Preventing Substance Abuse in Adolescents: A Review of High-Impact Strategies

Hailey Hsiung,¹ Karan Patel,² Henna Hundal,³ Basil M Baccouche,³ and Kuang-Wen Tsao⁴

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Abstract

Substance abuse has been an intractable societal concern in the US for more than half a century. The recent opioid epidemic has only accentuated this problem. Adolescents are significant long-term contributors to the crisis due to their susceptibilities to drug abuse and impressionable age. This review examines the particular vulnerabilities of the adolescent brain to drug abuse and the risk and protective factors thereof, especially in light of the Rat Park studies. In addition, the article provides an overview of the evidence-based prevention program registries and offers detailed summaries of two: Blueprints for Healthy Youth Development (Blueprints) and the Washington State Institute for Public Policy (WSIPP). By combining inputs from Blueprints and WSIPP, five programs with the highest benefit-cost ratios (BCR) were identified: Functional Family Therapy, Positive Family Support, Lifeskills Training, Positive Action, and Good Behavior Game. In light of their outstanding characteristics, these programs are poised to be widely implemented and to make a measurable difference in the fight against substance and opioid abuse.

Keywords: evidence-based, substance use prevention, blueprints, rat park, substance use disorder, opioids, youth, adolescents, substance abuse, prevention programs

Introduction and background

Substance abuse and addiction is a protracted societal problem that has long defied attempts to tame it. Since the War on Drugs was declared more than 50 years ago, the situation has not improved. In fact, it has worsened with the recent opioid crisis. According to the National Institute on Drug Abuse, the cost of substance abuse in the United States, including that of healthcare, lost productivity, addiction treatment, and criminal justice involvement, is approximately $600 billion annually [1], with prescription opioid misuse accounting for $78.5 billion [2]. Adolescents are especially vulnerable to substance abuse. In 2020, people ages 15 to 24 experienced the greatest percentage increase in deaths due to drug overdose [3]. Despite the discouraging statistics, however, there has been significant and accelerating scientific progress toward the prevention and treatment of substance use disorder (SUD). The purpose of this paper is to review the literature and highlight the progress and new ideas in SUD prevention, especially as pertaining to adolescents.

Review

The adolescent brain: susceptibility and vulnerability

Adolescence is a critical time for the development of the brain. During this period, which continues until the mid-twenties, cognitive and social skills develop, and the brain changes to prepare the teenager for the independence of adulthood [4,5]. Numerous studies have demonstrated that adolescents are especially susceptible to drug use compared to adults because of these neuroanatomical changes, including those occurring in the prefrontal cortex (PFC), striatal cortex, and limbic system. The PFC, which is the reasoning and decision-making part of the brain, grows during childhood but is pruned back during adolescence [5,6]. At the same time, the teenage striatal cortex becomes more sensitive to immediate rewards such as sugar and money, when compared to that of a child or adult [7]. Furthermore, the limbic region, which processes emotion and memory, matures earlier during adolescence, while the PFC lags behind and continues to develop until the age of 25 [8]. For these reasons, adolescents tend to make decisions based on emotion and immediate rewards instead of long-term consequences, making them more likely to experiment with drugs.

More concerningly, the developing adolescent brain is also more vulnerable to addiction and the damaging effects of substance abuse than the adult brain. In an experiment designed to model the effects of adolescent drug use, it was found that cocaine use altered the gene expression patterns and histone modification in the PFC of the rats, suggesting that cocaine exposure during adolescence has profound and long-lasting cellular and behavioral consequences even after the drug is no longer administered [9]. Human studies revealed equally troubling findings. In a recently published study that followed over 5000 people for 32 years, from ages 18 to 50, researchers found that, among individuals with severe SUD symptoms at 18, 62% still experienced two or more SUD symptoms in adulthood. In addition, they also had the highest adjusted odds of prescription drug use as adults. These findings suggest that individuals with severe SUD symptoms as adolescents do not grow out of their drug problems; they also face more severe long-term consequences than adolescents with no or low SUD symptoms [10].

Common socially and culturally tolerated substances affect the development of the brain. Alcohol, for example, can cause long-lasting neurophysiological changes, including alterations in both gray-matter and white-matter brain structures, as well as aberrations in brain activity. These structural and functional differences translate into poorer performances in neurocognitive tests of attention, working memory, spatial functioning, verbal and visual memory, and executive functioning [11]. Nicotine, another substance popular amongst teenagers, has been shown to negatively affect impulse control, attention span, memory, and executive function in adolescents. Compared to non-smokers, teenage smokers are significantly more likely to use other drugs, engage in high-risk sexual behavior, and develop psychiatric disorders. In addition, adolescents also experience greater pleasure than adults from nicotine due to their overdeveloped excitatory glutamatergic system, which facilitates dopaminergic neurotransmission, as well as underdeveloped inhibitory GABAergic system [12]. For this reason, the age of first cigarette use is a risk factor for nicotine dependence [13]. In fact, approximately 90% of adult smokers began smoking prior to turning 18 years of age [12], suggesting that adolescence is a critical developmental window related to lifelong nicotine dependence.

