1. Connecticut Best Practices
Technical Assistance and
Building Prevention Capacity to Address Prescription Drugs, Tobacco, Marijuana, and Heroin
Wethersfield, CT
Nov 29, 2010
Jo Romano, CAPT NE RT Associate
Matt Myers, CAPT NE RT Associate

2. Objectives for the Day
Increase knowledge and deepen understanding about the impact and consequences of Prescription Drug Misuse, Tobacco, Marijuana, and Heroin
Identify Risk Factors and Evidence Based Strategies for the prevention of Prescription Drug Misuse, Tobacco, Marijuana and Heroin.

3. Objectives for the Day (cont’d.)
Determine shared risk factors and strategies across problem areas including underage drinking, Prescription Drug Misuse, Tobacco, Marijuana and Heroin
Examine sample community logic models for Prescription Drug Misuse, Tobacco, Marijuana and Heroin to provide effective TA to local communities
Identify challenges and solutions for TA

4. Overview of Prescription Drug Misuse, Tobacco, Marijuana and Heroin
Share what we know about:
Prescription drug use and misuse
Tobacco
Marijuana
Heroin
Cultural considerations
Availability
Onset usually under 18
Low perception of harm

5. Prescription Drug Consequences
Opioids, including OxyContin and Vicodin, depress the respiratory system and may be fatal if taken in large doses.
Prolonged use of central nervous system depressants like Valium and Ambien can lead to serious withdrawal symptoms, including seizures1.

6. Prescription Drug Health Consequences
High doses of stimulants like Adderall and Dexedrine can cause irregular heartbeat, high body temperature, and cardiovascular failure1.
Excessive amounts of dextromethorphan, the active ingredient in over-the-counter cough medicine, can lead to vomiting, increased heart rate, high blood pressure, and impaired coordination1.

7. Prescription Drugs Risk Factors and Strategies
Sample Strategy
Project Northland
Coalitions / Marketing
Lock Medicine Cabinet
Take Back Program
Social Access/Availability
Community Norms
Prior Marijuana Use
Early Initiation
Reconnecting Youth
Parent Monitoring
Parental Internet Controls

8. Prescription Drug Risk Factors and Strategies (cont’d.)
Sample Strategy
Parent Approval
Parent/Sibling Use
Lack of Awareness
Perception of Harm
Transitions
Strengthening Families
Information Dissemination
Community Mobilization
Skill Enhancement Training
School Climate Change

9. Community- Specific Risk Factors
Logic Model
Short-Term Outcomes
Community- Specific Risk Factors
Strategies
Resources and Inputs
Long-Term Outcomes

10. Sample Community Logic Model Problem: Prescription Drugs
Community- Specific Risk Factors
Strategies
Resources and Inputs
Short Term Outcomes
Increased awareness of risk of improper storage
Increased use of safer storage and/or disposal practices
Increased demand for take-back programs
Increased perception of harm or social disapproval
Collect and analyze data on the intervention
Recruit local DEA or police department to staff take-back event.
Access Ease of Availability
Drug Dispersal Take-Back Program
Collect and analyze data on the intervention
Develop a marketing plan
Partner with media
Secure earned and paid media
Community Norms
Perceived Risk
Social Marketing Lock Up Your Medicine Cabinet
Long-Term Outcomes
Reduction in Use
Delayed Onset
Reduction in Availability

11. Prescription Drug Use Some Considerations for TA Providers
What drug(s)?
Pain relievers, stimulants, psychotherapeutics
Non medical use or misuse (with prescription)
Different risk factors and strategies
Poly-substance abusers
Communities may not have resources to work with prescription monitoring programs
Sources for young people are mostly social
The most commonly used prescription drugs fall into three classes:
Opioids. These include Oxycodone, (Oxycontin), hydrocodone (Vicodin) and meperidine (Demerol).
Central Nervous System (CNS) Depressants include pentobarbital sodium (Nembutal), diazepam (Valium) and Alprazolam (Xanax).
Stimulants to include methylphenidate (Ritalin) and amphetamine/dextroamphetamine (Adderall).

12. Prescription Drug Use Some Considerations for TA Providers
What are challenges and pitfalls communities may face when planning and implementing for Prescription Drug Misuse Prevention?
What resources can you provide and/or will you need to provide effective TA?

