Applying Risk and Protective Factor Approaches to Opioid Prevention

Community coalitions that organize and build momentum to address prevention priorities in their community, based on local data with a focus on addressing inequities in the data, are a proven strategy to prevent and intervene with substance misuse concerns locally. Communities That Care (CTC) is one such proven prevention science model that guides communities to organize diverse, multi-sector coalitions to address risk and protective factors and implement evidence-informed solutions to improve youth health and behavior outcomes. These coalitions foster local capacity to make lasting changes in communities by using local data to address risk and protective factors that lead to outcomes like violence, poor mental health, and substance misuse. As CTC coalitions mature, they become a mobilizing force capable of addressing a broad spectrum of prevention in the community, which can include opioid misuse. CTC coalitions can be particularly effective in addressing opioid misuse in their communities because of the collaborative partnerships that have been created between stakeholders, ranging from educators, community members, and local government agencies. Authentic engagement of individuals directly affected by adverse social and health outcomes creates unique pathways for their involvement in the planning, implementation, or evaluation phases of the work. As a result, solutions more effectively address issues in the community and members of CTC coalitions become advocates of community-driven prevention efforts.


The goal-oriented nature of the coalitions, as well as the creation of clear implementation plans facilitate the deliberate action steps that are key in effective implementation of opioid prevention efforts. CTC coalitions plan the work by building the core components of successful systems change and focusing on capacity areas in their implementation and evaluation efforts. Coalitions focus on six elements that ensure the strength and health of the coalition to address systems-level change by

  1. developing goal-directedness,

  2. cohesion,

  3. efficiency,

  4. diverse stakeholders,

  5. opportunities for participation, and

  6. new skills.


As elements of effective coalition functioning coalesce, coalitions create an action plan that is continually evaluated and improved over time to achieve their goals. The coalition’s focus on shared risk and protective factors in local prevention efforts also impacts opioid misuse and therefore can help to inform prevention efforts needed. By engaging in prevention work, coalitions can continue to expand their sphere of influence to include strategies that go beyond the spectrum of upstream prevention.


CTC coalitions that are ready to address opioid misuse prevention can leverage their existing assessment and gaps analysis of community resources, supplementing data where needed, to identify which opioid prevention efforts will be most effective to address the gaps seen in their communities. These prevention efforts range from individual- to community-level.


Individual-level prevention aims to increase knowledge and change the attitudes and behaviors of individuals in the community on opioid misuse, abuse, and overdose. Drug take-back programs, safe storage, and provider education are a few examples of individual prevention that align with the CTC model. Community-level prevention aims to increase cross-sector capacity to collaborate and implement projects that serve the general community or specifically prioritized populations on opioid misuse, abuse, and overdose prevention. This level of prevention aims to build connections between people and communities to reduce the availability and misuse of opioids.


This literature review features current research that draws the connection between shared risk and protective factors and opioid misuse. This review is not meant to be comprehensive as research on opioid misuse is ongoing.

Risk and Protective Factors With Specific Opioid-related Activities

Availability or Substances &/Or Community Norms Favorable to Substance Use

One of the greatest predictors of opioid misuse is the availability of prescription drugs in a community.4 The development of new medications and a doctor’s prescribing practices, specifically relating to pain management, could increase the availability of substances youth have access to.4 One study found that roughly 67% of youth often obtained prescription medication from family members or friends who got the medication through legitimate means, prescribed from a doctor.6 This suggests that more education about safeguarding medication, or increased opportunities for safe disposal of unused prescription medication would decrease the availability of prescription drugs in a community.6


The availability of prescription medication often leads to perceived safety in using these drugs because they are prescribed by doctors to family and friends, sometimes even to children.6 Community perceptions and norms can lead to the normalization of nonmedical prescription drug use and ultimately misuse because these perceptions and norms help to shape a youth’s perception.6


There is some data that suggests that youth living in more rural areas may be more at risk for substance use because of increased availability and the community’s perception of substances, including opioids.4 For instance, physicians in rural communities are more likely to prescribe drugs than doctors in urban communities.6 Provider-level education might be one way to reduce rates of opioid misuse in communities. The disparity of higher drug use among rural communities is an equity concern because there is often lower access to treatment services due to distance, capacity, and transportation to medical centers.6


Evidence-based Strategies or Programs

Ordinances, Regulations, Requirements for Establishments Selling Liquor, Marijuana, or Promoting Prescription Drug Use

Opioid-specific activities within that strategy

  • Limit access to prescription drugs in communities by reducing supply through provider education.

