Family-Focused Interventions to Prevent Substance Use Disorders in Adolescence: A Workshop

Why is this topic critical?

Most adults with substance use disorders began using substances in adolescence. Youth who choose not to use substances are less likely to suffer from substance use disorders as adults. They are also more likely to graduate from high school and less likely to experience depression and anxiety. This makes adolescence a crucial period of life for intervention. Early prevention efforts can play a crucial role in preventing substance use disorders later in life.

While people often assume that peer pressure drives youth drug use, research shows that parent and caregiver actions can also play an important role in preventing substance use. However, most funding for substance use disorders is directed toward law enforcement and treatment efforts that address substance use after it has begun. Shifting focus to funding prevention efforts has the potential to reduce substance abuse throughout life and to reduce the number of people who require intervention via treatment or law enforcement.

Issues explored at the workshop include…

Family-focused prevention interventions to address substance use disorders in primary health care settings
Existing state policy efforts to incorporate family-focused interventions into state health care strategies
Barriers to implementing family-focused interventions
Lessons learned from successful efforts to scale up such interventions

Why focus on primary care settings?

The vast majority of youth have some engagement with a primary care setting, making it a promising venue for early screening and prevention for substance use. Over 98 percent of adolescents have a regular health care provider, and nearly 93 percent have had a well-child visit in the last year. Well child visits provide an opportunity for primary care providers to ask specific questions about substance use in the household and other risk factors.

Primary care providers can also offer a trusted and destigmatizing forum for the discussion of substance use. Youth deserve messages that are effective and clear, and primary care providers are seen as trusted messengers. Families generally perceive primary care as a less stigmatizing place to receive services. Parents and caregivers generally believe it is appropriate for pediatricians to ask about substance use in the household.

Treatment for parents and caregivers is often a form of prevention and/or treatment for their children.

Video of Hoover Adger, Jr., Johns Hopkins University School of Medicine, speaking at the workshop on how treating a parent or caregiver’s substance use disorder can be a form of prevention and/or treatment for their children.

Best practices for whole-family intervention

For more detailed accounts of many of these best practices, see Core Competencies for Involvement of Health Care Providers in the Care of Children and Adolescents in Families Affected by Substance Use

Be familiar with community resources

Provide parents with tools

Communicating appropriate concern while offering information and support

Talk about family dynamics and history in a non-threatening way

Avoid shaming parents

Provide appropriate screening for substance use

Challenges

Primary care providers do not always have the skillset and knowledge to perform appropriate screenings or share necessary resources with patients and families.

Primary care visits are limited by time constraints, which may make incorporating substance use screening and response difficult.

Youth are less likely to come in for primary care appointments as they get older, particularly as teenagers.

The current youth mental health crisis could lead to higher rates of substance use in the near future as mental health struggles are a common risk-factor for substance use.

There are a number of challenges to measuring the effectiveness of prevention programs including:

Determining how to scale up evidence-based programs
Limited uptake of evidence-based science in real world community settings

For meaningful impact, prevention programs require sustained funding to ensure that they can operate over the long-term. This is particularly important given the time required to see (and measure) results from prevention efforts.

Solutions for how to engage families and communities to participate in interventions

Build interventions to fit with the setting from the beginning
Make use of Community-Based Participatory Research (CBPR)
Design interventions from the outset to align with the end user’s needs, resources, capacities, and desires
Establish long-term infrastructure that can be customized to different community needs

Examples:

Pediatric Residency Training
- Should focus on increasing comfort with and use of screening tools for household substance use
Family Check Up Program
- Takes advantage of the fact that families are already present at health care appointments
- More than 93% of families identified through screening completed the intervention program
- Participation in the intervention reduced risk of initiative a new substance by 37 percent and reduced the risk of drinking by 26 percent. Additionally, the results showed decreased rates of reported anxiety.
- Intervening for children as young as two can lead to decrease substance use in adolescence
- Genetic risk can be thought of as malleable
- Potential for reimbursement for such interventions
Guiding Good Choices for Health (GGC)
- GGC as an effective program in reducing alcohol, cannabis, and cigarette use, as well as reducing depressive symptoms and antisocial behaviors over time.
- They have been able to reach more diverse families, in terms of race and ethnicity and Medicaid status, and have received positive feedback from providers throughout implementation.

When the intervention has cultural significance, youth are better able to connect with and internalize it. Programs without cultural competency are far less effective.

John Lowe from The National Academies on Vimeo.

John Lowe, a Cherokee tribal member, asked youth what they would do if a bear came into the room – would they run or stay and fight? The bear is used as metaphor for adverse situations youth experience in their lives. This conversation aims to teach youth that there are other ways to deal with “bears” in their lives than turning to substance use.

Familias Unidas – telenovela intervention from The National Academies on Vimeo.

eHealth Familias Unidas – created an online intervention using a culturally informed program focusing on preventing drug use and risky sexual behaviors among Hispanic youth. The program was modeled after telenovelas and featured eight episodes that directly mapped to the content of parent group video sessions.

