Prevention and Societal Impact of Drug and Alcohol Abuse

Robert T. Ammerman, Peggy J. Ott, Ralph E. Tarter

• Publisher: Psychology Press
• Year: 1999
• ISBN:
  9781135672157
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

It is generally acknowledged that the most cost-effective means of curtailing alcohol and drug abuse is prevention. Providing interventions to at-risk individuals before they develop serious problems with substance use is the most important component of the "war on drugs." Fortunately, the past decade has seen a dramatic increase in the quantity and quality of scientific research on those areas crucial to the advancement of prevention science. This book compiles a tremendous amount of information about prevention which has accumulated in recent years. Documenting these accomplishments and setting the stage for future efforts comprise the focus of this book. Prevention and Societal Impact of Drug and Alcohol Abuse is divided into four parts. Part I contains introductory chapters addressing current issues in prevention science and characteristics of abusable substances. Part II includes chapters on the historical contexts of substance abuse and the deleterious health consequences of alcohol and other drugs. Part III focuses on the impact of drug and alcohol abuse on society. Included are chapters on alcohol and drug abuse and driving, infectious illness, disability, managed care, the criminal justice system and adolescents and adults, sale and distribution, the media, and community responses. Part IV consists of chapters on prevention in specific settings and with certain populations.

PART I
INTRODUCTION

CHAPTER 1
Critical Issues in Prevention of Substance Abuse

Robert T.Ammerman
MCP-Hahnemann University and Allegheny General Hospital

Peggy J.Ott
Ralph E.Tarter
University of Pittsburgh School of Medicine

Timothy C.Blackson
The Pennsylvania State University

Substance abuse is one of the most challenging problems facing society in the late 1990s. The prevalence of substance use and abuse is staggering. Alcohol consumption is commonplace, with approximately 140 million Americans using alcohol in 1995 (Office of Applied Studies, 1995). An additional 13 million persons used illicit drugs in at least 1 month during 1994 (U.S. Department of Health and Human Services, 1995). The consequences of alcohol and drug abuse are equally disconcerting, as evidenced by the link between substance abuse and acute and chronic health problems, car-related injuries and deaths, poor work performance and attendance, psychosocial maladjustment, and involvement in criminal activity. Considerable financial expenditures also result from substance use and abuse, involving the health care system, law enforcement, the criminal justice system, and lost economic efficiency. Substance use typically emerges in adolescence. For a significant proportion of individuals, problems with drugs and alcohol will continue through adulthood. As with many social ills, treatment of affected individuals is expensive and has a limited rate of success. Accordingly, it is almost universally acknowledged that the most effective approach to decreasing substance abuse is prevention. Curtailing the full clinical expression of substance use disorders preserves resources currently allocated to treatment and other forms of intervention (e.g., law enforcement) and mitigates the harmful impact of substance abuse on individuals, families, communities, and society.

Coie et al. (1993) coined the term prevention science to describe the systematic and empirically driven approach to studying the averting of psychological and behavioral disorders, including substance abuse. They noted the multidisciplinary nature of this “new” discipline, joining together the combined expertise of psychology, psychiatry, public health, sociology, criminology, education, and human development. In the past decade, prevention science has coalesced into a vibrant and informative domain of study. Reflections of this include the founding of professional organizations devoted to prevention science (such as the Society for Prevention Research), special editions of journals devoted to prevention, and the plethora of recent journal articles focusing on prevention of mental health problems in general, and substance abuse in particular. Clearly, this is a field that has emerged from its nascent stage to a new level of scientific maturity and sophistication.

The purpose of this chapter is to succinctly review the major issues in the prevention science of substance abuse. We begin by briefly recounting the impact of substance use and abuse, because this documents the negative consequences of the phenomenon and provides an important starting point from which prevention efforts can be explored. After an overview of current issues in the conceptualization of prevention science, we examine important elements of efficacious prevention programs. Finally, we end with a summary and proposed template to guide the future directions that research and practice might take. It should be noted that, although substance abuse prevention efforts have been implemented across the life span, much of the work in the field has focused on children and adolescents, and this population is the primary focus of this chapter. The reasons for this are compelling. First, exposure to and initiation of substance use typically occurs in adolescence. Second, a sizable proportion of substance use problems (including the development of abuse and dependence) begin in adolescence and extend into adulthood. Third, the goal of prevention is to intervene with individuals before they begin using and develop problems with alcohol and drugs, thus necessitating an emphasis on children and youth. And fourth, childhood and adolescence are times of dynamic change and development in psychological and physical domains. It is desirable to influence these more malleable developmental processes before they become entrenched and more resistant to intervention.