13. Tobacco: Health Consequences
Heart disease is the leading cause of death in Connecticut. Smoking is the leading cause of heart disease3.
Women who reported smoking during pregnancy were 1.5 times more likely to experience premature labor.
Connecticut reports spending over $1.6 billion on health care expenditures attributable to tobacco use each year.
The consequences of secondhand smoke include increased risk of respiratory illness and asthma6.
References
1. State Estimates of Substance Use and Mental Health from the National Surveys on Drug Use and Health.
2. Connecticut School Health Survey (2009). Graphs of Question Results,
3. Moore, T.H.M., Zammit, S., Lingford-Huges, A., Barnes, T.R.E., Jones, P.B., Burke, M., & Lewis, G. (2007). Cannabis use and risk of psychotic or affective mental health outcomes: A systematic review. Lancet, 370, p
4. Hall, W., & Degenhardt, L. (2009). Adverse health effects of non-medical cannabis use. Lancet, 374,
5. Zvolensky, M.J., Johnson, K.A., Cougle, J.R., & Bonn-Miller, M.O. (2010). Marijuana use and panic psychopathology among a representative sample of adults. Experimental and Clinical Pharmacology, 18(2),
6. Kalant, H. (2004). Adverse effects of cannabis on health: an update of the literature since Progress in Neuro-Psychopharmacology & Biological Psychiatry, 28,
7. Office of National Drug Control Policy (2008, January). State of Connecticut, Profile of Drug Indicators.
8. University of Virginia Library, Geospacial and Statistical Data Center. Uniform Crime Reports from http: //fisher. lib. virginia. edu/collections/stats/crime/index. html
9. Jacobus, J., Bava, S., Cohen-Zion, M., Mahomood, O., & Tapert, S.F. (2009). Functional consequences of marijuana use in adolescents. Pharmacology, Biochemistry, and Behavior, 92, p

14. Tobacco: Mental Health Consequences
45% to 88% of individuals with schizophrenia smoke cigarettes and 40% to 60% of individuals with clinically significant depression use cigarettes. These rates are substantially higher than those of the general population7.
ADHD is associated with higher rates of smoking and an earlier onset of smoking7.
References
1. State Estimates of Substance Use and Mental Health from the National Surveys on Drug Use and Health.
2. Connecticut School Health Survey (2009). Graphs of Question Results,
3. Moore, T.H.M., Zammit, S., Lingford-Huges, A., Barnes, T.R.E., Jones, P.B., Burke, M., & Lewis, G. (2007). Cannabis use and risk of psychotic or affective mental health outcomes: A systematic review. Lancet, 370, p
4. Hall, W., & Degenhardt, L. (2009). Adverse health effects of non-medical cannabis use. Lancet, 374,
5. Zvolensky, M.J., Johnson, K.A., Cougle, J.R., & Bonn-Miller, M.O. (2010). Marijuana use and panic psychopathology among a representative sample of adults. Experimental and Clinical Pharmacology, 18(2),
6. Kalant, H. (2004). Adverse effects of cannabis on health: an update of the literature since Progress in Neuro-Psychopharmacology & Biological Psychiatry, 28,
7. Office of National Drug Control Policy (2008, January). State of Connecticut, Profile of Drug Indicators.
8. University of Virginia Library, Geospacial and Statistical Data Center. Uniform Crime Reports from http: //fisher. lib. virginia. edu/collections/stats/crime/index. html
9. Jacobus, J., Bava, S., Cohen-Zion, M., Mahomood, O., & Tapert, S.F. (2009). Functional consequences of marijuana use in adolescents. Pharmacology, Biochemistry, and Behavior, 92, p

15. Tobacco Risk Factors and Strategies
Sample Strategy
Environmental Strategies*
Access and Availability
Mentoring / “Across Ages”
Onset of Use
Community Norms
Coalition Development
Cessation Interventions/NOT
Prior Use/Mixed Drugs
Parent/Sibling Use
SMART Leaders/Life Skills

16. Tobacco Risk Factors and Strategies (cont’d.)
Sample Strategy
Perception of Harm
Information Dissemination
Workforce
Prevention Policies

17. Sample Community Logic Model Problem: Tobacco
Community- Specific Risk Factors
Strategies
Resources and Inputs
Short-Term Outcomes
Decrease in Compliance Failure Rates
Increase in Accurate Perception of Smoker Prevalence
Increase in Intentions Not to Smoke
Compliance Checks
Collect and analyze data on the intervention
Recruit staff and/or train youth to conduct compliance checks
Develop and distribute vendor education packets
Easy Access to Tobacco
Vendor Education
Normative Beliefs
Prevalence estimates;
Motivation to comply with other
smokers; Beliefs
Collect and analyze data on the intervention
Identify staff to design and implement intervention
Normative Education
Curriculum infusion
Long-Term Outcomes
Reduction in Lifetime Tobacco Use

18. Tobacco Use Some Considerations for TA Providers
There are possibilities for efficient of use youth across tobacco and alcohol
Youth can be effective in working on policy initiatives
Counter-advertising may be an efficient, low-cost strategy
Environmental scanning is a useful assessment method coalitions can employ to gather visible information on local conditions surrounding tobacco

19. Tobacco Use Some Considerations for TA Providers
What are challenges and pitfalls communities may face when planning and implementing for Tobacco Prevention?
What resources can you provide and/or will you need to provide effective TA?

