The Science of Prevention:A Webinar for HIDTA Directors on
Evidence-Based Strategies to Prevent Drug Use
August 4, 2015
Office of National Drug Control PolicyWashington, DC
The Science of PreventionOpening Remarks
Michael Botticelli Director
Office of National Drug Control Policy
National Drug Control Strategy
• The President’s science-based plan to reform drug policy:1) Prevent drug use before it ever begins
through education2) Expand access to treatment for Americans
struggling with addiction3) Reform our criminal justice system4) Support Americans in recovery
• Coordinated Federal effort on 112 action items
• Signature initiatives:– Prescription Drug Abuse– Prevention– Drugged Driving
Examples of Risk and Protective FactorsRisk Factors
Early Aggressive Behavior
Poor Social Skills
Lack of Parental Supervision
Substance Use
Drug Availability
Poverty
Domain
Individual
Individual
Family
Peer
School
Community
Protective Factors
Self-Control
Positive Relationships
Parental Monitoring & Support
Academic Competence
Anti-Drug Use Policies
Strong Neighborhood Attachment
Reduce these Elevate these
Source: Preventing Drug Use: A Research-Based Guide, NIDA, 2nd Ed, 1997
Effective Prevention Programs
Drug-Free Communities Support Program• Small amount of Federal funding combined with
local resources and volunteer support
• Mobilize community leaders to identify and respond to the drug problems unique to their communities
• Focus on community change to prevent youth drug use
Example of 2015 HIDTA & DFC Map
The Science of Prevention:A Webinar for HIDTA Directors
Thank you and welcome!
The Science of PreventionKeynote Address
Dr. Wilson ComptonDeputy Director
National Institute on Drug Abuse
9
Wilson M. Compton, M.D., M.P.E.Deputy Director
National Institute on Drug Abuse
The Science of Drug Abuse Prevention
Healthy Heart Diseased Heart
Decreased Heart Metabolism in Heart Disease Patient
ADDICTION IS A DISEASE OF THE BRAINas other diseases it affects the tissue function
Control Cocaine Abuser
Decreased Brain Metabolism in Drug Abuse Patient
Sources: From the laboratories of Drs. N. Volkow and H. Schelbert
High
Low
Many Factors Lead toDrug Abuse and Addiction
Addiction
DRUG
Brain Mechanisms
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Addiction Tends to Start at a Young Age:
When the brain is less developed
0.000
0.002
0.004
0.006
0.008
0.010
5 10 15 20 25 30 35 40 45 50 55 60
Haz
ard
Rat
e
Age
DSM-IV Abuse
DSM-IVDependence
Age of Onset of Drug Abuse and Dependence Source: Compton, et al. Archives of General Psychiatry 2007. NESARC Study.
Children in an orphanage who experienced deprivation had fewer connections between
the parts of brain that regulate emotions and the parts that control thinking
Social Neglect During Early Childhood Decreases Brain Connectivity
Govindan et al., Cereb Cortex 2009
0
2
4
6
8
10
0 1 2 3 4 5
Odd
s ra
tio
ACE Score
Ever Addicted
Adverse Childhood Experiences (ACE) Affect Illicit Drug Use
SR Dube, et al. PEDIATRICS 111: 564-572, 2003
1.0
(n = 8603)
Preventive Interventions Can Have Long-term Effects on Drug
Use and Abuse
• Prevention Approaches Should Enhance Protective Factors & Reduce Risk Factors
Reduce these Elevate these
Risk Factors in Action: Childhood self-control predicts health, wealth, and public safety (Dunedin Study; 1000+ children)
Health Problems Wealth Criminal behavior
Moffitt et al., PNAS 2011
Early childhood interventions that enhance self-control are likely to bring a greater return on investment than harm reduction programs targeting adolescents alone.
Children with low self-control had poorer health, lower incomes, more single-parenthood, and more crime convictions and drug use than those with high self-control
Low Self-control High Low Self-control High Low Self-control High
How Prevention Interventions Work
MODIFIABLE RISK and PROTECTIVE
FACTORSBackground Factors
AgeGenderRace/ethnicityPoverty levelGenotype
Early aggressionSocial skills deficitsAcademic problem
Misperceived drug use normsAssociation with deviant peers
Neighborhood availabilityMedia glamorization
Parental monitoring and support
INTERVENTIONS
Parent skills trainingSocial skills training
Self-regulationImpulse control
TutoringNorms training
Refusal skillsCommunity policing
Health literacy
We know that childhood prevention interventions can reduce the use of drugs during adolescence, but do they help in other areas, like education?
