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

Biology/GenesJo

hn S

mith

Jam

es S

mith

Ann

Jone

s

John

Jone

s

Mar

y Hi

ll

Wal

ter

Jone

s

Jam

es H

ill

Susa

n A

dam

s

Alic

e Pr

ice

Thom

as Jo

nes

Will

iam

Pric

e

Rich

ard

Hill

Stev

en

Adam

s

Allis

on

Fiel

ds

Mar

y W

alte

rs

Alic

e B

enso

n

Rebe

cca

Wils

on

Thom

asSm

ith

John

Sm

ithEd

war

dSm

ith

Anne

Cook

Jane

Wal

kerJo

hn W

alke

r

Jane

Jone

s

Susa

n E

dwar

ds

Jam

esCo

ok

Beth

Bry

sonJo

nath

anCo

ok

Edw

ard

Brys

onAm

y M

ason

Beth

Ca

rter

Environment

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

0.0%

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

0.5

1

1.5

2

2.5

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

s Ra

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

2

Aver

age

Poin

t Diff

eren

ce in

IQ s

core

(IQ

at a

ge 3

8 –

IQ a

t age

13)

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

0

0.2

0.4

0.6

0.8

1

1.2

HS Complete

0

5

10

15

20

CannabisDepend

0

2

4

6

8

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(Jamila_K_Robinson@ondcp.eop.gov)

Jayme Delano(Jayme_A_Delano@ondcp.eop.gov)

For More Information WHITEHOUSE.GOV/ONDCP