20. Marijuana Consequences
Of those individuals who initiate use during adolescence, one in six will go on to become marijuana dependent4,6.
Heavy adolescent users have shown deficits in learning, attention, and memory even after one month of abstinence9.
References
1. State Estimates of Substance Use and Mental Health from the National Surveys on Drug Use and Health.
2. Connecticut School Health Survey (2009). Graphs of Question Results,
3. Moore, T.H.M., Zammit, S., Lingford-Huges, A., Barnes, T.R.E., Jones, P.B., Burke, M., & Lewis, G. (2007). Cannabis use and risk of psychotic or affective mental health outcomes: A systematic review. Lancet, 370, p
4. Hall, W., & Degenhardt, L. (2009). Adverse health effects of non-medical cannabis use. Lancet, 374,
5. Zvolensky, M.J., Johnson, K.A., Cougle, J.R., & Bonn-Miller, M.O. (2010). Marijuana use and panic psychopathology among a representative sample of adults. Experimental and Clinical Pharmacology, 18(2),
6. Kalant, H. (2004). Adverse effects of cannabis on health: an update of the literature since Progress in Neuro-Psychopharmacology & Biological Psychiatry, 28,
7. Office of National Drug Control Policy (2008, January). State of Connecticut, Profile of Drug Indicators.
8. University of Virginia Library, Geospacial and Statistical Data Center. Uniform Crime Reports from http: //fisher. lib. virginia. edu/collections/stats/crime/index. html
9. Jacobus, J., Bava, S., Cohen-Zion, M., Mahomood, O., & Tapert, S.F. (2009). Functional consequences of marijuana use in adolescents. Pharmacology, Biochemistry, and Behavior, 92, p

21. Marijuana: Mental Health Consequences
Marijuana users may have an increased risk of schizophrenia. In fact, researchers have estimated that 14% of schizophrenia diagnoses could be prevented if marijuana use was similarly prevented3,4.
Heavy marijuana use has also been linked to depression, suicide, and panic disorder3,5.
References
1. State Estimates of Substance Use and Mental Health from the National Surveys on Drug Use and Health.
2. Connecticut School Health Survey (2009). Graphs of Question Results,
3. Moore, T.H.M., Zammit, S., Lingford-Huges, A., Barnes, T.R.E., Jones, P.B., Burke, M., & Lewis, G. (2007). Cannabis use and risk of psychotic or affective mental health outcomes: A systematic review. Lancet, 370, p
4. Hall, W., & Degenhardt, L. (2009). Adverse health effects of non-medical cannabis use. Lancet, 374,
5. Zvolensky, M.J., Johnson, K.A., Cougle, J.R., & Bonn-Miller, M.O. (2010). Marijuana use and panic psychopathology among a representative sample of adults. Experimental and Clinical Pharmacology, 18(2),
6. Kalant, H. (2004). Adverse effects of cannabis on health: an update of the literature since Progress in Neuro-Psychopharmacology & Biological Psychiatry, 28,
7. Office of National Drug Control Policy (2008, January). State of Connecticut, Profile of Drug Indicators.
8. University of Virginia Library, Geospacial and Statistical Data Center. Uniform Crime Reports from http: //fisher. lib. virginia. edu/collections/stats/crime/index. html
9. Jacobus, J., Bava, S., Cohen-Zion, M., Mahomood, O., & Tapert, S.F. (2009). Functional consequences of marijuana use in adolescents. Pharmacology, Biochemistry, and Behavior, 92, p

22. Marijuana Risk Factors and Strategies
Community Mobilization
Project Northland
Environmental Strategies
Keepin’ It R.E.A.L.
Sample Strategy
Access/Availability
Community Norms
Early Age of Onset
Peer Approval

23. Marijuana Risk Factors and Strategies (cont’d.)
Social Refusal Skills
Guiding Good Choices
Drug Free School Zone
Social Norms Campaign
Sample Strategy
Prior Use/Mixed Use
Peer Use
School Performance
Perception of Harm

24. Sample Community Logic Model Problem: Marijuana
Community- Specific Risk Factors
Strategies
Resources and Inputs
Short-Term Outcomes
Increase in School Bonding
Improved Academic Achievement
Reduction in Problem Behavior
Academic Skills Enhancement
Collect and analyze data on the intervention
Purchase curriculum,
train teachers, provide
booster sessions
Academic Failure
Interactive Curriculum
Collect and analyze data on the intervention (e.g., Raising Healthy Children)
Provide teacher/ staff development workshops
Provide booster session
Lack of Commitment
Low Bonding to School
Enhanced Socialization
Social Support
Long-Term Outcomes
Reduction in Lifetime Marijuana Use
Reduction in Delinquency

25. Marijuana Use Some Considerations for TA Providers
Available literature is largely focused on illicit drug use
The relationship between drugs and crime is key
Perception of harm and social disapproval are influenced by the observance of peers using
Reduced influence of parental attitudes from middle to high school
Easy social access is a strong factor
Environmental strategies are being studied
Parental monitoring shows promise

26. Marijuana Use Some Considerations for TA Providers
What are challenges and pitfalls communities may face when planning and implementing for Marijuana Prevention?
What resources can you provide and/or will you need to provide effective TA?