Two reasons to consider drug abuse/addiction prevention when examining ways to enhance educational outcomes:1. Drugs can impair academic achievement2. The very same targets that are useful for
drug abuse prevention are useful for improving academic functioning
Drug Prevention Interventions and Positive Educational Outcomes: Examples across development
• Infancy Interventions: Nurse Family Partnership Family Check Up 2-3 years old
• Early grade school interventions: Good Behavior Game Seattle Social Development Program
• Elementary/Middle School: Family Check Up Strengthening Families Program 10-14 Positive Action Intervention
Family Check Up (FCU) at Ages 2 & 3 Leads to Higher Academic Achievement at Ages 5 & 7.5
Brennan et al. 2013 Prevention Science
FCU
Academic Skills Age 5Positive
Behavior Support
Age 3Academic Skills Age
7.5
.17*
.20**
.19**
.53**
* p < .05. ** p < .01
Indirect effect of FCU assignment on child academic achievement through changes in Parent’s Positive Behavior Support.
Drug Prevention Interventions and Positive Educational Outcomes: Examples across development
• Infancy Interventions: Nurse Home Visitation Family Check Up 2-3 years old
• Early grade school interventions: Good Behavior Game Seattle Social Development Program
• Elementary/Middle School: Family Check Up Strengthening Families Program 10-14 Positive Action Intervention
37
38
39
40
41
42
43
44
45
Grade 12 Reading (KTEA) Grade 12 Math (KTEA)
GBG-2 - BoysControl - BoysGBG-2 - OverallControl - Overall
p < 0.01*
Good Behavior Game-2 (GBG-2) Increases Grade 12 Reading/Math Achievement
Bradshaw et al. 2009 Journal of Educational Psychology
GBG-2: Classroom Centered Intervention combining GBG and enhanced school curriculumKTEA: Kaufman Test of Educational Achievement* Significance of mixed-model regression analysis
p < 0.02*
p = 0.005*
p = 0.001*
Drug Prevention Interventions and Positive Educational Outcomes: Examples across development
• Infancy Interventions: Nurse Home Visitation Family Check Up 2-3 years old
• Early grade school interventions: Good Behavior Game Seattle Social Development Program
• Elementary/Middle School: Family Check Up Strengthening Families Program 10-14 Positive Action Intervention
Spoth, R., Randall, G. K., & Shin, C. (2008) School Psychology Quarterly, 23(1), 70-89
Strengthening Families Program 10-14 during Grade 6 Leads to Greater Academic Success in Grade 12
Prevention Interventions Can Have Unintended Positive Effects on Other
Health Risking Behaviors, including Emerging Drugs of Abuse
Prescription Opioid Drug Abuse
Near Tripling of Opioid Prescriptions Dispensed by U.S. Retail Pharmacies, Years 1991-2013
IMS Health, Vector One®: National, Years 1991-2011, Data Extracted 2012IMS Health, National Prescription Audit, Years 2012-2013, Data Extracted 2014
2013 OD Deaths: • 43,982 Any Drug
– (41,3(22,810 in 2011)
• 16,235 Rx opioid– (16,917 in 2011)
• 8,257 Heroin – (4,397 in 2011)bb
Marked Increases in Opioid-related Deaths (parallel to opioid sales and Rx opioid treatment admits), USA
Sources: National Vital Statistics System, DEA Automation of Reports and Consolidated Orders System, SAMHSA TEDS
0
1
2
3
4
5
6
7
8
Rate
Year
Opioid Sales (Kg/10,000)
Opioid-Related Deaths/100,000
Opioid Treatment Admissions /10,000
It’s Not Just Opioids: Increasing Overlap of Benzodiazepines and Opioids
0
5
10
15
20
25
30
35
Deaths Involving Benzodiazepines ED Visits Involving Benzodiazepines
2004 2005 2006 2007 2008 2009 2010 2011
Perc
ent
Source: CM Jones, JK Mcaninch, American Journal of Preventive Medicine, 2015
Opioid-Related OD Deaths Opioid-Related ED Visits
Universal Drug Abuse PreventionReduces Prescription Drug Misuse
Note: General=Misuse of opioids, depressants or stimulants. Source: R Spoth et al. American Journal of Public Health 2013
In this study, for 100 young adults in general population starting Rx abuse, only 35 young adults from an intervention community started.
