted from the scope and sequence. When researching and making a program selection, careful attention should be given to the fidelity model and the intended design of the program.

There are times when an evidence-based program may not be an option due to readiness, cost, capacity, funding, and/or training barriers. In these cases, locally developed programs are often created. When it comes to substance use prevention, extreme levels of caution must be exercised to ensure that the best intentions do not backfire and actually hinder or even cause harm to the local conditions and people the program was intended to help.

Relevant Research

Although most youth are in good health, some are at an increased risk for behaviors that can lead to poor health outcomes, such as high-risk substance use. According to national datasets, the prevalence of alcohol, tobacco, and other drug use increases rapidly from early to late adolescence, peaks during the transition to young adulthood, and declines through the remainder of adulthood. There is accumulating evidence showing that the initiation of substance use early in life contributes to higher levels of use and abuse later in life. Early-onset is also associated with a host of later negative health, social, and behavioral outcomes including physical and mental health problems, violent and aggressive behavior, and adjustment problems in the workplace and family. The majority of adults who meet the criteria for having a substance use disorder started using substances during their teen and young adult years.

Youth Risk Behavior Survey (YRBS) The Center for Disease Control’s YRBS monitors priority health risks and experiences among high school students across the country. The YRBS results help in understanding risks that contribute to the leading causes of death and disability among youth and young adults. The 2019 YRBS results serve as a baseline for years to come as we understand the impact of COVID and help adolescents recover from the effects, both mental and physical, of the COVID-19 pandemic. National, state, and local surveys are conducted every 2 years among high school students throughout the United States. More than 13,000 U.S. high school students participated in the 2019 national YRBS. The report includes national YRBS data and data from surveys conducted in 44 states, such as Pennsylvania Youth Survey (PAYS), Maryland Youth Risk Behavior Survey (YRBS/YTS), New Jersey, High School YRBS, Healthy Kids Colorado Survey (HKCS), and the Montana YRBS. The national YRBS also surveys 28 large urban school districts, 3 territories, and 2 tribal governments.

Impact of COVID-19 The Monitoring the Future survey is given annually to students in 8th, 10th, and 12th grades who self-report their substance use behaviors over various time periods, such as past 30 days, past 12 months, and lifetime. The survey also documents students’ perception of harm, disapproval of use, and perceived availability of drugs. The survey results are released the same year the data are collected. From February through June 2021, the Monitoring the Future investigators collected 32,260 surveys from students enrolled across 319 public and private schools in the United States. The percentage of adolescents reporting drug use decreased significantly in 2021 as the COVID-19 pandemic endured according to 2021 Monitoring the Future survey. These rates "held steady" in 2022. Reported 2021 declines in the use of substances among teens include:

• Alcohol: The percentage of students who reported using alcohol within the past year decreased significantly for 10th and 12th grade students and remained stable for eighth-graders.
  • 8th graders: 17.2% reported using alcohol in the past year in 2021, remaining steady compared to 20.5% in 2020 (not a statistically significant decrease)
  • 10th graders: 28.5% reported using alcohol in the past year in 2021, a statistically significant decrease from 40.7% in 2020
  • 12th graders: 46.5% reported using alcohol in the past year in 2021, a statistically significant decrease from 55.3% in 2020

• Marijuana: The percentage of students who reported using marijuana (in all forms, including smoking and vaping) within the past year decreased significantly for eighth, 10th, and 12th grade students.
  • 8th graders: 7.1% reported using marijuana in the past year in 2021, compared to 11.4% in 2020
  • 10th graders: 17.3% reported using marijuana in the past year in 2021, compared to 28.0% in 2020
  • 12th graders: 30.5% reported using marijuana in the past year in 2021, compared to 35.2% in 2020

• Vaping nicotine: Vaping continues to be the predominant method of nicotine consumption among young people, though the percentage of students who reported vaping nicotine within the past year decreased significantly for eighth, 10th, and 12th grade students.
  • Eighth graders: 12.1% reported vaping nicotine in the past year in 2021, compared to 16.6% in 2020
  • 10th graders: 19.5% reported vaping nicotine in the past year in 2021, compared to 30.7% in 2020
  • 12th graders: 26.6% reported vaping nicotine in the past year in 2021, compared to 34.5% in 2020

• Any illicit drug, other than marijuana: The percentage of students who reported using any illicit drug (other than marijuana) within the past year decreased significantly for eighth, 10th, and 12th grade students.
  • 8th graders: 4.6% reported using any illicit drug (other than marijuana) in the past year in 2021, compared to 7.7% in 2020
  • 10th graders: 5.1% reported using any illicit drug (other than marijuana) in the past year in 2021, compared to 8.6% in 2020
  • 12th graders: 7.2% reported using any illicit drug (other than marijuana) in the past year in 2021, compared to 11.4% in 2020
  • Significant declines in use were also reported across a wide range of drugs for many of the age cohorts, including for cocaine, hallucinogens, and non-medical use of amphetamines, tranquilizers, and prescription opioids.