  • Reduce access to existing supply through safe storage and disposal efforts.

  • Community education to reduce demand for opioids and increase safe storage practices.

Parent Attitudes Favorable Toward Substance Use

When youth have strong bonds to a parent or trusted adults they are less likely to misuse drugs because the youth value their relationship with their parent and may believe that substance use would put this relationship at risk.5 Parents have a significant influence over a youth’s perception of substance use. One study found that when parents have a more favorable attitude towards substance use, their children are more likely to report nonmedical use of prescription medications in the past year.4

Evidence-based Strategies or Programs

Use Blueprints or Families First Prevention Act registries to identify parent education opportunities that address the risks of substance misuse.

Opioid-specific activities within that strategy

  • Include parent education on the risks of opioids, recommendations against using opioids for most adolescent injuries and surgeries, and increase safe storage practices.


Additional Risk and Protective Factors Linked to Prevention of Opioid Misuse

Limited Economic Opportunities

There are several factors that can influence extreme economic deprivation. Several studies reported that there is a direct relationship between low income and an individual’s use of drugs. Living in a low-income household increases the risk of substance use in young people, with one study showing that low-income students were twice as likely to report using substances than other students.4

Ample evidence exists that adverse childhood experiences (ACEs) can lead to adolescent opioid misuse. ACEs are potentially traumatic experiences as well as living in environments that can undermine a child’s sense of safety, stability and bonding between the ages of 0-17 years.3 Approximately 56-64% of drug use in adults are associated with ACEs, and many studies show that there is a strong connection between ACEs and adolescent opioid misuse.12 One study of youth who misuse opioids found that youth who experience emotional abuse or neglect were about 5 times more likely to have misused opioids than their peers who didn’t have those same experiences.12

There are ways to prevent ACEs in our communities by strengthening community supports. If communities can increase the support and engagement for paid family leave, income tax credits, and affordable childcare, then families can gain access to resources that they would need to create more positive and stable environments. Children can also benefit from getting a strong start at the beginning of their lives by having access to quality early childcare that is affordable for parents.


Youth who experience housing insecurity are two to ten times more likely to misuse prescription drugs than their peers who have a stable home environment.2 When youth experience housing insecurity there may be a higher probability that they will experience physical or mental trauma, which can increase their use of prescription drugs because youth are either trying to self-medicate or to block painful memories.2 When we look at Colorado specifically, some studies have found that there is an increased risk of misusing prescription drugs in youth who are experiencing housing insecurity.2 One study found that youth who experience homelessness in Denver were significantly more likely to misuse prescription drugs than other cities in their study.2


Another study shows that there is a strong correlation between youth experiencing homelessness who are currently misusing prescription medication and their rates of injection drug use.1 This shows that youth who are experiencing housing insecurity are more likely to be misusing multiple substances and increasing the severity of negative health outcomes by injecting drugs. Transmission of several blood-borne infections, like HIV/AIDS and Hepatitis C, greatly increases with injection drug use. The risk of youth misusing prescription drugs and injection drug use increases when youth experience housing insecurity for longer periods of time.1

Evidence-based Prevention Strategies or Programs to Address this Risk Factor:

Community Opportunities for Prosocial Involvement

Communities that increase prosocial opportunities for community members to participate in can increase the bonds and networks that exist within the community. Ample evidence exists that adverse childhood experiences (ACEs) can lead to adolescent opioid misuse. ACEs are potentially traumatic experiences as well as living in environments that can undermine a child’s sense of safety, stability and bonding between the ages of 0-17 years.3 Research shows that community-level engagement can help to reduce the number of ACEs in youth regardless of their home environment. ACEs are potentially traumatic experiences as well as living in environments that can undermine a child’s sense of safety, stability.3 There is evidence that ACEs can be intergenerational, meaning that parents who have higher rates of ACEs often have children with higher number of ACEs during their childhood.12 Community-based solutions are one of the ways that the negative effects of parental ACEs can be lessened.12 One study that was conducted on a rural, lower socio-economic status community found that when members perceived that their community had high social cohesion, there was a decrease in ACEs across generations.12 Increasing the number of opportunities in a community helps to create more social cohesion.