1.2**0.6***
5.4**4.7**
9.38.7
15.5
13.5
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2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
14.0%
16.0%
18.0%
Age 21 General Age 21 Narcotics Age 25 General Age 25 Narcotics
Family Program
Control
**p<.01; ***p<.001; RRRs = 65-93%**p<.01; ***p<.001; Relative Reduction Rates (RRRs)= 65-93%
Overall, three studies now suggest the impact of universal prevention on prescription drug abuse.
Age 25 OpioidsAge 21 GeneralAge 21 OpioidsAge 21 General
Family Program (in the 6th grade)
Comparison (no family program)
Prevention: Overdose Intervention
• Naloxone Distribution for opioidoverdose victims. The potential for direct intervention to save lives.
• Naloxone Nasal Spray DevelopmentNeedle-free, unit-dose, ready-to-use opioid overdose antidote.
Note the April 3, 2014 FDA approval of the naloxone auto-injector (called “Evzio”)
NIDA STTR Grantee – AntiOp, Inc., Daniel Wermeling, CEO
NIDA clinical study with LightlakeTherapeutics, Inc.
Prescription Drug Abuse: What can be done?
• Primary Prevention• Less abusable analgesics• Overdose Intervention• Better Access to Effective
Addiction Treatments(especially medications for opioid addiction)
• Public and Clinician Education
Fewer High School Seniors Reporting Use of Narcotics Other than Heroin,
in USA
0
5
10
15
20
12th grade
SOURCE: University of Michigan, 2014 Monitoring the Future Study
Denotes significant difference between 2013 and 2014
%
2013 OD Deaths:• 16,235 Rx opioid
– (16,917 in– )
• 8,257 Heroin – (4,397 in 2011)bb
Recent Slight Reductions in Rx Opioid-Related Deaths but Marked Increases in Heroin
Sources: National Vital Statistics System, CDC
– (16,007 in 2012 and 16,917 in 2011)
– (5,927 in 2012 and 4,397 in 2011)
Another Key Emergent Drug Issue in the USA:
The Shifting Marijuana Legal Environment: Linking Epidemiology and Neuroscience
1 to 2 Days23%
3 to 5 Days17%
6 to 19 Days19%
20 or More Days41%
Among Current Marijuana Users, Two In Five Are Daily or Almost Daily Users
Source: SAMHSA, 2013 National Survey on Drug Use and Health (September 2014).
19.8 Million Past Month Users of Marijuana in 2013
Number of Days Used Marijuana in the Past Month
Increasing Potency of Marijuana (% Δ-9 THC)
SOURCE: University of Mississippi Marijuana Project
%
0
2
4
6
8
10
12
14
16
∆-9 THC
0
20
40
60
80
100
95 96 97 98 99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14
8th Grade 10th Grade 12th Grade
SOURCE: University of Michigan, 2014 Monitoring the Future Study
Denotes significant difference between 2013 and 2014.
Perceived Riskiness of Smoking Marijuana has Declined
%
Perceiving Great Risk of Smoking Marijuana Occasionally
0
20
40
60
80
100
75 77 79 81 83 85 87 89 91 93 95 97 99 01 03 05 07 09 11 13
Past Year Use
Perceived Risk is Correlated with Use of Marijuana
SOURCE: University of Michigan, 2014 Monitoring the Future Study
Denotes significant difference between 2013 and 2014.
%
12th Graders’ Use vs. Perceived Risk of Occasional MJ Use
0
10
20
30
40
50
60
70
80
75 77 79 81 83 85 87 89 91 93 95 97 99 01 03 05 07 09 11 13
Percentage of U.S. 12th Grade Students Reporting Past Month Use of Alcohol,
Cigarettes
SOURCE: University of Michigan, 2014 Monitoring the Future Study.
CigarettesAlcohol
Marijuana
and Marijuana
Status of Marijuana Laws in the USA
Cerda M et al. Drug and Alcohol Dependence 2012; 120: 22 – 27.NESARC: National Epidemiologic Survey on Alcohol and Related Conditions
1.811.92
1.03
0
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1
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2
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Past Year MJAbuse/Dependence
Past Year MJ Use Past Year MJAbuse/Dependence
Among Current Users
Map of States that Legalized Medical Marijuana by 2004
passed laws legalizingmedical MJ
Odd
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tioStates that Legalized Marijuana Use For Medical Purposes Have Significantly Higher Rates Of
Marijuana Use and of Marijuana Abuse and Dependence
Source of Marijuana* among 12th Graders in 2012 and 2013, by State Policy
0
20
40
60
80
100Medical Marijuana States Non-Medical Marijuana States
**
**
*Categories not mutually exclusive ** Statistically significant difference SOURCE: University of Michigan, 2013 Monitoring the Future Study
%
Methods of Using Marijuana Among12th Grade Past Year Users, 2014
0.0
20.0
40.0
60.0
80.0
100.0
Smoking In Food In Drink Other
Non-MMJ States MMJ States
SOURCE: University of Michigan, 2014 Monitoring the Future Study
0
5
10
15
20
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Percent Who Reported
12th Graders Who Drove After Smoking Marijuana or Drinking Alcohol, 2001-2014
Source: University of Michigan, 2014 Monitoring the Future study, Unpublished special tabulations (December 2014).