“In addition to looking at these significant one-year declines in substance use among young people, the real benefit of the Monitoring the Future survey is our unique ability to track changes over time, and over the course of history,” said Richard A. Miech, Ph.D., team lead of the Monitoring the Future study at the University of Michigan. “We knew that this year’s data would illuminate how the COVID-19 pandemic may have impacted substance use among young people, and in the coming years, we will find out whether those impacts are long-lasting as we continue tracking the drug use patterns of these unique cohorts of adolescents.”

“We have never seen such dramatic decreases in drug use among teens in just a one-year period. These data are unprecedented and highlight one unexpected potential consequence of the COVID-19 pandemic, which caused seismic shifts in the day-to-day lives of adolescents,” said Nora Volkow, M.D., NIDA director. “Moving forward, it will be crucial to identify the pivotal elements of this past year that contributed to decreased drug use – whether related to drug availability, family involvement, differences in peer pressure, or other factors – and harness them to inform future prevention efforts.”

Cost-Benefit of Evidence-Based Prevention. Research has shown that preventing drug abuse and other problem behaviors can produce benefits for communities that outweigh the monetary costs. The analysis of the return on investment of evidence-based prevention programs is part of a series of reports prepared by researchers at the Washington State Institute for Public Policy. Together, these reports consistently show that effective prevention programs not only work but can produce dramatic savings:

• Botvin LifeSkills Training (LST) program produced a $50 benefit for every $1 invested in terms of reduced corrections costs, welfare, social services, drug and mental health treatment, and increased employment and tax revenue. LST had the highest return on investment of all substance abuse prevention curricula studied.
• The Strengthening Families Program: For Parents and Youth 10–14 (SFP 10–14) also produced net benefits in preventing adult cases of alcohol abuse. For every dollar spent, a $10 benefit was measured as a result of the SFP 10–14 program.
• Guiding Good Choices (GGC) yielded a $6 benefit.
• The Skills, Opportunity, And Recognition (SOAR) program had a benefit-to-cost ratio of $4.25 for every dollar spent.

Impactful Federal, State, and Local Policies

National Programs

In general, all prevention policies and selected programs are designed and implemented to reduce risk factors while also harnessing the buffering effects of protective factors. The specific approaches taken to drug prevention are quite varied in states across the county due to the autonomy granted to individual states and schools on the topic. However, all schools in the United States are charged with complying with National Academic Standards, Common Core Standards, and State Standards for Health Education when selecting a drug prevention program/curriculum.

Dr. Rahul Gupta, Director of the White House Office of National Drug Control Policy has stated that “the Biden-Harris Administration is committed to using data and evidence to guide our prevention efforts so it is important to identify all the factors that may have led to this decrease in substance use to better inform prevention strategies moving forward. The Administration is investing historic levels of funding for evidence-based prevention programs because delaying substance use until after adolescence significantly reduces the likelihood of developing a substance use disorder.”

SAMHSA has directed billions of dollars to states through block grants and other programs such as the State Opioid Response. SAMHSA maintains information on laws and regulations pertaining to substance abuse and mental health services, programs, and related topics. A few examples of relevant legislation and funding follow:

• Safe and Drug-Free Schools and Communities Act (SDFSCA) is Title IV of the "Improving America's Schools Act of 1994” which was a reauthorization of the Elementary and Secondary Education Act of 1965 (ESEA). Programs authorized under this legislation provide financial assistance for state and local drug and violence prevention activities in elementary and secondary schools and institutions of higher education. Activities may be carried out by state and local educational agencies and by other public and private nonprofit organizations.

• Education Department General Administrative Regulations (EDGAR) Part 86 has particular import for all institutions of higher education (IHEs) that receive federal funding. These regulations were established as part of the 1990 Drug and Alcohol Abuse Prevention Act.

• Comprehensive Addiction Recovery Act in 2016 and the SUPPORT for Patients and Communities Act in 2018 addresses opioid misuse, addiction, and overdose deaths through a variety of initiatives in prevention, treatment, harm reduction, and recovery support.

• In 2021, amid considerable increases in substance use during the COVID-19 pandemic, funding to address opioid and other substance use and addiction was included in several COVID-19-relief packages.

Training resources and information regarding best practices is available through the Department of Education. The Office of Safe and Healthy Students (formerly OSDFS) administers, coordinates, and recommends policy for improving the quality and excellence of programs and activities which are designed to:

• Provide financial assistance for drug and violence prevention activities and activities that promote the health and wellbeing of students in elementary and secondary schools, and institutions of higher education. Activities may be carried out by state and local educational agencies and by other public and private nonprofit organizations.
• Participate in the formulation and development of ED program policy and legislative proposals and in overall Administration policies related to violence and drug prevention.
• Participate in interagency committees, groups, and partnerships related to drug and violence prevention, coordinating with other federal agencies on issues related to comprehensive school health, and advising the Secretary of Education on the formulation of comprehensive school health education policy.
• Participate with other federal agencies in the development of a national research agenda for drug and violence prevention.
• Administer the Department's programs relating to character and civics education.