27. Enjoy Lunch!

28. Heroin: Health Consequences
35% of admissions to drug and alcohol treatment programs in Connecticut during 2006 listed heroin as the primary substance of dependence3.
Heroin dependence is associated with serious withdrawal symptoms, including vomiting, cold flashes, joint pain, insomnia, intense craving for the drug, and involuntary movements. If a heavily dependent user is already in poor health, sudden heroin withdrawal may lead to death4
References
1. State Estimates of Substance Use and Mental Health from the National Surveys on Drug Use and Health.
2. Connecticut School Health Survey (2009). Graphs of Question Results,
3. Moore, T.H.M., Zammit, S., Lingford-Huges, A., Barnes, T.R.E., Jones, P.B., Burke, M., & Lewis, G. (2007). Cannabis use and risk of psychotic or affective mental health outcomes: A systematic review. Lancet, 370, p
4. Hall, W., & Degenhardt, L. (2009). Adverse health effects of non-medical cannabis use. Lancet, 374,
5. Zvolensky, M.J., Johnson, K.A., Cougle, J.R., & Bonn-Miller, M.O. (2010). Marijuana use and panic psychopathology among a representative sample of adults. Experimental and Clinical Pharmacology, 18(2),
6. Kalant, H. (2004). Adverse effects of cannabis on health: an update of the literature since Progress in Neuro-Psychopharmacology & Biological Psychiatry, 28,
7. Office of National Drug Control Policy (2008, January). State of Connecticut, Profile of Drug Indicators.
8. University of Virginia Library, Geospacial and Statistical Data Center. Uniform Crime Reports from http: //fisher. lib. virginia. edu/collections/stats/crime/index. html
9. Jacobus, J., Bava, S., Cohen-Zion, M., Mahomood, O., & Tapert, S.F. (2009). Functional consequences of marijuana use in adolescents. Pharmacology, Biochemistry, and Behavior, 92, p

29. Heroin: Health Consequences
Street heroin can contain toxic additives that damage the cardiovascular system, causing serious and permanent damage to vital organs. Questions around drug purity and dose can lead to fatal overdose4.
Prolonged use can lead to collapsed veins, diseases of the liver and kidney, infection of heart valves and lining, and serious damage to the respiratory system4.
Injection of heroin can put users at risk for infectious disease, including HIV/AIDS and Hepatitis4.
References
1. Johnston, L.D., Bachman, J.G., O’Malley, P.M. et al. (2008). Monitoring the Future: A continuing study of American Youth (12th grade survey).
2. Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA Findings). Rockville, MD
3. Office of National Drug Control Policy (2008, January). State of Connecticut, Profile of Drug Indicators.
4. National Institute on Drug Abuse (2010, March). NIDA InfoFacts: Heroin.
5. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (December 3, 2009). The TEDS Report: Characteristics of Adolescent Heroin Admissions. Rockville, MD.
6. Grant, B.F., Stinson, F.S., Dawson, D.A., chou, S.P., Dufour, M.C., Compton, W., Pickering, R.P., & Kaplan, K. (2004). Prevalence and Co-occurrence of Substance Use Disorders and Independent Mood and Anxiety Disorders: Results From the National Epidemiologic Survey on Alcohol and Related Conditions Arch Gen Psychiatry, 61,

30. Heroin: Mental Health Consequences
Psychiatric disorders are common among those with substance use disorders. National data have demonstrated that about 20% of those with a current substance use disorder also have at least one current mood disorder, and 18% have at least one current anxiety disorder6.
Nearly one-third of adolescents in treatment for heroin dependence/abuse have a co-occurring psychiatric disorder5.
References
1. Johnston, L.D., Bachman, J.G., O’Malley, P.M. et al. (2008). Monitoring the Future: A continuing study of American Youth (12th grade survey).
2. Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA Findings). Rockville, MD
3. Office of National Drug Control Policy (2008, January). State of Connecticut, Profile of Drug Indicators.
4. National Institute on Drug Abuse (2010, March). NIDA InfoFacts: Heroin.
5. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (December 3, 2009). The TEDS Report: Characteristics of Adolescent Heroin Admissions. Rockville, MD.
6. Grant, B.F., Stinson, F.S., Dawson, D.A., chou, S.P., Dufour, M.C., Compton, W., Pickering, R.P., & Kaplan, K. (2004). Prevalence and Co-occurrence of Substance Use Disorders and Independent Mood and Anxiety Disorders: Results From the National Epidemiologic Survey on Alcohol and Related Conditions Arch Gen Psychiatry, 61,

