Substance use in youth can lead to a variety of negative outcomes, including health issues, poor academic performance, and increased risk of addiction and overdose. Primary prevention is a public health strategy of intervening before negative health effects occur, including delaying or preventing young people’s use of harmful substances that may lead to overdose or other substance-related harms. Increased rates of mental health challenges among youth, as well as rising overdose rates driven by illicit fentanyl (even as youth substance use remains at historically low levels) underscores the need for multi-faceted prevention strategies that reduce risk factors that lead to drug use, support early intervention and linkage to services, and provide information and access to overdose prevention resources such as naloxone.
States can employ these approaches at these distinct levels as part of a comprehensive prevention strategy, which recognizes the importance of different risk and protective factors that interplay at the individual, relationship, community, and societal levels. States have a variety of substance use prevention activities already underway, often overseen by state prevention coordinators and supported by a patchwork of funding that includes the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Substance Use and Mental Health Block Grants and State Opioid Response Grants, the Centers for Disease Control and Prevention’s (CDC) (Overdose to Action funding, and other sources. With state opioid settlement funds providing an important opportunity to address priorities, invest in gaps in infrastructure, and promote sustainability of current efforts, this brief highlights evidence-based prevention activities that can be supported through state settlement funds.
Prevention: What Works?
Prevention requires understanding the multiple factors that influence individual choices and behaviors related to substance use. The socio-ecological model offers a framework for assessing the range of factors that put people at risk for experiencing the negative effects of substance use, as well as the factors that can protect against those risk factors. Individual-level efforts might involve interventions with children who are at risk, while community-level strategies might address social determinants of health and other factors that influence substance use. Importantly, prevention activities have a variety of benefits beyond reduced substance use, including lower long-term treatment costs, less premature mortality, and overall higher quality of life for young people, among many others. Figure 1 illustrates prevention strategies that can work to address risk factors for substance use at the individual, relationship, and school and community levels.
A more specific model, the SAMHSA Strategic Prevention Framework, guides state officials and local providers in assessing all of these risk factors to tailor prevention responses to the real needs and strengths of a specific community. The framework offers a comprehensive approach to understanding and addressing the substance use and related behavioral health problems within communities, which can then inform the development of programs and practices that address widespread behavioral health issues. By investing across this continuum, states can work to build and support a prevention infrastructure for both state and community-level prevention efforts. NASHP’s case study on Connecticut highlights a state’s successful approach to supporting a comprehensive prevention infrastructure.
Leveraging Settlement Funding to Support Primary Prevention
As a part of the terms of the National Opioids Settlement, states and counties distributing opioid settlement funding must spend at least 70 percent of settlement funds on current and future opioid remediation. Exhibit E within the master settlement agreement defines core strategies and details a range of allowable activities across prevention, treatment, recovery, and harm reduction. Specific activities listed for preventing the misuses of opioids (Section G) provide states with significant latitude to invest in a wide range of primary prevention activities, including upstream community-level interventions and initiatives specifically targeted at youth with mental and behavioral health needs. These activities include:
- Funding media campaigns to prevent opioid misuse
- Funding community anti-drug coalitions that engage in drug prevention efforts and supporting community coalitions in implementing evidence-informed prevention, such as reduced social access and physical access and stigma reduction
- Engaging nonprofits and faith-based communities as systems to support prevention
- Funding evidence-based prevention programs in schools
The following examples show best and promising practices for implementing these allowable primary prevention activities, using settlement funding or other funding streams.
Funding Media Campaigns to Prevent Opioid Use
Research points to the idea that prevention efforts should focus on enhancing the understanding of the risks associated with opioid misuse and reducing the stigma against those who use drugs. Efforts to reduce stigma can remove barriers for individuals seeking support for substance use disorders and help to garner wider public support for policies and programs that facilitate recovery.
Many regional and national media campaigns to address stigma are underway, and the SAMHSA-funded Prevention Technology Transfer Center offers a list of current campaign resources. The CDC states that airing campaign messages at sufficient levels of reach among the target audience can lead to changes in campaign-targeted knowledge and attitudes within six to 12 months and changes in behaviors within 12 to 24 months after the campaign launch. At the state level, numerous states are investing in efforts to reduce stigma and increase awareness of available supports.
For example, Minnesota is funding several media campaigns through its Opioid Epidemic Response Advisory Council (OERAC), including a statewide project that informs the public not only of the harms of opioid use, but also provides information about pathways to recovery and naloxone and offers tailored educational materials for medical professionals.
Engaging Nonprofits and Faith-Based Communities as Systems to Support Prevention
Working with established community-based organizations allows states to bolster existing locally informed prevention projects that have longstanding trust among residents. Among a robust set of prevention activities that Michigan supports, the state prioritizes connecting with faith-based institutions to better engage a wider range of state residents. Faith-based prevention products include information tailored for congregations, training, connection to harm reduction services, and a faith-based learning collaborative. In Kansas, funding awarded through Kansas Fights Addiction will support efforts in Sedgwick, Kansas, to prevent substance use and other risky behaviors in marginalized youth through evidence-based prevention programs to enhance protective factors and address risk factors such as adverse childhood experiences and trauma.
