Mobilizing community coalitions to address inequities identified through local data is a proven strategy to prevent and intervene with community substance use concerns. Communities That Care (CTC) is one effective 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 outcomes.
CTC coalitions foster local capacity to make lasting changes in communities by using local data to address risk and protective factors that lead to reductions in outcomes like experience of violence, mental health conditions, and substance use. As CTC coalitions mature, they become a mobilizing force capable of addressing a broad spectrum of prevention in the community, which can include opioid use. CTC coalitions can be particularly effective in addressing opioid use in their communities because of the collaborative partnerships that have been created between stakeholders, ranging from educators, community members, and local government agencies.
Equitable prevention strategies rely on an approach that centers individuals with lived or living experience. Individuals directly affected by social conditions and prevention interventions can provide essential information on how to address their actual conditions of risk. Authentic engagement and empowerment 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 coalition’s focus on shared risk and protective factors in local prevention can be applied to the biological, social, and psychological factors that increase risk of opioid use and inform prevention strategies. Coalitions can apply methods to increase protective factors across the prevention continuum through the development of strategies that are informed by an understanding of the social determinants of health.
CTC coalitions that are ready to address opioid use prevention can leverage their existing data and analysis of community resources to identify which opioid use prevention efforts will be most effective to address community risk factors and disparities. These prevention efforts range from individual- to community-level.
Individual-level prevention aims to increase knowledge and empower individuals as primary agents of change in reducing risk and harm associated with opioid use, including overdose. Substance use education, safe medicine storage, and naloxone distribution are a few examples of individual prevention strategies 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 including populations experiencing disproportionate overdose and other opioid use-associated harm. This level of prevention aims to build connections between people and communities to reduce the availability and use of opioids through strategies such as provider education and public awareness.
This literature review features current research that assesses the impact of shared risk and protective factors on risk of opioid use and attendant harm. This review provides examples of evidence-informed strategies to address community concerns associated with opioid use. This review is not meant to be comprehensive, as research and best practices continue to evolve.
Availability of Substances &/Or Community Norms Favorable to Substance Use
One of the risk factors for opioid use is the availability of prescription drugs in a community.13 There are a number of avenues through which adolescents and adults may be introduced to prescription opioids. Access through a friend or relative and prescription by a medical professional are the two most common routes of access to opioids for adolescents and young adults, respectively (same source in comment).4 One study found that roughly 55.7% of youth often obtained prescription medication from family members or friends and 25.4% received them from a doctor.14 This suggests opportunities for strategies such as education about the risks of sharing medication, safe medicine storage methods, and increased provider education on screening prior to prescription to 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 use because these perceptions and norms help to shape a youth’s perception of risk.6
There are 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 opioids than doctors in urban communities.6 Provider-level education might be one way to reduce rates of opioid use 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 lack of transportation to medical centers.6
Increase the range of pain management options available in the community, including non-opioid pain management. You can find the most recent guidelines for prescribing opioids for pain here.
Provider education and screening tools to assess for risk and protective factors prior to prescribing opioids or other substances
Reduce distribution of prescription medication through safe storage and disposal resources.
Community education to increase understanding of opioids and risks of use and increase safe medicine storage practices.
Parent Attitudes Favorable Toward Substance Use
When young people have strong bonds to a parent or trusted adults they are less likely to use substances because the young person values their relationship with an adult and may believe that substance use would put this relationship at risk.5 Parents and guardians have a significant influence over a youth’s perception of substance use. One study found that when parents and guardians have a more favorable or permissive attitude towards substance use, their children are more likely to report nonmedical use of prescription medications in the past year.4
Use Blueprints or Families First Prevention Act registries to identify parent education opportunities that address the risks of substance use.
Include parent and guardian education on the risks of opioids, understanding of risk and protective factors for young people, and increase safe medicine storage practices.
Provide opportunities for trusted adults to develop skills related to discussing substance use with young people and providing a safe, open channel of communication.
Provide parents and trusted adults with a range of resources to provide factual information to young people about how to keep themselves and their friends safe, how to get help, and how to identify values and boundaries related to risky behavior.
Resources:
Interior Health has a Youth Harm Reduction: A toolkit for Service Providers that also has resources for parents.
Ask Listen and Learn has a Parents page with resources.