31. Heroin Cultural Considerations
Heroin abuse among women who are pregnant may result in spontaneous abortion4.
Heroin abuse during pregnancy and associated factors like poor prenatal care and nutrition can lead to low birth weight, which can put babies at risk for later developmental delay4.
Infants born to mothers who have regularly abused heroin during pregnancy may be born heroin dependent, which can result in serious medical complications for the baby4.
References
1. Johnston, L.D., Bachman, J.G., O’Malley, P.M. et al. (2008). Monitoring the Future: A continuing study of American Youth (12th grade survey).
2. Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009 National Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, NSDUH Series H-38A, HHS Publication No. SMA Findings). Rockville, MD
3. Office of National Drug Control Policy (2008, January). State of Connecticut, Profile of Drug Indicators.
4. National Institute on Drug Abuse (2010, March). NIDA InfoFacts: Heroin.
5. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (December 3, 2009). The TEDS Report: Characteristics of Adolescent Heroin Admissions. Rockville, MD.
6. Grant, B.F., Stinson, F.S., Dawson, D.A., chou, S.P., Dufour, M.C., Compton, W., Pickering, R.P., & Kaplan, K. (2004). Prevalence and Co-occurrence of Substance Use Disorders and Independent Mood and Anxiety Disorders: Results From the National Epidemiologic Survey on Alcohol and Related Conditions Arch Gen Psychiatry, 61,

32. Heroin Risk Factors and Strategies
Project Northland
Harm Reduction Approach
Civil Anti-Drug Remedies
Sample Strategy
Access/Availability
Prior Use
Age of Onset
Treatment

33. Heroin Risk Factors and Strategies (cont’d.)
Counseling
Family Management
Sample Strategy
Family Conflict
Child Abuse

34. Sample Community Logic Model Problem: Heroin
Community- Specific Risk Factors
Strategies
Resources and Inputs
Short-Term Outcomes
Increased Perception of Harm of Heroin Use
Increased Access to Mental Health and Treatment Services
Improved Access to Parenting Skills Training via Drug Court Referrals
Curriculum
Collect and analyze data on the intervention
Curriculum,
teacher training
Hire and train community outreach workers
Perception of Harm
Community Outreach Worker
Education and Referral
Collect and analyze data on the intervention
Court and enforcement partnerships
Low Parental Care
Family Conflict
Drug Court
Long-Term Outcomes
Reduction in Lifetime Heroin Use
Reduction in Delinquency

35. Heroin Use Some Considerations for TA Providers
Difficult to influence access to diverted pharmaceuticals
Can be difficult to define and access the target population
Some strategies are considered risk reduction
Non-traditional sectors need to play strong roles
Prescribers, treatment, criminal justice, hospitals

36. Heroin Use Some Considerations for TA Providers
What are challenges and pitfalls communities may face when planning and implementing for Heroin Prevention?
What resources can you provide and/or will you need to provide effective TA?

37. What is a Health Disparity?
Health disparities (also called healthcare inequality in the U.S.) refer to gaps in the quality of health and health care across racial, ethnic, sexual orientation and socioeconomic groups. The Health Resources and Services Administration defines health disparities as "population-specific differences in the presence of disease, health outcomes, or access to health care."
What are health disparities? 
Health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. These disparities are inequitable and are directly related to the historical and current unequal distribution of social, political, economic, and environmental resources. Populations can be defined by factors such as race or ethnicity, gender, education or income, disability, geographic location (e.g., rural or urban), or sexual orientation. What factors contribute to health disparities? Poverty. Environmental threats. Access to health care. Individual and behavioral factors. Educational inequalities. How are health disparities and educational inequalities interrelated?
Higher levels of education are associated with more years of life and an increased likelihood of obtaining or understanding basic health information and services needed to make appropriate health decisions.2-4 Less education predicts higher levels of health risks, such as obesity, substance abuse, and violence.5-6 At the same time, good health is associated with academic success. Health risks such as teenage pregnancy, poor dietary choices, inadequate physical activity, physical and emotional abuse, substance abuse, and gang involvement have a significant impact on how well students perform in school.7-11 

38. Special Populations Sexual Orientation: LGBT
Active Military and Veterans
Homeless
Older Adults
Women
Youth
Race
Ethnicity: African Americans, Alaska Natives, American Indians, Asian Americans, Hispanics/Latinos, and Pacific Islanders

39. Contributing Factors to Disparity
Poverty
Access to health care
Individual and behavioral factors
Educational inequalities
Disability
Geographic location: urban or city
Mental Illness

40. How Are Disparities Interrelated?
Example: Education and Health
High level of education brings longer life span, easier access to health services
Less education predicts higher levels of health risks such as obesity, substance abuse and violence
Good health is associated with academic success
Poor health predicts substance abuse, inadequate physical activity, emotional abuse, teen pregnancy, and poor performance in school