Current research shows that youth report higher use of prescription drugs when they live in communities where there is a lack of opportunity for social participation.6 Communities that have stronger community bonds, networks, and a sense of belonging are less likely to have issues with prescription drug misuse than communities without those opportunities.6 Higher rates of crime and public intoxication may be indicators of communities with a lack of prosocial opportunities.6 In those communities lacking these opportunities, there is an increase in a youth’s chances of using substances and becoming drug dependent.7

Evidence-based Prevention Strategies or Programs to Address this Risk Factor:

Limited Academic Success

There is a significant relationship between a student’s use of prescription drugs and poorer school performance, including dropping out of school.4 When a youth has a long-time history of misuse of prescription drugs, they tend to have lower overall GPAs than students who are not misusing drugs.4 However, it doesn’t take a long history of misuse for nonmedical use of prescription drugs to affect a student’s performance. One study reported that if a student has any nonmedical use of prescription drugs within the past year, they are more likely to have a grade of D or worse.4

Evidence-based Prevention Strategies or Programs to address this risk factor:


Limited Commitment to the Value of School

Students who have a strong bond to their school are less likely to report nonmedical use of prescription drugs than students who don’t feel connected to their school.5 When students are involved in school activities, invested in their academics, and feel connected to their peers they are less likely to jeopardize their goals by misusing prescription medication.5 In fact, school connectedness shows a stronger connection to lower rates of drug use in youth when compared to the connection to their parents.5

Evidence-based Prevention Strategies or Programs to address this risk factor:


Opportunities and Rewards for Prosocial Involvement in School

Increasing opportunities for students to connect to school activities and caring adults can decrease the likelihood that they would misuse opioids. Ample evidence exists that adverse childhood experiences (ACEs) can lead to adolescent opioid misuse. ACEs are potentially traumatic experiences as well as living in environments that can undermine a child’s sense of safety, stability and bonding between the ages of 0-17 years.3 Schools can help to prevent ACEs in their students by teaching them the skills needed to handle stresses and manage their emotions so that they can deal with everyday challenges.12 This can include connecting youth to caring adults and activities that would help to build those skills in students. Access to after-school activities and incorporating evidence-based curriculums in the classroom can increase a student’s prosocial involvement in their school environment.12 Increasing school bonds can help to decrease the amount of youth who would misuse opioids.

Evidence-based Prevention Strategies or Programs to Address this Risk Factor:


Limited Parent Time to Monitor Youth Behavior

When youth have strong bonds to a parent or trusted adults they are less likely to misuse drugs because the youth value their relationship with their parent and may believe that substance use would put this relationship at risk.5 Studies also show that when parents are more involved in their child’s lives that the child is less likely to misuse substances.4 This increased involvement leads youth to believe that if they were to misuse drugs that this behavior would be more likely noticed by their parent.5 A closer monitoring of youth can also limit the amount of opportunities that they might have to use drugs versus youth that don’t have any monitoring of their behavior.5 The bonds or connections that parents or caregivers have with their children can significantly reduce the risk of substance use.

Evidence-based Prevention Strategies or Programs to Address this Risk Factor:

  • Family-Friendly Business Practices

  • Use Blueprints or Families First Prevention Act registries to identify parenting programs that support effective and developmentally appropriate and emotionally supportive monitoring skills for parents.


Youth Perceive Substance Use as Low Risk

When youth perceive their risk of harm from using prescription medication, they may develop more favorable attitudes towards substance use.4 One study found that students who had a low perceived risk of harm from prescription drugs were more likely to have misused prescription drugs in the past year.4 This is in part due to the normalization of prescription medication. In one study participants stated that they perceived prescription drugs to be less harmful because most people had taken prescription drugs in their lifetime.6

Evidence-based Prevention Strategies or Programs to address this risk factor:

  • Use Blueprints or Families First Prevention Act registries to identify school health education or social emotional health curricula that address the risks of substance misuse and increase healthy coping skills.


Youth Favorable Attitudes Towards Substance Use

Peers have a significant influence over a youth’s perception of substance use. If the youth’s peer-group has a more favorable attitude towards substance use, the youth is more likely to hold similar beliefs which increases their risk to misuse substances.4

Evidence-based Prevention Strategies or Programs to Address this Risk Factor:

  • Use Blueprints or Families First Prevention Act registries to identify school health education or social emotional health curricula that address the risks of substance misuse and increase healthy coping skills.


