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
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.
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
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
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.
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.
Sample Strategy
Social Access/Availability
Community Norms
Prior Marijuana Use
Early Initiation
Prescription DrugsRisk Factors and Strategies
Project Northland
Coalitions / Marketing
Lock Medicine Cabinet
Take Back Program
Parent Monitoring
Reconnecting Youth
Parental Internet Controls
Sample Strategy
Community Mobilization
Skill Enhancement Training
Information Dissemination
Strengthening FamiliesParent Approval
Parent/Sibling Use
Lack of Awareness
Perception of Harm
Transitions School Climate Change
Prescription Drug Risk Factors and Strategies (cont’d.)
Logic Model
Community- Specific Risk Factors
Long-Term Outcomes
Short-Term Outcomes
Strategies Resources and Inputs
Sample Community Logic Model Problem: Prescription Drugs
Community- Specific Risk
Factors
Long-Term Outcomes
Reduction in Use
Delayed Onset
Reduction in Availability
Access Ease of
Availability
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
Strategies Resources and Inputs
Community Norms
Perceived Risk
Drug Dispersal Take-Back Program
Social Marketing Lock Up Your
Medicine Cabinet
Collect and analyze data on the intervention
Recruit local DEA or police department to staff take-back event.
Collect and analyze data on the intervention
Develop a marketing plan
Partner with media
Secure earned and paid media
Prescription Drug UseSome 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
Prescription Drug UseSome 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?
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.
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.
Sample Strategy
Coalition Development
Cessation Interventions/NOT
Mentoring / “Across Ages”
Environmental Strategies*Access and Availability
Community Norms
Prior Use/Mixed Drugs
Onset of Use
Parent/Sibling Use SMART Leaders/Life Skills
Tobacco Risk Factors and Strategies
Sample Strategy
Prevention Policies
Information DisseminationPerception of Harm
Workforce
Tobacco Risk Factors and Strategies (cont’d.)
Sample Community Logic ModelProblem: Tobacco
Community- Specific Risk
Factors
Long-Term Outcomes
Reduction in Lifetime Tobacco Use
Easy Access to Tobacco
Short-Term Outcomes
Decrease in Compliance Failure
Rates
Increase in Accurate Perception of Smoker
Prevalence
Increase in Intentions Not to Smoke
Strategies Resources and Inputs
Normative Beliefs
Prevalence estimates;
Motivation to comply with
othersmokers; Beliefs
Compliance Checks
Normative Education
Curriculum infusion
Collect and analyze data on the intervention
Recruit staff and/or train youth to conduct compliance checks
Develop and distribute vendor education packets
Collect and analyze data on the intervention
Identify staff to design and implement intervention
Vendor Education
Tobacco UseSome 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
Tobacco UseSome 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?
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.
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.
Community Mobilization
Project Northland
Environmental Strategies
Keepin’ It R.E.A.L.
Sample Strategy
Access/Availability
Community Norms
Early Age of Onset
Peer Approval
Marijuana Risk Factors and Strategies
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
Marijuana Risk Factors and Strategies (cont’d.)
Sample Community Logic ModelProblem: Marijuana
Community- Specific Risk
Factors
Long-Term Outcomes
Reduction in Lifetime Marijuana Use
Reduction in Delinquency
Academic Failure
Short-Term Outcomes
Increase in School Bonding
Improved Academic Achievement
Reduction in Problem Behavior
Strategies Resources and Inputs
Lack of CommitmentLow Bonding to
School
Academic Skills Enhancement
Enhanced SocializationSocial Support
Collect and analyze data on the intervention
Purchase curriculum,train teachers, providebooster sessions
Collect and analyze data on the intervention (e.g., Raising Healthy Children)
Provide teacher/ staff development workshops
Provide booster session
Interactive Curriculum
Marijuana UseSome 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
Marijuana UseSome 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?
Enjoy Lunch!
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
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.
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.
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.
Project Northland
Harm Reduction Approach
Civil Anti-Drug Remedies
Sample Strategy
Access/Availability
Prior Use
Age of Onset
Heroin Risk Factors and Strategies
Treatment
Counseling
Family Management
Sample Strategy
Family Conflict
Child Abuse
Heroin Risk Factors and Strategies (cont’d.)
Sample Community Logic ModelProblem: Heroin
Community- Specific Risk
Factors
Long-Term Outcomes
Reduction in Lifetime Heroin Use
Reduction in Delinquency
Perception of Harm
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
Strategies Resources and Inputs
Low Parental Care
Family Conflict
Curriculum
Drug Court
Collect and analyze data on the intervention
Curriculum, teacher training
Hire and train community outreach workers
Collect and analyze data on the intervention
Court and enforcement partnerships
Community Outreach Worker
Education and Referral
Heroin UseSome 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
Heroin UseSome 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?
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."
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
Contributing Factors to Disparity
• Poverty• Access to health care• Individual and behavioral factors• Educational inequalities• Disability• Geographic location: urban or city• Mental Illness
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
Multi-Cultural Risk Factors and Strategies
Sample Strategies
Integrated Care FamiliesVeterans/Military
Educational Inequity
Young Mothers
Lock The Medicine Cabinet CampaignPoverty
Project Northland
Home Visits
Guiding Good Choices
Maternal Smoking
Mental Health
Nurse/Family Partnerships
Cognitive Behavioral Therapy
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
Behavioral Health Connections to Substance Abuse
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.
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?
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
Ris
k Fa
ctor
Ris
k Fa
ctor
Ris
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ctor
Community Specific Risk Factor(s)
Strategy
Sector or DomainStrategySector
Primary Priority
Secondary Priority
Ris
k Fa
ctor
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
Cross-Walking Risk Factors
Cross-Walking Risk Factors
Enfo
rcem
ent
Leve
ls
Early
Initi
atio
nAc
cess
Community Specific Risk Factor(s)
Strategy
Partner or Sector1) Party Patrols
1) Law Enforcem
ent
Underage Drinking
Marijuana
Soci
al C
ompe
tenc
e
1) Compliance Checks
1) Business
2) Project Alert
2) School
1) After-School Program
1) School2) School
2) After-School Program
Already Identified
Risk Factors
Already Identified
Risk Factors
Data Sources in Binder
Data Sources in Binder
Strategy Tables in
Binder
Strategy Tables in
Binder
Risk Factor for Second Priority
Literature Review in Binder
Risk Factor for Second Priority
Literature Review in Binder
Already- Identified
Risk Factors
Already- Identified
Risk Factors
Cross-Walking Risk Factors : Create An Example
Text
Text
Text
Community Specific Risk Factor(s)
Strategy
Partner or Sector
Underage Drinking
Prescription Drugs
Text
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
Analyzing Risk Factors
Thinking through Risk Factors that Cross Multiple Problems
Gambling and AlcoholConceptual Model of Hypothesized Predictors of Youth Problem Behaviors
Socialization FactorsParental Monitoring,
Peer Delinquency
Individual FactorsImpulsivity, Moral
Disengagement
Gambling
Alcohol Misuse
Delinquency
Drug Use
Socio-demographic Factors
Gender, Age, Race, SES
Source: Shared Predictors of Youthful Gambling, Substance Use, and Delinquency 2007
Suicide and Alcohol
Depression
Alcohol Use
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
Risk Factors Across Problem AreasSome 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?
TA Challenges and Next Steps
• Identify challenges and pitfalls you may face when providing TA
• Find solutions to meet those challenges
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?
Resources and Take-Aways