State Programs

Some states have prevention laws in place that date back to the 1970s. Two recent examples of statewide policies include:

• The Start Talking Maryland Act of 2017. The Code of Maryland Regulations (COMAR) 13A.04.18: Programs in Comprehensive Health Education training standard, Using a Skills-Based Approach to Substance Abuse Prevention Education.
• Colorado HB21-1276 - Prevention of Substance Use Disorders was signed into law in 2021. Section 18 has a focus on the establishment of a Prevention Collaborative.

Available Tools and Resources

SAMHSA:

• SAMHSA Evidence-Based Resource Center
• SAMHSA Focus on Prevention/Strategies and Programs to Prevent Substance Use
• "Student Assistance Guide: A Guide for School Administrators" outlines how to build effective and evidence-based substance use prevention/early-intervention/treatment programs in the school setting.

SAFE Project:

• SAFE Choices is a program within SAFE Project that focuses on fostering resiliency in youth development through collaborative and diversified approaches that reduce risk of substance addiction and mental health challenges while empowering SAFE Choices in all stages of youth development.
• See the wiki titled "Empower Parents" for more detailed information on how parents can discuss the adverse effects of substance use, misuse, and abuse with their children in an effective and compassionate manner.

Searchable online registries of evidence-based prevention programs:

• Blueprints for Healthy Youth Development at the University of Colorado, Boulder

• California Evidence-Based Clearinghouse for Child Welfare

• Coalition for Evidence-Based Policy

• Collaborative for Academic, Social and Emotional Learning Curricula

• Office of Juvenile Justice and Delinquency Prevention Model Programs Guide

• Promising Practice Network

• PTTC Network Guide to Online Registries for Substance Misuse Prevention Evidence-based Programs and Practices

• Social Programs That Work

• Results First Clearinghouse

• Washington State Health Care Authority, Division of Behavioral Health and Recovery – the Athena Forum

• What Works Clearinghouse

For more information on prevention programs and frameworks:

• CDC Framework for Thinking about Evidence

• NIDA Preventing Drug Use among Children and Adolescents

Helpful resources and guides:

• The Network for Public Health Law "Policies in Schools to Reduce Overdose and Other Drug-related Harm" Webinar explores substance abuse policy issues in schools.

• The Washington State Institute on public policy (WSIPP) has information on cost-benefit for public health and drug prevention programs.

• Washington State Health Care Authority, Division of Behavioral Health and Recovery – the Athena Forum

• The National Institute on Drug Abuse

• Suicide Prevention Resource Center: Mental Health Promotion and Suicide Prevention for LGBTQIA2S+ Youth a Resource guide for Professionals, Families and Communities

Other Relevant Data Sources:

• National Center for Drug Abuse Statistics

• National Survey on Drug Use and Health

• National Youth Tobacco Survey

Promising Practices

SPORT Prevention Plus Wellness: A single-session screening and brief intervention that integrates substance use prevention with the promotion of physical activity and healthy behaviors for youth.

Positive Prevention Plus: A comprehensive school-based sexual health education and teen pregnancy prevention curriculum.

Olweus Bullying Prevention Program: Includes school-wide, classroom, individual, and community strategies.

Media Detective: Increasing media literacy is a promising approach to school-based substance abuse intervention. Beneficial outcomes include:

• Increased media skepticism
• Increased perceived efficiency in resisting pro-drug media messages
• Greater ability to make counter-arguments to beer advertisements
• Increased belief that smoking and drinking are "wrong"
• Reduced middle school boys' intentions to use alcohol or tobacco in the future
• Reduced opioid misuse

SAFIR -- Substance Abuse Free Indian River This Drug Free Coalition in Vero Beach, Florida, has been implementing several promising programs in schools and working with community partners. “We are very proud of our initiatives: SAFIR Rx, Talk, They Hear You, No One’s House and Friday Night Done Right, but we are particularly excited about Know the Law, which is conducted by law enforcement officers (LEOs) in the classroom,” said Robin Dapp, Executive Director. “It helps bring students and officers together.” At the beginning of each school year, school resource officers provide the Know the Law classes to incoming high school freshmen. The program is designed to make our local youth and young adults aware of the laws and the consequences of breaking the law. The training covers the common offenses committed by youth on a regular basis. Civil Citation is a significant environmental strategy that has been embraced by local law enforcement. SAFIR has supported the delivery of a comprehensive prevention strategy for middle school youth. All middle schools in the community receive Botvin’s LifeSkills Training program, beginning in 6th grade through 8th grade. The curriculum is delivered by the Substance Awareness Center, and consists of a total of 30 lessons.

Boy Scouts & Girl Scouts Each of these groups participates in the DEA Red Ribbon Patch Program. This program empowers young people to create, embrace and strengthen their drug free belief. The Girl Scout Research Institute has aligned its three sets of leadership outcomes (Discover, Connect, and Take Action) to the Developmental Asset framework that is promoted by the Search Institute.