Early Initiation of Substance Use

Early initiation of substances is a key risk factor in the development of a substance use disorder later in life. Studies show that the earlier an individual initiates substance use, the higher the odds of developing a substance use disorder throughout their lifetime.11 Early initiators also are at risk of developing poorer psychosocial outcomes and increase their odds of using heroin during their adolescence.11 These studies also demonstrate a connection in early initiators between substance use disorders and lower educational achievement, and lower socioeconomic status.11 Youth who delay substance use can see roughly a 5% decrease per year in developing a substance use disorder throughout their life with every year that they delay using substances.11

Evidence-based Prevention Strategies or Programs to Address this Risk Factor:

  • Use Blueprints or Families First Prevention Act registries to identify school health education or social-emotional health curricula that address the risks of substance misuse and increase healthy coping skills.


Best Practices in Opioid Intervention

The CDC outlined evidence-based approaches to provide therapeutic support to opioid users, prevent overdoses, and assist in their path toward recovery. Though these strategies do not align directly with the upstream prevention approaches outlined in the Communities That Care (CTC) model, CTC Coalition Members can be powerful advocates for evidence-based strategies that can save lives in their communities.

From the CDC report:

Targeted Naloxone Distribution

Naloxone is an opioid antagonist that can quickly and safely reverse the potentially fatal effects of an opioid overdose. Targeted distribution programs seek to train and equip individuals who are most likely to encounter or witness an overdose—especially people who use drugs and first responders—with naloxone kits, which they can use in an emergency to save a life. There are many different approaches to distributing naloxone to people at high risk of experiencing or witnessing an overdose. Effective approaches include community distribution programs, co-prescription of naloxone, and equipping first responders. You can read more about accessing Naloxone and training in Colorado here.

Medication-Assisted Treatment (MAT)

MAT is a proven pharmacological treatment for opioid use disorder. The backbone of this treatment is FDA-approved medications. Agonist drugs, methadone and buprenorphine, activate opioid receptors in the brain, preventing painful opioid withdrawal symptoms without causing euphoria; naltrexone blocks the effects of opioids. MAT is effective at reducing use and helping people to lead normal lives.

Screening for Fentanyl in Routine Clinical Toxicology Testing

The standard panel of substances included in routine clinical drug screens (carried out in hospitals, clinics, treatment centers, etc.) should include screening for fentanyl exposure, particularly in jurisdictions where fentanyl is known to be prevalent in the local illicit drug market.

Educating about Colorado’s existing 911 Good Samaritan Laws

The term “911 Good Samaritan Law” refers to local or state legislation that may provide overdose victims and/or overdose bystanders with limited immunity from drug-related criminal charges and other criminal or judicial consequences that may otherwise result from calling first responders to the scene. The scope of 911 Good Samaritan Laws varies across U.S. states, but each is written with the goal of reducing barriers to calling 911 in the event of an overdose. You can read more about Colorado’s laws here.

Syringe Services Programs

Sometimes called “needle exchange” or “syringe exchange,” syringe services programs provide access to clean and sterile equipment used for the preparation and consumption of drugs as well as tools for the prevention and reversal of opioid overdoses, such as naloxone training and distribution, fentanyl testing strips, and more. Comprehensive syringe services programs also provide additional social and medical services such as: safe disposal of syringes and needles; testing for HIV and hepatitis C infection and linkage to treatment; education about overdose and safer injection practices; referral and access to drug treatment programs, including MAT; tools to prevent HIV and other infectious diseases, such as condoms, counseling, or vaccinations; and linkage to medical, mental health, and social services.


WORKS CITED

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  2. Barman-Adhikari, A. Et al. (2019) Prevalence and Correlates of Nonmedical Use of Prescription Drugs (NUMPD) Among Young Adults Experiencing Homelessness in Seven Cities Across the United States. Journal of Drug and Alcohol Dependence. 200:153-160

  3. CDC. (2020). Preventing Adverse Childhood Experiences. National Center for Disease Prevention and Control – Division of Violence Prevention. Website.

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  6. Ford, J. Sacra, S. Yohros, A. (2017). Neighborhood Characteristics and Prescription Drug Misuse Among Adolescents: The Importance of Social Disorganization and Social Capital. International Journal of Drug Policy. 46, 47-53

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  8. Monnat, S. Rigg, K. (2016). Examining Rural/Urban Differences in Prescription Opioid Misuse Among US Adolescents. The Journal of Rural Health. 32, 204-218

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  11. Schepis, T. Hakes, J. (2017). Age of Initiation, Psychopathology, and Other Substance Use Are Associated With Time to use Disorder Diagnosis in Persons Using Opioids Nonmedically. Substance Use and Misuse. 55:6, 928-936

  12. Swedo, E. Et al. (2020) Adolescent Opioid Misuse Attributable to Adverse Childhood Experiences. The Journal of Pediatrics. 224, 102-109.