41. Multi-Cultural Risk Factors and Strategies
Risk Factor / Causal Factor
Sample Strategies
Veterans/Military
Integrated Care Families
Lock The Medicine Cabinet Campaign
Poverty
Project Northland
Educational Inequity
Guiding Good Choices
Young Mothers
Home Visits
Veterans/Military: Integrated Care Facilities (in which substance abuse/mental health issues can be addressed along with primary care issues), such as those operated by the US Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ), can be effective for veterans. The 14 centers around the country can provide necessary services to veterans
Minority Race: Increased Advocacy. According to an advocacy group, Center for Lawful Access and Abuse Deterrence, advocating for increased recruitment and retention of racial and ethnic minorities will help to eliminate disparities in pain management techniques, which are biased toward women and minorities. This could help reduce prescription drug abuse and misuse.
Minority Race: Prevention Program Evidence suggests that a comprehensive prevention curriculum that includes drug-resistance skills, anti-drug norms, and the facilitation of personal and social skills can be an effective tool in preventing minority youth from abusing drugs. The author of this book, Gilbert Botvin, is an authority on substance abuse issues among minority youth.
Low Socioeconomic Status: The goal of a Community Empowerment program (usually in the form of a coalition) is to address the negative consequences of substance use/abuse and related effects. This coalition usually conducts a needs assessment to determine the community’s pressing problems, and then mobilizes resources, selects and implements a strategy, and finally evaluates it. Project Northland in Minnesota claimed a fifteen percent decrease in youth marijuana use.
Child Abuse. Physical or Sexual. Counseling. Research seems to suggest that youth who suffered abuse at the hands of parents or adult caregivers are more likely to abuse illicit drugs, including heroin.
*Prenatal Infancy. Young Mothers. Home Visitation. Research has found that a program that sent trained nurses to educate low-income, first-time mothers achieves results including forty-four percent fewer drug-related behavioral problems.
Maternal Smoking. Nurse Family Partnership: Research has found that the NFP is an effective way to combine pre-natal care, education, and health services through in-home visitation by nurses. NFP has been shown to decrease maternal smoking rates, as well as other substance abuse issues
Low Economic Status: Altering the physical Environment. Project Northland. The goal of a Community Empowerment program (usually in the form of a coalition) is to address the negative consequences of substance use/abuse and related effects. This coalition usually conducts a needs assessment to determine the community’s pressing problems, and then mobilizes resources, selects and implements a strategy, and finally evaluates it. Project Northland in Minnesota claimed a fifteen percent decrease in youth marijuana use.
Low Educational Achievement. Adolescents in Transition and Guiding Good Choices. Research demonstrates that a family-centered intervention, coupled with school-based life skills, can effectively strengthen school bonds
Mental Health. Cognitive Behavior Therapy CBT. There is emerging evidence that suggests that an approach like Cognitive Behavioral Therapy (CBT), in which youth in a group-therapy setting are taught to manage their feelings so as to prevent depression, may be an appropriate strategy to prevent substance abuse.
Take Back Program: Drug dispersal and take-back activities can be an effective strategy to counter prescription drug misuse and abuse.
Environmental Strategy: One strategy discussed by CADCA is the use of a locking medicine cabinet, so prescription drugs are kept out of unwanted hands. According to the research, almost seventy percent of prescription drugs were obtained through friends and family, making this strategy an effective environmental strategy
Project Northland: According to researchers, a delay in onset reduces substance abuse problems later in life. An effective program would help prevent thirty percent fewer youth from using cocaine.
The goal of a Community Empowerment program (usually in the form of a coalition) is to address the negative consequences of substance use/abuse and related effects. This coalition usually conducts a needs assessment to determine the community’s pressing problems, and then mobilizes resources, selects and implements a strategy, and finally evaluates it. Project Northland in Minnesota claimed a fifteen percent decrease in youth marijuana use.
Control and Reduce Use: Reconnecting Youth An effective program such as Reconnecting Youth can be an effective tool to reduce and control use by youth who are already using drugs.
Lack of Parental Monitoring: According to NIDA, an effective strategy to reduce the potential for harm from prescription drug abuse and misuse is by monitoring the internet settings on the family’s personal computer so as to prevent youth from ordering prescriptions online.
Family Management: Strengthening Families. An effective Family Management program (such as the Strengthening Families Program) can help families in conflict or those that present certain risk factors for adolescent drug use—such as parental support for drugs—to achieve certain reductions in risky, multi-use behavior.
Nurse/Family Partnerships
Maternal Smoking
Cognitive Behavioral Therapy
Mental Health

42. Common Risk Factors Across Multiple Problems
Tobacco, alcohol, marijuana, prescription drug misuse, heroin, other drug use, anti-social behavior, depression, sexual behavior and drunk/drugged driving are common among young people (Biglan, Brennan, Foster, & Holder, 2004)
These problems are interrelated; moreover the same young people tend to engage in multiple problem behaviors
The approach should concentrate on affecting the risk and protective factors influencing the involvement with multiple problems

43. Behavioral Health Connections to Substance Abuse
Mental Health Problems
Depression
Suicide
Serious Psychological Distress