Start prevention work earlier in life – including social and emotional learning for preschoolers and sustaining prevention work as children get older will be critical in facilitating better outcomes.
Target each level of risk separately (i.e., sociocultural, community, school, family, individual)

Schools and health care settings are great opportunities because of their easy access to the targeted age group
70 to 80 percent of children receiving mental health supports receive them in school (Rones and Hoagwood, 2000)
Nurses provide most health promotion in the U.S. (health promotion and wellness is delivered by the more than four million nurses in the United States. Comparatively, there are roughly 35,000 pediatricians in the country.)
Leverage and support the full workforce in school and health care settings

Families with youth at higher risk are more likely to engage
Meet families where they are
Schools can offer designated family liaisons to connect with families, or community-based family peer support partners who have navigated prevention/treatment resources for their child and can offer support and advice to others.

Example of a state-level center that could provide aggregated information and support implementation in different contexts:

EPIS center in Pennsylvania acts as a statewide technical assistance center and supports prevention by connecting research, policy, and practice. It also facilitates dissemination and sharing of best practices, provides technical assistance and access to learning networks, and supports continuous improvement of locally developed positive youth programs.

1115 Waiver – a broad authority to test policy innovations – could be used for early prevention
Agencies bill Medicaid for the Strengthening Families Program as family group therapy
Substance use prevention is well aligned with the current Medicaid policy priorities. Medicaid has been increasing its focus on reducing the longstanding health inequities that have emerged in recent years, and policymakers are becoming aware of the behavioral health crisis among adolescents.
Some Medicaid agencies contract with providers directly, but many states have Medicaid run through a managed care program.
Medicaid Integrated Care for Kids model – where state-specific delivery systems and payment models will be piloted to improve early identification and treatment of health needs in a more integrated way.

Key Takeaways for State Policies for Payment Strategies

State investment
States expanding Medicaid
An often under-utilized Medicaid benefit: Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program, which allows Medicaid to pay for well-child visits and other things related to the child’s well-being
Pay for success and other outcomes-based financing models to scale prevention investment READ MORE
- “Blending and braiding” allows states to better coordinate funding where funders at all levels can play a role in coordinating multiple streams of funding toward a unified goal and desired outcome
- Example: Children’s Services Act in Fairfax County, VA blends funds in ways that support upstream substance use prevention. Case managers have flexibility to tailor their services to the individual needs of those families they are working with – including emergency rent support or car repair – that can keep adolescents safely housed and in school.
States setting standards for managed care organizations or tie a portion of managed care payment to specific quality measures that relate to prevention READ MORE
- Oregon ties a portion of payment to its care coordination organizations to meeting performance targets, including screenings and brief interventions for substance use and activities related to social and emotional health. Oregon also requires care coordination organizations to participate in a performance improvement project aimed at improving access to mental health services for anyone over the age of two.
- Washington state is working towards a more flexible payment system by implementing a multi-payer Primary Care Transformation Model aimed at increased investment in and incentives for integrated, whole-person, and team-based care. Another innovation launched in 2020 is the Medicaid Integrated Care for Kids model, where state-specific delivery systems and payment models will be piloted to improve early identification and treatment of health needs in a more integrated way.
- Integrated Care for Kids model launched in 2020 where state-specific delivery systems and payment models will be piloted to improve early identification and treatment of health needs in a more integrated way.
SAMHSA also recently announced its first ever harm reduction grant

Disparities

Disparities in exposure to risk-factors, access to resources, and experience within the health care system can have a significant impact on substance use. They can also offer primary care providers with essential insights in their efforts to screen for and respond to substance use among youth.

Racial/ethnic disparities in rates of substance use are not due to racial/ethnic differences, but rather due to differing exposure of populations to risk factors for substance use.

Approaches to addressing substance use have historically been laden with racism, judgment, and attacks on drug users. Without deconstructing this historical perspective, it will be difficult to provide effective family-focused prevention interventions in health care settings.

Lack of trust in the health care system resulting from negative experiences or historic disparities in treatment may prevent some families from participating. Emerging distrust of scientific experts could also influence participation.

Other Opportunities

COVID-19 relief funding for school-based mental health services and family poverty reduction efforts
Pandemic presents an opportunity to talk to the public about prevention in ways that has not been done in the past
Pandemic taught investigators to think about novel methods of delivering interventions
People introduced to public health during the COVID-19 pandemic, and added this is an opportunity to leverage public interest to address mental health and substance use in new ways.

Dedicate state funds to bolster early prevention efforts in an equitable way
Have someone in charge of leveraging the opioid settlement money and coordinate with other resources in the state, including primary health care providers.

Key Definitions

Universal prevention addressing the entire population, regardless of risk level

Culture of prevention is the values and beliefs about prevention and its role within health promotion. These concepts include:

Public acceptance of values and ideals
Policies and legal frameworks that support prevention
Equitable allocation of resources
Incorporation of scientific findings and clinical knowledge-communicating
Coordination of services across multiple sectors of NGOs and government agencies

Youth aged 10-19, with an emphasis on the earlier years in the range

Including all healthcare providers (e.g., pediatricians, physician assistants, and nurse practitioners), as well as health educators

Not necessarily a biological family, but those who are responsible for nurturance, connectedness, role modeling, communication

Get the Proceedings

Family-Focused Interventions to Prevent Substance Use Disorders in Adolescence: Proceedings of a Workshop

Read the Proceedings

Learn more about this project

Sponsored by: Foundation for Opioid Response Efforts (FORE)