IMPACT OF SUBSTANCE ABUSE

The damaging consequences of alcohol and drug abuse impact individuals, families, and the systems in which they live. They can be expressed in financial terms: it has been estimated that federal, state, and local drug control policies substance abuse cost the United States approximately $20 billion per year (Office of National Drug Control Policy, 1996). It can also be expressed in the incalculable suffering and lost potential of those afflicted with substance use disorders. Prevention is clearly the most cost-effective means of mitigating the negative effects of substance abuse.

Substance abuse undermines physical health. For example, chronic alcohol abuse is associated with diseases of the liver, central nervous system, and heart (see Goodwin & Gabrielli, 1997). Often, as in the case of the brain disorder Korsakoff’s syndrome, the damage resulting from alcohol abuse is irreversible. Additional health problems stemming from the use of other substances are well documented (see Lowinson, Ruiz, Millman, & Langrod, 1997). Well-known examples are lung cancer caused by smoking, and pervasive central nervous system damage resulting from the inhaling of solvents. In addition, many substances are toxic in excessive doses, resulting in numerous acute and chronic effects on physical health, potentially leading to permanent disability or death. Finally, substance abuse increases the risk for acquiring other health-related problems, such as HIV, sexually transmitted diseases, or trauma secondary to accidents while under the influence of psychoactive substances.

Mental health disorders often occur with substance abuse. Comorbidity is relatively common, with up to one third of individuals with psychiatric disorders reporting a lifetime history of substance abuse disorders as well (Helzer & Pryzbeck, 1998). In some instances, psychiatric disorder precedes or even contributes to the development of substance abuse, whereas in others, emotional and behavioral disturbances arise within the context of alcohol and drug use problems. A large body of research has delineated the disproportionate representation of psychological dysfunction in substance abusers (see Tarter, Ammerman, & Ott, 1998). Included are problems in personality, mood, self-esteem, coping, behavior, and social functioning. Once again, some of these psychological difficulties may be evident prior to the onset of substance abuse, although psychological functioning often worsens over time in individuals with substance use disorders.

Abuse of specific substances may also contribute to relatively unique psychological presentations, such as the amotivational state that has been linked to chronic marijuana use (see Grinspoon & Bakalar, 1997). Other psychological effects of substance abuse are directly linked to the biological impact of psychoactive substances (such as anxiety and irritability stemming from withdrawal) and the behaviors that result from dependence on drugs and alcohol (such as craving and preoccupation with obtaining desired substances).

The family, too, is significantly impacted by substance abuse. Behavioral patterns that often accompany addiction (e.g., preoccupation with obtaining drugs or alcohol, engaging in criminal activities to financially support addiction, lying, involvement in dangerous and risky activities, educational and vocational underachievement) can put tremendous strain on the emotional and financial resources of affected families. Moreover, because substance abuse (particularly when it occurs during adolescence) is more likely to emerge in families that are already distressed or dysfunctional, stress arising from a family member’s addiction may further tax already compromised coping capabilities. Drug and alcohol use in parents can contribute to child abuse and neglect (Peterson, Gable, & Saldana, 1996), couples violence (Hotaling & Sugarman, 1986), and poor communication and lack of support and cohesion within the family.

The cost of substance abuse to the community is also of concern. There is a strong association between substance abuse and crime (Bureau of Justice Statistics, 1993), especially involving illicit substances that are highly addictive (such as crack cocaine and heroin). As the disorder progresses, persons dependent on such drugs often turn to crime to obtain sufficient quantities of drugs to maintain their addictions. Up to 75% of the prison population regularly uses alcohol or drugs, or has been incarcerated for substance-related offenses (see Kleber, Califano, & Demers, 1997). Moreover, addiction also increases the risk of being a victim of crime. Drug activity (such as selling) further undermines the community by exposing children to drugs, providing easy accessibility to illicit substances, and facilitating gang and other organized crime infiltration. Finally, substance abuse deprives the community of human resources that might otherwise be used to strengthen and enhance neighborhood vitality.