44. Success with Common Risk Factors
The Seattle Social Development Project (SSDP) shows that 15 years after a childhood intervention ended:
11% had fewer mental health disorders*
12% had fewer STDs*
9% were at or above the median in socio-economic * attainment
SSDP is a long term study and intervention that looks at the development of positive and problem behaviors among adolescents and young adults.
* Results are in comparison to the control group used for the study.
Findings from the Seattle Social Development Project show that 15 years after a childhood intervention ended, the participants reported significantly better mental health, sexual health, and higher educational and economic attainment than a control group.
11% fewer with mental health disorders
12% fewer with STDs
9% more were at or above the median in socio-economic attainment
Hawkins, J. D., Kosterman, R., Catalano, R. F., Hill, K. G., & Abbott, R. D. (2008). Effects of social development intervention in childhood fifteen years later. Archives of Pediatrics and Adolescent Medicine, 162,

45. Finding the Fit
The following are three criteria that determine the best fit to include in a comprehensive prevention plan:
Conceptual fit: Is the intervention relevant?
Practical fit: Is the intervention appropriate?
Strength of evidence: Is the intervention evidence- based?
Relevance: If the prevention intervention does not address the underlying risk and protective factors and conditions that drive or contribute to the targeted substance abuse problem, then it is unlikely to produce positive outcomes or changes in that problem.
Appropriateness: If the prevention program, policy, or practice does not fit the community’s capacity, resources, or readiness to act, then the community is unlikely to implement the intervention effectively.
A second important concept in selecting prevention interventions is practical fit with the capacity, resources, and readiness of the community itself and the organizations responsible for implementing interventions. Practical fit is assessed through a series of utility and feasibility checks that grow out of the needs and resource assessment and capacity-building activities conducted in SPF Steps 1 and 2.
Utility and Feasibility Checks
Utility Checks
Is the intervention appropriate for the population identified in the community needs assessment and community logic model? Has the intervention been implemented successfully with the same or a similar population? Are the population differences likely to compromise the results?
Is the intervention delivered in a setting similar to the one planned by the community? In what ways is the context different? Are the differences likely to compromise the intervention’s effectiveness?
Is the intervention culturally appropriate? Did members of the culturally identified group participate in developing it? Were intervention materials adapted to the culturally identified group?
Are implementation materials (e.g., manuals, procedures) available to guide intervention implementation? Are training and technical assistance available to support implementation? Are monitoring or evaluation tools available to help track implementation quality?
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Feasibility Checks
Is the intervention culturally feasible, given the values of the community?
Is the intervention politically feasible, given the local power structure and priorities of the implementing organization? Does the intervention match the mission, vision, and culture of the implementing organization?
Is the intervention administratively feasible, given the policies and procedures of the implementing organization?
Is the intervention technically feasible, given staff capabilities, time commitments, and program resources?
Is the intervention financially feasible, given the estimated costs of implementation (including costs for purchase of implementation materials and specialized training or technical assistance)?
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Each of the points in the checklist warrants thoughtful consideration among those involved in planning, implementing, and evaluating the prevention strategies in the comprehensive community plan. l l

46. Working Across Sectors
Start with who is at the table
Think strategically about new partnerships
Develop an outreach strategy
Create a plan for tracking changes in multiple problems

47. Cross-Walking Risk Factors
Community Specific Risk Factor(s)
Goal: To identify a risk factor that is common to both underage drinking and your second priority
Pre-populate the chart. Include:
Community-specific risk factors (your choice) for underage drinking
Identified strategies
Community sectors with which you are already working
Add your second priority
Include risk factors, strategies, and sectors with which you will work
Analyze
Review the chart. Look for risk factors that have the potential to efficiently impact multiple drugs or problems
Look for similar strategies in the same sector or domain
Risk Factor
Risk Factor
Risk Factor
Risk Factor
Primary Priority
Secondary Priority
Strategy
Strategy
Sector
Sector or Domain

48. Cross-Walking Risk Factors
Community Specific Risk Factor(s)
Already- Identified Risk Factors
Already Identified Risk Factors
Risk Factor for Second Priority
Literature Review in Binder
Enforcement Levels
Social Competence
Early Initiation
Access
Data Sources in Binder
Underage Drinking
Marijuana
Strategy Tables in Binder
1) Party Patrols
1) Compliance Checks
2) Project Alert
1) After-School Program
2) After-School Program
Strategy
1) School
2) School
1) Business
2) School
1) Law Enforcement
Partner or Sector

49. Cross-Walking Risk Factors : Create An Example
Community Specific Risk Factor(s)
Text
Text
Text
Text
Underage Drinking
Prescription Drugs
Strategy
Partner or Sector

50. Primary Health Care Talking Points for TA Providers
Substance abuse, mental health and primary health care share risk factors
Substance use and abuse contributes to physical and mental health conditions early on
Poor primary care contributes to substance abuse
Patients not diagnosed and often not treated
(Blount,
Schoenbaum, Kathol, Rollman, Thomas, O’Donohue, & Peck, 2007; deGruy, 1996).
Use Synopsis of Primary Care Handout.