The adolescent brain is a dynamic and changing organ, second only to the infant brain in terms of synaptogenesis [5]. With its traits of sensation seeking and risk-taking, it is optimized for survival in the natural environment but is ill-prepared for the modern world, in which addictive substances are widely available. For one, it is prone to drug use. It is also especially vulnerable to the negative effects of drug use. These twin vulnerabilities are the reasons adolescents should be prime targets for substance use prevention.

New ideas in SUD prevention and treatment

One of the most influential new ideas in SUD research is actually more than 40 years old: In the late 1970s, Canadian researchers Bruce K. Alexander and colleagues housed rats either individually in small cages known as Skinner boxes or socially in a mixed-sex colony known as the Rat Park, which was 200 times larger than normal cages and offered a variety of compartments for play and social enrichment. The experiments showed that, while the socially isolated rats obsessively self-administered morphine until they died, the Rat Park rats mostly abstained from morphine water; they would try it, but not to the point of addiction and overdose. In fact, they showed a statistically greater preference for plain water over morphine water [14,15]. In another experiment, Alexander and colleagues forced rats to become addicted by giving them only morphine-laced solutions for over 50 days. When these rats were moved into Rat Park, they chose to drink plain water instead of the morphine solution and showed minimal signs of withdrawal and dependence [15,16]. This is a significant finding, especially in the context of the War on Drugs, which focused almost exclusively on the largely failed approach of prohibition and supply reduction [17–19]. These studies pointed to a way to actually reduce the demand for drugs. With insights gained from his Rat Park studies, Alexander proposed that SUD should be considered a manifestation of social isolation and dislocation [20].

Alexander’s landmark studies were ignored for more than 30 years. However, they have enjoyed renewed research interests in the last decade. In a recent study, researchers revisited the Rat Park experiments, but with a twist: Instead of choosing between drugs and no drugs, the rats had to choose between drugs and social interaction. In this scenario, the rats pressed the lever to enter the “social peer chamber” instead of the “drug self-administration chamber” more than 90% of the time – even for the rats that had previously been exposed to methamphetamine for three weeks and exhibited signs of addictive behavior. This finding corroborated with Alexander’s finding that addicted rats in Rat Park preferred plain water to morphine. The research also highlighted a qualitative difference in rat addiction behaviors, initially identified by Alexander, between the voluntary abstinence rats that chose social reward and the involuntary abstinence rats that had their drugs removed – with the former showing little or no signs of drug craving behavior while the latter showing an intensification of drug craving behaviors over time known as the “incubation of craving” [21]. This suggests that social reward has a protective effect on drug-addicted rats by alleviating the expected withdrawal symptoms. Further experiments pinpointed this protective effect as due to the inhibition of the activities in the central amygdala and the anterior ventral insular cortex, which are brain regions related to drug craving [21].

Studies in humans also support the link between social factors and SUDs. For example, negative experiences such as bullying, social conflict, and economic stress are found to be common triggers of drug relapse. On the other hand, positive social experiences, such as having friends and social support, can be restorative factors over relapse [22–25]. Therefore, it is not surprising that therapies that improve the adolescents’ most important social environments – their families – are found to be helpful in the treatment of SUDs. A meta-analysis by Tanner-Smith et al. found family therapy programs to be more effective than other therapy programs, such as behavioral therapy, cognitive behavioral therapy, motivation enhancement therapy, psychoeducational therapy, group counseling, and “practice as usual” (the default therapies that served as controls). Their study revealed that family therapy programs resulted in a 40% greater reduction in drug use than did other treatments [26].

Another well-supported evidence-based drug treatment method, community reinforcement approach (CRA), also takes advantage of the therapeutic benefits of positive social interactions. It focuses on helping clients to become more positively engaged with their families, friends, school, work, and community organizations and to enhance the enjoyment and frequency of non-drug-related social activities. A meta-analysis of six outcome studies shows CRA’s effect size for SUD to be large (ES=-0.58) and highly significant [26,27].

Risk and protective factors of SUD

Over the years, addiction researchers have identified many factors associated with SUD. Some are risk factors that make an individual more prone to develop the disorder while others are protective factors that make an individual less likely to do so [28,29]. In light of the importance of the social factor in SUD prevention and treatment, as revealed by the Rat Park and more recent studies, many of the risk and protective factors may be broadly categorized as factors that weaken or strengthen social ties. The remaining risk and protective factors may be categorized as factors that are either restrictive or permissive toward drug use. As shown in Table ​Table1,1, we categorized “Poor control over school drug consumption” and “Availability and cost of drugs and alcohol” as risk factors related to the category of “Permissiveness (toward drug use).” On the other hand, “Opportunity for fulfilling extracurricular activities” and “Attachment or sense of belonging to school” were considered protective factors in the “Social ties” category. We also grouped “Psychiatric disorder” and “Emotional distress” as individual risk factors related to “Social ties” since they interfere with normal social functioning.

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