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 use. 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 use.12 One study of youth who use opioids found that youth who experience emotional abuse or neglect were about 5 times more likely to have used 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 child care that is affordable for parents.
Youth who experience housing insecurity are two to ten times more likely to use 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 in an attempt to cope with attendant physical and psychological distress.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 use 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
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 use. 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 use 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
Resources
Integration of young people with lived experience as peer support
Build relationships with existing community resource providers to enhance referrals and support for students
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 use 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 use 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
Zero tolerance policies that result in suspension, expulsion, or even arrest at school due to substance use or other minor infractions can increase young people’s risk of engagement in the carceral system later in life, also known as the “school to prison pipeline”.15 Removal from school as a consequence of substance use can increase likelihood of further risks associated with substance use as well as the removal of a prosocial environment in which young people can engage with peers and trusted adults to improve their protective factors.
Young people of color, particularly Black students, are disproportionately subjected to zero tolerance policies for substance use despite no meaningful correlation with actual differences in disruptive school behavior compared with their White peers.16 Since they are already at higher risk of engagement in the criminal legal system due to discriminatory policing practices and drug policy, suspension and expulsion can have a particularly devastating effect on both their behavioral health outcomes and future health and social conditions.15
Connect Families to Head Start, Early Head Start, and Preschool Education
Use Blueprints or Families First Prevention Act registries to identify school climate and social-emotional health curricula.
Resources:
Provide on-site or trusted community behavioral health resources for students and families
Enhance capacity to assess and address experiential factors contributing to students’ school achievement
Development of alternatives to zero tolerance policies with feedback from families, behavioral health providers and young people. Including an emphasis on evidence informed early intervention strategies. Take a look at the Department of Education’s Alternative to Zero Tolerance: Best Practice Summary.
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 Development of school connectedness and protective factor differ among young people with intersecting marginalized identities including race, socioeconomic status, disability status, sexual orientation, and gender identity (source). The application of evidence-informed policies is essential to ensure that all young people have equitable opportunities to develop strong bonds to their school.
Use Blueprints or Families First Prevention Act registries to identify school health education or social emotional health curricula.
Adopt School Policies and Practices that Promote Student Sense of Belonging
Increased Funding and Access to High Quality School-based Extracurricular Activities
Enhance School Quality Through Funding and Operational Improvements
Resources:
Implement equity practices such as anti-bias and multicultural training and policy for school staff, establishing restorative justice programs, and social emotional learning programs. Educational resources like Drexel University’s The Importance of Diversity & Multicultural Awareness in Education and the Universal Design for Learning Guidelines may be helpful.
Create opportunities for students to provide feedback on factors that would increase their connectedness. Check out the Resource Hub’s 6 Strategies to Promote School Connectedness.
Create spaces for empowering youth-led coalitions and alliances for students experiencing marginalized identities and their peers
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 use opioids. Ample evidence exists that adverse childhood experiences (ACEs) can lead to adolescent opioid use. 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 use opioids.
Use Blueprints or Families First Prevention Act registries to identify social-emotional health curricula.
Increased Funding and Access to High Quality School-based Extracurricular Activities
Resources:
Provide opportunities for students to contribute to inclusive activity development and implementation. One example from Inclusive School Communities is The Art of Inclusion: Teaching Students to be Includers.
Limited Parent Time to Monitor Youth Behavior
When youth have strong bonds to a parent or trusted adults they are less likely to use 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 use substances.4 This increased involvement leads youth to believe that if they were to use 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 Young people also benefit from clearly communicated expectations and avenues for support. Development and maintenance of strong bonds with trusted adults or parents can also increase communication about the risks young people may be facing and how to work in partnership on managing them.The bonds or connections that parents or caregivers have with their children can significantly reduce the risk of substance use due to enhanced engagement in young peoples’ lives, stronger trust and communication, and collaborative opportunities to reduce risk.
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.
Resources:
Enhance skills and strategies for trusted adults and parents to pragmatically address substance use with young people, provide clear boundaries, and communicate avenues for safety and adult support should the young person engage in substance use or other behaviors. Resources like Getting Candid and Having Tough Conversations can help.
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 used 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
Use Blueprints or Families First Prevention Act registries to identify school health education or social emotional health curricula that address the risks of substance use and increase healthy coping skills.
