Where Is the Prevention in the President’s Opioid Report?

The following originally appeared on The Upshot (copyright 2017, The New York Times Company). It also appeared on page A15 of the print edition on November 28, 2017.

It’s a shame that President Trump’s opioid commission said little about demand-side prevention.

It’s a lot less costly (both in dollars and in lives disrupted) to stop opioid misuse before it starts than to deal with its aftermath. And many prevention programs are cost effective, according to an analysis by the Washington State Institute for Public Policy.

The report from the commission last month emphasized limiting supply much more than demand — targeting opioid sources like prescriptions and the black market. That’s important, too.

But among the report’s 56 recommendations, only two aim to prevent people from seeking out opioids for no medical purpose: an advertising campaign and a structured discussion with a health professional. Neither approach has particularly strong science behind it. We wrote about the weakness of ad campaigns this month.

The other demand-side prevention approach recommended by the commission isn’t a lock either. The approach — called screening, brief intervention and referral to treatment, or S.B.I.R.T. — begins with an assessment to identify people who may already be engaged in risky use of opioids or other substances. This could occur during a regular doctor’s visit. Those found to be using drugs in high-risk ways are given advice and feedback or referral to treatment, if warranted. This could prevent progression to worse outcomes of opioid misuse like addiction and overdose, but wouldn’t prevent misuse of opioids before it starts.

“The brief intervention part of S.B.I.R.T. has had success at changing problem drinking, but little with drug use,” said Keith Humphreys, a professor at Stanford University School of Medicine who advises governments on drug prevention and treatment policies. “Referral to treatment has been a failure across the board. Almost no one follows up.”

Though this screening-referral approach has been applied to patients of all ages, the report emphasizes its use in school-based settings. It draws examples from programs in Massachusetts for middle-to-high school students and in Ohio for college students. This leaves out useful prevention programs for younger children and older adults. It’s worth engaging these populations, too.

Though few children below middle-school age use or misuse opioids, some programs aimed at them can prevent their use at older ages, by identifying risk factors and countering them. For example, a favorable attitude toward substance use — either within the family or by children directly — increases the risk that a child will later get into trouble with addictive drugs, tobacco or alcohol. Other risk factors are family conflict, poor peer relationships or difficulty in school. Community characteristics like deterioration of physical infrastructure; high rates of mobility into and out of the area; and easy availability of opioids are also risk factors.

To counteract those risks, these programs aim to increase “protective factors,” such as meaningful involvement in school, family or community activities; recognition for achievement; coping skills for dealing with stress and emotions; and a social environment that conveys an expectation of not using drugs.

There are evidence-based programs that address risk and protective factors, even for young children. The Nurse Family Partnership sends nurses on home visits with first-time mothers. The visits include education to improve pregnancy and infant health and development, and to strengthen parenting skills. One randomized trial of the program followed children for 12 years and another for 15 years. Both studies found the program reduced a host of problematic behaviors, including those related to drugs and alcohol.

Another early elementary school-based program, the Good Behavior Game, also has some solid science behind it. The program rewards children for good behavior during classroom instruction. A randomized trial found it reduces rates of alcohol and drug use in young adulthood among males. Another test involving the Good Behavior Game showed it reduces use of cocaine and heroin.

By strengthening basic capacities of emotional management, social skills, decision-making, and social connections to parents and the community, programs like these help children and teenagers avoid drug misuse. But they also help with everything else in their lives. In this sense, we make a mistake when we think about preventing drug use as separate from addressing problems like bullying, dropouts or suicide. Providing children from a young age with certain basic skills and connections can help address all these issues.

“Prevention programs usually focus on one problem, like illicit drugs or smoking or school failure or obesity or bullying or depression,” Mr. Humphreys said. “But all those problems have common risk and protective factors, and targeting those brings benefits across the board for kids.”

Other programs for middle-to-high-school-aged students have solid evidence of effectiveness, particularly ones that engage entire communities in a shared effort. For example, the Communities That Care program builds coalitions in a community and provides tools to make decisions about the best evidence-based prevention programs.

A randomized trial across 24 small towns that followed about 4,000 children from fifth to 12th grade found encouraging results: Children in the Communities That Care program were a third less likely to take up alcohol or cigarettes in middle school, making them less likely to progress to other drugs, including opioids.

Parents are important, too, of course, and there are evidence-based drug-use prevention programs that involve them. One program — the Strengthening Families Program: For Parents and Youth 10–14 — aims to enhance parenting skills and adolescents’ ability to refuse drugs. Several studies found it reduces alcohol and drug use through young adulthood.

Finally, we should not overlook adults. Most drug experimentation occurs in young adulthood. In 2015, nearly 40 percent of adults in the United States reported using prescription opioids. Such use is most often for medical purposes, but 5 percent reported misusing them and 1 percent had use disorders.

For these people, workplace drug testing is a worthwhile approach. When the Department of Defense made drug use grounds for potential dismissal from service, positive tests fell, Mr. Humphreys told me. The rarity of drug-caused accidents in industries that test employees (like aviation) further suggests that this is a good strategy.

There are many evidence-based prevention programs that could be usefully applied to the opioid crisis. The commission’s report mentions some — including many of those described above — but it stops short of recommending any.


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