Youth-Led Prevention Efforts
Youth can be powerful ambassadors and partners in identifying challenges and developing approaches that resonate within their communities, and youth-led prevention work offers communication and peer networks from individuals that youth find credible: other youth. Youth who are leading prevention work can participate in planning, decision-making, implementation, evaluation, and recognition processes, which both provides better-informed prevention programming, as well as leadership skills for participants.
The Ohio Youth-Led Prevention Network Youth Council is made up of Ohio high school students who are part of local groups that work to prevent substance use/misuse, promote mental health, and empower other youth. The youth council chooses a topic that matters to young people and plans how to make a difference in their communities with help from their adult allies. By using comprehensive prevention strategies, youth council members develop and implement activities and messaging around their area of focus to engage with peers and adults across the state. In Kansas, Kansas Fights Addiction will support two school districts in Douglas County in implementing school-based prevention pilots that will center building youth leadership capacity and implementation of youth-led initiatives.
Community Coalitions
Community coalitions are community-based, formal arrangements for cooperation and collaboration among groups or sectors of a community in which each group retains its identity but all agree to work together toward a common goal of building a safe, healthy, and drug-free community. These coalitions offer a range of platforms and opportunities for community engagement, which is a critical factor in the scale-up of evidence-based practices, improvements in population health, and prevention. Outcomes associated with community engagement occur at implementation, service, and individual levels and include community coalition functioning, acceptability of evidence-based practices (EBPs) and/or prevention strategies, adoption of EBPs and/or prevention strategies, feasibility, sustainability, and behavioral health functioning.
The Oregon Opioid Settlement Prevention, Treatment, and Recovery Board provided approximately $3.8 million to community-based organizations and regional health equity coalitions to increase the number of primary prevention initiatives in communities experiencing disproportionate effects of substance use and overdose. The funds will go to organizations that are rooted in existing linguistic and cultural systems, building on their community engagement efforts and infrastructure. New York has also set aside $1.4 million in its state opioid settlement dollars to fund seven applicants up to $200,000 each to establish Fentanyl, Opioids, Rx Coalitions, which will build on the successful implementation of evidence-based opioid and heroin use prevention strategies.
Funding for Evidence-Based Prevention Programs in Schools
As noted, primary prevention works best when instituted at multiple points, and evidence-based prevention programs in schools offer an array of educational opportunities that increase skills, socioemotional wellness, and connections with others that may serve as protective factors against future substance use. In Virginia, Fairfax County offers an array of school-based prevention services, including education about drugs; group and individual prevention services for students, staff, parents, and the Fairfax County community; and partnerships with both school resources officers and parent-teacher-student organizations. New York earmarked $4 million in state opioid settlement funds for the development of primary prevention education programs to work with schools in communities that have higher than average opioid overdose deaths, non-fatal outpatient emergency department visits, and hospital discharges involving opioid use, poisoning, dependence, and unspecified use.
Key Takeaways
Opioid settlements provide an opportunity for states and localities to strategically invest in priorities for addressing the ongoing substance use crisis. Continued investment of evidence-based practices and strategies for reducing substance use, supporting early intervention, and reducing harms is critical to building a future addiction infrastructure. Johns Hopkins University’s Principles for the Use of Funds From the Opioid Litigation — which many states have incorporated into their settlement decision-making processes — includes investing in youth primary prevention programs as a key priority for settlement funding. With prevention activities already supported by wide variety of agencies and governmental levels, investing opioid settlements in prevention offers state officials an opportunity to collaborate strategically, strengthen existing prevention infrastructure, and create opportunities for future prevention activities.
Federal Resources
SAMHSA
- Engaging Community Coalitions to Decrease Opioid Overdose Deaths Practice Guide 2023
- Community Engagement: An Essential Component of an Effective and Equitable Substance Use Prevention System
- Principles of Substance Abuse Prevention for Early Childhood
- Data-Based Planning for Effective Prevention
- National Survey on Drug Use and Health
Other Resources
- Blueprints for Healthy Youth Development, a registry of evidence-based interventions that have been rigorously evaluated for effectiveness in prevention
NASHP Resources
Acknowledgments
The National Academy for State Health Policy provides this information with the ongoing support of the Foundation for Opioid Response Efforts (FORE) and thanks FORE Project Officer Ken Shatzkes and FORE President Karen Scott for their continued guidance and direction. The authors would also like to thank Chris Jones, Cara Alexander, Torrance Brown, Ingrid Donato, Charlene Jenkins, and Michelle Leff with the SAMHSA Center for Substance Abuse Prevention for their feedback, as well as Bobbie Boyer, Valerie Connolly-Leach, Joelle Foskett, Krista Machado, Sarah Mariani, Katie Postmus, Jennifer Rennquist, Lisa Shields, Kris Teters, and Jared Welehodsky for their input.
