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The recent and ongoing opioid crisis has prompted a surge in much-needed legislative attention and action to bolster our nation’s response to addiction. Congress passed the Comprehensive Addiction Recovery Act in 2016 and the SUPPORT for Patients and Communities Act in 2018 to address opioid misuse, addiction, and overdose deaths through a variety of initiatives in prevention, treatment, harm reduction, and recovery support. The federal government has also provided billions of dollars directly to states through the Substance Abuse and Mental Health Services Administration’s State Opioid Response grant program. More recently, 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.
Despite these noteworthy increases in attention to and funding for substance use and addiction, especially in ways consistent with an evidence-based public health approach, prevention has received mostly lip service within the substance-specific funding streams. Initiatives that have been promoted within these laws primarily have focused either on adding the topic of prescription opioid misuse to existing drug prevention curricula, modifying clinical practice to reduce access to prescription opioids, or preventing opioid overdose deaths. While helpful and necessary, this approach is not sufficient to curb future drug epidemics, including the growing cases of stimulant misuse and addiction we are currently facing in the United States. Our country traditionally underinvests in prevention and tends to take a narrow, drug-specific approach that fails to address the root causes of substance use, build youth resilience, or adequately protect our nation from experiencing the next substance use and addiction crisis.
To really meet the goal of preventing substance use and addiction, we have to fundamentally rethink our approach by both starting prevention efforts earlier in a child’s life and broadening the lens of what we consider to be effective prevention. Fortunately, with new and emerging legislation from the Biden administration, we seem to be on the cusp of an unprecedented opportunity to accomplish this much needed shift. Although preventing youth substance use is not the stated intention of the administration’s Build Back Better plan, many of the initiatives within the already passed or proposed components of the plan seek to invest in children and families in ways that undoubtedly will help to mitigate the risk factors known to contribute to youth substance use and the incidence of addiction in the United States.
We must seize this opportunity to measure and document the potential effects of these broad legislative efforts on one of the largest and most persistent public health problems our nation faces: youth substance use and addiction.
Research (and common sense) clearly shows that waiting until adolescence to lay the groundwork for addiction prevention is simply too late. A growing body of research on the effects of adverse—and positive—childhood experiences, along with neuroscientific evidence emerging from projects such as the National Institute on Drug Abuse’s Adolescent Brain Cognitive Development Study, have made it increasingly clear that the roots of addiction risk and resilience are planted very early in life. Experiences in early and middle childhood, coupled with biological vulnerabilities, really set the stage for how children will fare as they grow older. Recent evidence on the wide-ranging psychosocial consequences for youth and families of the COVID-19 pandemic also underscore the need to intervene at the earliest stages of life to thwart the development and progression of risk factors exacerbated by the pandemic that can increase the odds of substance use in adolescence and beyond.
In addition to starting earlier, prevention must encompass more than school-based programs. Traditionally, substance use prevention has involved public service announcements, school assemblies, or health course curricula that teach students about the effects of addictive substances and why they should be avoided. More recently, there have been some efforts to expand the way prevention is delivered to youth, acknowledging the importance of promoting coping and social skills as well as child mental health. Several programs, recognizing the influence of families in preventing youth substance use, offer education, skill building, and tools to help parents and other caregivers mitigate risk and bolster protection in the home. And there are substance-specific policies and regulations implemented in states and communities, such as minimum legal age of sale and zoning laws, that recognize and address the importance of limiting youth exposure and access to substances.
Improving substance use prevention requires the involvement not just of secondary schools and parents, but everyone who touches the lives of children and families: educators in preschool through college; community leaders and organizations; health care professionals in a broad range of clinical specialties; professionals in the juvenile, criminal justice, and child welfare systems; and local, state, and federal policy makers. Essentially, every adult has a significant role to play in protecting children and a responsibility to do so.
Indeed, people and interventions with seemingly little direct connection to substance use can play a significant and foundational role—albeit less easily tracked and measured than traditional interventions—in protecting youth from substance use and addiction. These include any structural change that facilitates healthy childhood development, such as reducing poverty; ensuring income security and housing stability; offering quality childcare and paid family leave; promoting neighborhood safety, child nutrition, and educational opportunities; and guaranteeing health insurance for adult mental health and addiction treatment so that children don’t grow up in a household scarred by untreated addiction and mental illness.
We know from our experience with COVID-19 how important and interdependent these interventions are for bolstering individual and family health and stability. Targeted interventions that were too narrowly focused did little to move the needle in protecting the population’s health and economic well-being in the face of a raging health crisis. It took broad-based policies, shoring up multiple areas of financial and social weaknesses and insecurities, to begin to take our nation and other countries out of the devastation wrought by this pandemic. This same type of approach will be required to turn the tide on the other public health crisis ravaging the United States.
Even small improvements in the many social determinants of a family’s health and welfare can successfully shift the course of a child’s life, including their risk for substance use and addiction. While in years past, tackling poverty, trauma, and mental illness might have sounded like an unattainable wish list for the specific goal of reducing addiction in this country, it is no longer as daunting as it once seemed. It is being manifested in recently implemented and proposed legislation to fundamentally change our nation’s priorities when it comes to families and children.
Legislation passed in response to the COVID-19 pandemic, including the Families First Coronavirus Response Act, the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), the Consolidated Appropriations Act, and the recently passed American Rescue Plan, have opened up unprecedented opportunities to tackle many of the historically intractable structural problems that have impeded true progress in preventing youth substance use and addiction. Although prevention is not the main aim of these laws, we should not miss the opportunity to track and demonstrate their impact on one of the largest preventable public health problems in our nation: adolescent substance use and addiction.
The federal funding that these laws provide are critical to making real progress in reducing substance use and addiction by helping to alleviate burdens on families and communities that both directly and indirectly contribute to the risk of youth substance use and addiction. These include:
President Joe Biden’s recently announced American Families Plan would continue to build on these efforts by investing $1.8 trillion in social welfare and family assistance programs, such as universal pre-K childcare programs, expanded child tax credits, and a national program for paid family and medical leave.
Knowing what we know about both the proximal and distal causes of substance use and addiction, there is little doubt that the success of these efforts will have measurable and positive downstream effects on youth substance use risk. Therefore, policy makers should consider substance use prevention to be a key target of these initiatives and, when evaluating their impact, should support research that documents their short- and long-term effects specifically on youth substance use and addiction.
Deliberately measuring and tracking changes in the prevalence of known risk factors for substance use among youth can help to establish an evidence base for expanding traditional prevention efforts by including interventions historically not considered within their direct scope, such as those that reduce financial stress on families and support child and parental mental health. That is not to say that these broader structural interventions should supplant more traditional prevention approaches. Rather, their inclusion can help break down the longstanding silos around the field of substance use prevention to encourage collaboration with those in other fields, such as early childhood development, poverty reduction, nutrition, child welfare, and others that have a direct impact on youth health and resilience.
By demonstrating that intervening earlier and more broadly can better prevent substance use in adolescence and put children on a healthy path to adulthood, we can ultimately steer more youth and adults away from developing addiction. With the value of investing in families and communities laid bare by recent national crises, let’s not forget the lessons we learned about the importance of their strength and security in promoting the health and wellness of children and future generations. As the details of these laws come into focus, it’s important to measure their impact on substance use and addiction, a public health problem that harms and kills many more people than COVID-19 and continues to disrupt and devastate countless lives and families.
Recent Legislation Can Dramatically Improve Substance Use Prevention: Here's How To Seize The Opportunity – Health Affairs
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