The deleterious effects of substance abuse are also seen at the societal level. Substance abusers are likely to perform inefficiently at work, and have higher rates of absenteeism (see Kleber et al, 1997). It is estimated that lost work hours and poor performance costs employers $35 billion per year (Rice, 1995). Additional employer costs are incurred through employee assistance programs for addicted workers, and premiums paid to insurance providers to cover substance abuse treatment. At both the local, state, and federal levels, a tremendous amount of human and financial resources is devoted to lowering the supply and accessibility of drugs. These efforts have only limited success (see Kleber et al., 1997), further underscoring the value of prevention in decreasing the incidence and prevalence of substance abuse.

CONCEPTUAL FOUNDATIONS OF PREVENTION SCIENCE IN ALCOHOL AND DRUG USE

The conceptual roots of prevention science reach back to the early stages of theoretical and empirical emergence of child development, developmental psychopathology, psychiatry, community psychology, and public health (see Institute of Medicine, 1994). However, the clear articulation of principles to guide prevention science is relatively recent. Kelly (1966) outlined four principles of ecological psychology that form the bedrock on which prevention science has been propagated: interdependence, cycling of resources, adaptation, and succession. Interdependence refers to the synergistic, bidirectional influences of systems comprising the individual’s environment. Changes in one system necessarily affect and alter other systems. Cycling of resources reflects the fact that changes in the availability of resources in one system have a subsequent impact on resources needed and used in others. Adaptation is the reaction of individuals to changes in influential factors and resources within and between ecological systems. Altering the features of one or more systems will elicit responses in individuals that constitute adaptations to these changes. Finally, succession describes the fact that ecological systems are dynamic and in a state of flux. Changes in systems, therefore, are likely to be temporary. Taken together, Kelly’s principles underscore the fact that individuals live in environments that are complicated, mutually dependent, and susceptible to change. In order to be effective, prevention programs must be constructed to reflect these characteristics of ecological systems.

The ecological model, originally proposed by Bronfenbrenner (1977) and expanded and refined by others (e.g., Belsky, 1993), draws on Kelly’s (1966) formulation of ecological systems. This conceptualization proposes four levels of influence on the individual’s psychological development and functioning. These systems, each nested one within the other in a hierarchical fashion, consist of the microsystem, mesosystem, exosystem, and macrosystem. The ontogenetic represents characteristics of the individual, including temperament, personality, and physical features. The microsystem describes settings where individuals spend the majority of time, such as family, school, and peer groups. The exosystem consists of the neighborhood and community where individuals reside. Finally, the macrosystem comprises the social and cultural forces that emanate from and, in turn, reciprocally influence the other systems. Included at this level are cultural values, shared beliefs, and economic events that have pervasive influence (e.g., economic depression). Bronfenbrenner highlighted the importance of ecological validity in social and behavioral research. Specifically, he argued that empirical investigations of individuals must take into account (and, ideally, directly measure and simultaneously examine) the systems in which they lived and developed, or else risk ignoring the complexity of development and psychosocial adjustment. Moreover, according to the implicit assumptions of the ecological model, magnitude of change and durability of intervention effects are directly linked to the degree to which prevention efforts target multiple systems and levels of ecological influence.

Iterations of the ecological model emphasize the transactional interplay of risk and protective factors in the etiology of social, emotional, and behavioral disturbance (e.g., Cicchetti & Rizley, 1981; Sameroff & Chandler, 1975). These formulations distinguish between risk factors, which increase the likelihood that psychopathology will develop, and protective factors, which serve as buffers that decrease the probability of psychosocial maladjustment. Consistent with the ecological approach, risk and protective factors can emerge from the multiple systems affecting the individual. In addition, risk and protective factors can be stable and unchangeable (e.g., family history of a disorder), or temporary (e.g., loss of a job). Risk factors interact and combine in dynamic and mutually interdependent ways. Protective factors car. serve as buffers, offsetting the negative influences of risk factors and their combinations. The relevance and salience of given risk and protective factors varies across development. As children and adolescents pass through different and sequential stages of cognitive, emotional, behavioral, and social development, those factors that are most important in promoting or protecting against the emergence of maladaptation may differ in both quantity and quality. As a result, the timing of the occurrence of influencing variables is critical to determining developmental course and outcome.