51. Analyzing Risk Factors
Thinking through Risk Factors that Cross Multiple Problems
Task: Using Information on Risk Factors create a fish bone setting forth what risk factors each drug have in common and with underage drinking
See handout for activity instructions

52. Socio-demographic Factors Socialization Factors
Gambling and Alcohol Conceptual Model of Hypothesized Predictors of Youth Problem Behaviors
Socio-demographic Factors
Gender, Age, Race, SES
Gambling
Alcohol Misuse
Individual Factors
Impulsivity, Moral Disengagement
Drug Use
Given that gambling, alcohol misuse, other drug use, and delinquency are correlated, researchers have hypothesized that these problem behaviors have shared antecedents. Measures from three explanatory domains—sociodemographic factors (gender, age, race, and socioeconomic status), individual factors (impulsivity and moral disengagement), and socialization factors (parental monitoring and peer delinquency)—were tested for links to problem behaviors in two longitudinal studies of adolescents. These studies revealed the following:
Black youth had lower levels of problem behaviors than Whites.
Impulsivity was identified as a significant predictor of alcohol misuse for females and delinquency for males.
Moral disengagement predicted gambling for males.
Parental monitoring showed a significant inverse relationship to alcohol misuse and other substance use for males.
Peer delinquency showed numerous prospective paths to youth problem behaviors for both genders.
This study significantly extends our own previous work and that of other investigators by confirming that problem behaviors are intertwined and that there are shared antecedent factors, from various domains, that predict these outcomes among adolescents in the general population. It is therefore likely that prevention strategies such as improved parenting may have the benefit of successfully reducing multiple problem behaviors in adolescence.
Socialization Factors
Parental Monitoring, Peer Delinquency
Delinquency
Source: Shared Predictors of Youthful Gambling, Substance Use, and Delinquency 2007

53. Suicide and Alcohol Alcohol Use Depression Suicide- Related Behavior
Other
Risk Behaviors
(Alcohol-Related Consequences
Depression
Alcohol use as an important risk factor for depression and suicide. Mental health promotion and suicide prevention program planners should collaborate with substance abuse prevention professionals to address this serious problem. Here’s what we know about the relationship between alcohol use, depression, and suicide:
Alcohol use may precede depression. Several longitudinal studies suggest that alcohol use may precede the onset of depression (Fergussen et al., 2009; Owens & Shippee, 2009; Hallfors et al., 2005; Wang & Patten, 2002; Brook et al., 2002; Gilman & Abraham, 2001; Wang & Patten, 2001; Hartka et al.,1991). Alcohol use may also exert physiological effects on the brain’s dopamine levels, which affect mood. (Volkow, 2004).
Alcohol-related consequences are risk factors for depression and suicide. Adolescents who experience alcohol-related consequences are more likely to develop major depression over time (Mason et al., 2008). The negative consequences of drinking can include relationship problems, academic trouble, and physical and sexual violence—all risk factors for depression and suicide (SPRC, 2003; Hufford, 2001).
Alcohol use may directly contribute to suicide-related behavior. It may constrict thinking and lead to impulsivity (Cherpitel et al., 2004; Hufford, 2001).
Alcohol prevention strategies may reduce suicide risk. A lower minimum legal drinking age is associated with higher suicide risk among 18- to 21-year-olds. (Birckmayer & Hemenway, 1999). Limiting alcohol availability may also reduce suicide mortality (Pridemore & Snowden, 2009; Varnik et al., 2006; Markowitz et al., 2003).

54. Selecting Common Risk Factor(s) Considerations for TA Providers
Resources, focus on primary priority
Efficiency is critical with the secondary priority
Relative strength of the relationship of risk factor to the priority
All risk factors are not equal
Age of target population
Factors gain and lose strength as the target ages
Similar strategies and domains
Practical, conceptual, levels of evidence

55. Risk Factors Across Problem Areas Some Considerations for TA Providers
What are challenges and pitfalls communities may face when planning and implementing for Risk Factors across Problem Areas?
What resources can you provide and/or will you need to provide effective TA?

56. TA Challenges and Next Steps
Identify challenges and pitfalls you may face when providing TA
Find solutions to meet those challenges

57. Next Steps: Planning for TA
Strategic plan for TA roll-out
Guidance document
Community training
Community assessment tool
Tool development
What resources do you need from whom?
What else?
What resources do you need from CAPT?
Talk about potential of creating a tool for them to help communities look at universal, selected and indicated strategies. Also to look across different age groups and help community identify sectors that need to get involved. Also to help identify potential disparities and subpopulations they need to focus on.
The Community Assessment tool presented here today is designed from a school perspective. It can be adapted to be a community. Assessment tool.  

58. Resources and Take-Aways