Adopt School Policies and Practices that Promote Student Sense of Belonging
Enhance School Quality Through Funding and Operational Improvements
Resources:
Provide factual information to young people about substance use. Include information about youth brain development and health, effects and risks of substances, harm reduction strategies to reduce risk. The Drug Wheel and Safety First: Comprehensive Drug Education are resources that can help get you started.
Youth Favorable Attitudes Towards Substance Use
Peers have a significant influence over a youth’s perception of substance use. Perceived peer substance use, acceptance or approval has an impact on the adoption of substance use behaviors for young people.4, 17 Perceived or actual social acceptability of substance use or non-use through indirect means such as media and social networking platforms are also avenues through with young people’s perception of risk associated with initiation of use may be influenced.
Use Blueprints or Families First Prevention Act registries to identify school health education or social emotional health curricula that address the risks of substance use and increase healthy coping skills.
Adopt School Policies and Practices that Promote Student Sense of Belonging
Enhance School Quality Through Funding and Operational Improvements
Resources:
Provide a wide range of representation across the substance use spectrum e.g. peers and public figures in recovery, with lived experience.
Empower young people to create substance use messaging campaigns and awareness activities that speak to their priorities and perceptions
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 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
Use Blueprints or Families First Prevention Act registries to identify school health education or social-emotional health curricula that address the risks of substance use and increase healthy coping skills.
Adopt School Policies and Practices that Promote Student Sense of Belonging
Increased Funding and Access to High Quality School-based Extracurricular Activities
Enhance School Quality Through Funding and Operational Improvements
Resources:
Utilize age appropriate education to support students in identifying their boundaries and priorities as it relates to substance use risk and protective factors.
Provide opportunities for parents and other guardians to access factual information on substance use and available community resources.
Best Practices in Opioid Intervention
The CDC outlined evidence-based approaches to provide therapeutic support to people who use opioids and those who have an opioid use disorder, prevent overdoses, and reduce potential harm. 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.
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 naloxone here, and how to access Naloxone in Colorado here.
Medication for Opioid Use Disorder (MOUD)
MOUD is a proven pharmacological treatment for opioid use disorder. The backbone of this treatment is FDA-approved medications. Agonist or partial agonist drugs, methadone and buprenorphine, activate opioid receptors in the brain, managing opioid withdrawal and craving through medically monitored doses. Naltrexone (brand name Vivitrol), was marketed as an MOUD that had no opioid-receptor stimulation properties, solely blocking the effects of opioids. However, newer evidence has identified underreporting of overdose events associated with the original approval of naltrexone as an MOUD.18 Naltrexone is not recommended for MOUD due to its enhanced risk of overdose and lack of craving or withdrawal symptom management. It is currently being researched as a drug cessation tool for alcohol use disorder. MOUD are part of a group of substances associated with Medication for Addiction Treatment/Medication Assisted Treatment (MAT). MAT is effective in reducing the risks associated with variable potency and purity of substances in the illicit drug supply and provides opportunities for individuals to access medical care that provides manageable craving and withdrawal management.
Provision of drug checking tools for people who use drugs
Drug checking is a harm reduction practice in which individuals can test their substances for adulterants and additives such as fentanyl and xylazine. Availability of drug checking tools has been shown to increase changes in drug use behavior as individuals have more information about the substance they intend to use and its potential risks.19 Individuals may choose to avoid using the substance altogether or utilizing other risk reduction strategies such as having someone there who can respond to an overdose or using a smaller amount. Drug checking is one of many strategies that support continued morbidity and mortality prevention if substance use has already been initiated. Learn more about drug checking tools here.
Substance Use Screening and assessment
Assessing patients for substance use can create opportunities to communicate about risk reduction and relevant resources. It is important that providers are approaching any form of assessment with a non-judgemental, non-coercive stance to increase patient comfort in self-reporting substance use behaviors. Addressing health provider stigma and bias can positively impact health service utilization for people who use both legal and illegal drugs.20 If drug testing (urine or blood analysis) is utilized in a medical or carceral setting, providers should seek informed consent for testing and provide clear information about the impact of any results (particularly if they could be punitive). Results should also be used to inform conversations about risk reduction and supportive resources.21
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 responders 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. This and other laws are in place to encourage those most likely to be in a position to quickly respond to an overdose to do so. 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. You can find a list of Colorado Syringe Services here.
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