Tarter and Vanyukov (1994) proposed a liability model for alcohol abuse that is a logical extension of the ecological model and its derivatives. Specifically, they argue that some individuals are born with a genetic vulnerability to developing alcohol use disorders, and that the degree of vulnerability is variable within the population. This genetic liability is expressed in a variety of behaviors and traits (e.g., difficult temperament, emotional and behavioral dysregulation, compromised attentional capacities) that increase the likelihood of subsequently exhibiting alcohol problems in adolescence. The developmental trajectory toward alcohol abuse and dependence is propelled by the influence of environmental factors (e.g., low parental monitoring, affiliation with deviant peers) that interfere with normal adjustment and adaptation (Blackson, Tarter, Loeber, Ammerman, & Windle, 1996). Likewise, other variables strengthen the individual’s functioning, and reverse this negative trajectory, thereby offsetting the vulnerability to alcohol use disorders reflected in the genetic liability. As with the ecological and transactional models, the number, order, time of occurrence, and strength of risk and protective factors is important in determining developmental outcome. The liability model of alcohol use problems has considerable heuristic appeal because it (1) incorporates genetic vulnerability, a well-documented contributor to the etiology of alcohol abuse and dependence (see Vanyukov, Neale, Moss, & Tarter, 1996); (2) invokes the importance of development in understanding the emergence of alcohol use problems; and (3) incorporates the multisystem and transactional conceptualization of the ecological approach. Although Tarter and Vanyukov originally presented the liability model from the perspective of alcohol use problems, it is equally applicable to other substances of abuse. Indeed, it provides a useful framework for conceptualizing other psychiatric disorders and psychopathologies, as well.

RISK FACTORS AND ETIOLOGIC CONTRIBUTORS TO ALCOHOL AND DRUG ABUSE

As noted above, those factors that contribute to negative developmental outcomes in general, and substance abuse in particular, exert their influence in complicated and multidetermined ways. No single factor or subset of factors has been identified that uniquely and consistently predicts the development of substance abuse. Rather, it is the timing, intensity, duration, interaction, and combination of contributory factors that leads to the clinical manifestations of alcohol and drug abuse. However, a number of variables have been identified as important in the etiology of, or serve as risk factors for, substance abuse. These are presented in Table 1.1, and categorized using the four-level schema of the ecological model. Although this is not an exhaustive list of potentially causative variables, those factors that have been consistently linked to substance abuse, and are thought to be important determinants of alcohol and drug use problems, are represented. (Comprehensive reviews of the etiology of alcohol and drug abuse are found in Hawkins, Catalano, & Miller, 1992; Hawkins, Kosterman, Maguin, Catalano, & Arthur, 1997; Institute of Medicine, 1996; Tarter & Vanyukov, 1994). Ideally, prevention efforts should be structured to alter and reverse those etiologic mechanisms that move individuals along a developmental trajectory toward substance use and abuse. To this end, factors listed in Table 1.1 should be addressed and targeted for change in prevention programs.

TABLE 1.1
Risk Factors and Etiologic Contributors to Alcohol and Drug Abuse

It is noteworthy that Coie et al. (1993) outlined a similar constellation (as that presented in Table 1.1) of risk and causative factors for mental health problems in children and youth in general, highlighting the fact that substance abuse often presents concurrently (and shares etiologic pathways) with other problem behaviors and psychopathologies (see Jessor & Jessor, 1977). Therefore, prevention programs that focus on altering causative mechanisms for substance abuse are also likely to simultaneously impact other social, emotional, and behavioral problems.

COMPONENTS OF SUCCESSFUL PREVENTION PROGRAMS

The concept of prevention originally emerged from a public health model (Commission on Chronic Illness, 1957). Within this framework, prevention was divided into three categories: primary, secondary, and tertiary. Primary prevention describ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Preface
• Part I: Introduction
• Part II: Historical Overview and Health Effects
• Part III: Societal Impact and Response
• Part IV: Intervention: Primary and Secondary Prevention