Preventing Substance Use Problems Among Young People - A Compendium of Best Practices

Section 1 - Introduction

There has been a general increase in substance use and associated problems among adolescents in this country in recent years. Various government and non-government organizations are being pressed to respond with effective solutions. This compendium presents evidence-based direction to effective programming for a broad range of prevention activities and should be of interest to educators, community developers, health promoters, law enforcement officers and public health nurses.

Scope of the Compendium

• What is the best way to prevent substance use problems among young people?
• What about effective programs to reduce harm for youth already using substances?
• What Canadian programs show most promise?

The compendium gives attention to prevention issues, principles and programs pertaining to all youth, ranging from mainstream to out-of-the-mainstream, and considers a variety of settings, from schools to street level. While some early childhood initiatives have shown strong preventive effect, they were considered beyond the scope of the investigation. Also, neither tobacco nor performance-enhancing drug use prevention programs were considered unless they reported other substance use results. Finally, policy-focused initiatives were considered only when linked to programming, but were discussed as an important underpinning to the direct service programs presented in this compendium.

Detailed discussion of current drug use patterns of Canadian youth is presented because it is crucial to base program decisions on accurate data. A number of programs that have either shown evidence of effectiveness or show promise are described in detail. To the greatest extent possible, relevant information has been collected from researchers and program sponsors, including aims, intended outcomes, prevention principles emphasized and, whenever possible, cost information. Complete contact information is included for each program.

Each of the programs presented reflects a number of prevention principles; however, it is wise to determine the extent to which programs being considered reflect the principles that are of greatest importance to you, rather than simply adopting a program.

The discussion presented in each section is relatively detailed; however, for those interested in investigating issues further, significant points are supported by cited sources to allow for follow-up.

In the appendix, a checklist is provided to guide an analysis of programs in relation to prevention principles. Also included in the appendix are various tools and resources for those interested in pursuing further research.

Key Terms

Substance use problem prevention:This term is used because it accommodates prevention in two contexts: (a) prevention activities designed to encourage youth not to use, and (b) activities designed to encourage users to avoid high-risk practices that could lead to serious problems or harm.

Youth: For the purposes of this compendium, the population of interest is young people in their teen years. Because psychosocial development is often delayed among high-risk youth, programming for these young people up to approximately age 24 is considered. Prevention necessarily involves a time period prior to the period of interest; consequently, later childhood (ages 7-12) issues are also part of this investigation. Youth are not a homogeneous population. At various points, the compendium accounts for distinctions between sub-populations of youth based on gender, urban-rural differences, level of risk, cultural background and stage of psychosocial development.

Universal, selective and indicated prevention: In this compendium, these terms replace the terms, primary and secondary prevention (tertiary prevention refers to treatment). The model was first described by R. Gordon in 1987 and was adapted by the US Institute of Medicine Committee on the prevention of mental disorders in 1994. It was applied to substance use issues by the National Institute on Drug Abuse in a 1997 publication, "Preventing drug use among children and adolescents: a research-based guide". The terms are more fully discussed in the Prevention principles section.

Methodology

Substance Use Patterns of Canadian Youth

A key premise of this resource is that prevention activities need to be based on the best available information on the nature and extent of youth substance use problems. Section 2 of the compendium sets the context for later discussion on principles and programs by detailing the current patterns of youth drug use in Canada. The information presented is based on an analysis of the most recent government surveys as well as key journal articles on the epidemiology of youth substance use in Canada. This section will detail information on age of first use, age and gender differences, age of peak use and problems reported from use. The following section shows how this information can guide program development.

Principles of Youth Substance Use Problem Prevention

Section 3 presents 14 principles that represent a consensus of the project team and steering committee on the most important considerations in developing and implementing youth substance use problem prevention programming. The principles were arrived at through an extensive review of the literature and other consensus-based statements from authoritative bodies.

Exemplary Programs from the Scientific Literature

Whether a programmer is developing a new program, revising an existing one, or considering the purchase of a marketed program, these principles provide sound direction.

This section describes and analyzes 33 programs with a range of aims, target groups and settings that have been shown to be effective through rigorous evaluation. Among the programs presented are eight that focus on the unique needs of injection drug using (IDU) youth. Programs in this section were identified through a process which:

• defined a minimum standard for inclusion into the candidate pool, which was a quasi-experimental design reporting positive effect on substance use measures in a peer reviewed journal;
• developed a matrix that categorized programs according to target group (universal, selective or indicated) and setting (school, family/parent, community, combined, street);
• reviewed nine credible reviews of effective programs and compiled a list of programs that met inclusion criteria;
• identified poorly represented areas of the matrix: high risk/street/IDU youth, DWI programs, parent/family programs;
• conducted a second, targeted search of the literature to fill in gaps and to capture any program evaluations reported in the scientific literature since the most recent reviews, (i.e., 1998 to 2000). Databases searched: CANBASE, CCSADOCS, CEI, ERIC, Medline, ETOH, NCADI and the French-language databases of the Centre québécois de documentation en toxicomanie, and the National Documentation Centre in Lyon, France;
• developed a coding form to rate each study on quality of research design and study outcomes;
• checked the reliability among three raters;
• rated 115 articles and selected 33 programs that ranked highest in overall quality of research design and outcomes;
• described the 33 programs based on information contained in research articles;
• sent description to principal authors of research articles for confirmation of information; in several cases, the request was forwarded to those marketing commercial versions of described programs;
• entered new information from authors or publishers.

Exemplary Canadian Programs

This section presents descriptions of 39 Canadian programs, including eight serving IDU youth. Among the programs serving IDU youth are treatment programs that are presented in this Compendium because they are engaged in the prevention of harmful effects associated with injection drug use. Programs in this section were identified through a process which:

• invited nominations from provincial/territorial government addiction agencies and Health Canada regional representatives;
• filled in gaps with nominations from key informants across Canada, programs known by team and steering committee members, and, in the case of IDU programs, an Internet search;
• developed a questionnaire/template that was sent to a total of 150 programs;
• conducted a first screen on the basis of a mix of considerations (i.e., availability of evaluation report, evidence of sustainability, degree of innovation, the extent to which prevention principles are reflected, and geographic and cultural representation);
• made personal contact with persons associated with youth treatment and general IDU programs to determine the extent to which they work with IDU youth;
• due to lack of available documentation, collected required information from screened-in IDU programs by interview; and
• developed descriptions of 39 programs based on information provided by questionnaire and interview, and forwarded to program sponsors asking for confirmation of information and elaboration in several areas;
• entered information into fully searchable database.

Limitations

Considerable effort went into conducting a broad investigation and adhering to a strict method; however, the following limitations were noted:

• when rating the published and Canadian programs, the author or sponsors interpretation of outcomes and other key information was used;
• while several approaches were used in the search for Canadian programs, it is quite possible that important programs were not nominated;
• because outcome evaluations are almost completely non-existent among Canadian programs, the criteria for selection of these programs became necessarily less stringent;
• program cost information is important in determining the efficiency of prevention activity. Effort was made to obtain direct cost information from authors and sponsors, however the information obtained is uneven and generally weak;
• due to their being marginalized, IDU youth are not as easily studied or served; as a result, the type of research or documentation made available didn't allow for the same level of confidence in outcomes as was generally the case;
• follow up contact was made with all "screened-in" candidates, however a small number of principal authors of published programs and sponsors of Canadian programs chose not to participate and were not included in the Compendium.