During the LAST TWO WEEKS, have you driven a car, truck, or motorcycle after …
… drinking alcohol
… smoking marijuana
Since 2009, more high school seniors reported driving after smoking marijuana than driving after drinking alcohol.
Non-usersused 1 Dx
used 2 Dx
used 3 Dx
-8
-6
-4
-2
0
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Aver
age
Poin
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ce in
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Persistent Marijuana Users Show A Significant IQ Drop between Childhood and Midlife
Source: Meier MH et al., PNAS Early Edition 2012
Followed 1,037 individuals from birth to age 38. Tested marijuana use at 18, 21, 26, 32 and 38. Tested for IQ at ages 13 and 38
Silins, et al., Lancet Psychiatry 2014;1:286-293
HS Complete
Never
< Monthly
Monthly +
Weekly +
Daily
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1.2
HS Complete
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10
15
20
CannabisDepend
0
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10
Other IllicitDrug
012345678
SuicideAttempt
More Teenage Use of Cannabis Associated with Worse Outcomes in 20’s (3 Australia/New Zealand Studies)
Odds Ratio
Odds Ratio
Odds Ratio
Odds Ratio
Adolescent Brain Cognitive DevelopmentNational Longitudinal Study
NIDA, NIAAA, NCI, NICHD, NIMHD, ORWH, NIMH, NINDS, OBSSR
Ten year longitudinal study of 10,000 children from age 10 to 20 years to assess effects of drugs on
individual brain development trajectories
Health Care Reforms
• Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (aka Parity)
• Patient Protection and Affordable Care Act of 2010 (aka ACA)
Summary• Neur0science reminds us of the
importance of development and provides a background for prevention intervention development
• Current and emerging drug abuse issues require our creative and vigorous responses
• Health care reforms may provide new ways to support prevention
www.drugabuse.gov
Q & A
• Dr. Compton will now field questions.• To alert the operator that you have a
question, please press *1 on your phone; each question will be answered in the order in which it was received.
• Please state your name and organization before each question.
• Questions?
The Science of Prevention:Closing Remarks
Michael GottliebNational HIDTA Director
Office of National Drug Control Policy
Evidence-Based Prevention Resources
Preventing Drug Use Among Children and Adolescents National Institute on Drug Abuse - “The Red Book”http://www.drugabuse.gov/sites/default/files/redbook_0.pdf
Drug Prevention 4 TeensDrug Enforcement Agency http://www.dea.gov/pr/multimedia-library/publications/prevention4teens.pdf
Links to Resources• DFCs and HIDTAs
– List of all 2015 DFCs• https://www.whitehouse.gov/ondcp/Drug-Free-Communities-Support-Program
– Map of all 2015 DFCs within each HIDTA• https://www.whitehouse.gov/sites/default/files/ondcp/grants-content/2015-dfc-hidta-program-
maps.pdf • Prevention Programs:
– “The Red Book”• https://www.drugabuse.gov/sites/default/files/preventingdruguse_2.pdf
– National Drug Facts Week• http://teens.drugabuse.gov/national-drug-facts-week/order-free-materials
– Marijuana Infographic • http://www.drugabuse.gov/related-topics/trends-statistics/infographics/marijuana-use-educational-
outcomes – Monitoring the Future Infographic
• http://www.drugabuse.gov/related-topics/trends-statistics/infographics/monitoring-future-2014-survey-results
• DEA– Drug Prevention for Teens Guidebook
• http://www.dea.gov/pr/multimedia-library/publications/prevention4teens.pdf • SAMHSA
– Alcohol Abuse Infographic• https://www.stopalcoholabuse.gov/resources/infographics/share.aspx?info=6
The Science of Prevention:A Webinar for HIDTA Directors
Thank you! Questions or Comments?
Jamila Robinson([email protected])
Jayme Delano([email protected])
For More Information WHITEHOUSE.GOV/ONDCP