Effective Prevention in New Jersey

E ective Prevention in New Jersey A COMMUNITY GUIDE TO REDUCING YOUTH SUBSTANCE USE

Purpose The New Jersey Prevention Network (NJPN) assembled a workgroup comprised of representatives from the Regional Prevention Coalitions to develop this interactive toolkit to address evidence- based prevention theories that drive effective prevention. This toolkit highlights how and why research is the foundation of our prevention work in New Jersey. The toolkit provides a community guide to relevant research in a user-friendly way that highlights the key components as well as links to additional information that support evidence-based strategies. This includes factors such as Adverse Childhood Experiences and their impact on children and families; the importance of developing and enhancing resilience; identifying gaps, needs, and other best practices all while using SAMHSA’s Strategic Prevention Framework to plan and implement these best practices. This toolkit will be available to all who are interested in implementing evidence-based programs and strategies to reduce the negative impact of substance use and addiction on our communities. The Regional Prevention Coalitions are charged with expanding the state’s prevention capacity and can utilize this toolkit to educate their key stakeholders including schools, elected officials, parents, Children’s Interagency Coordinating Councils (CIACCs), and other youth serving organizations. Thank you to the key prevention leaders that assisted in the development of the document: • Partners In Prevention (Hudson County) • The Center for Prevention & Counseling (Sussex County) • RWJ Barnabas Institute for Prevention and Recovery (Ocean County) • Atlantic Prevention Resources (Atlantic County) • Prevention Resources, Inc. (Hunterdon and Somerset Counties)

This product was supported by grant number SP023017 from the Substance Abuse and Mental Health Services Administration (SAMHSA). The content of this publication does not necessarily reflect the views or polices of SAMHSA or the U.S. Department of Health and Human Services (HHS).

Table of Contents

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Selecting Evidence-based Best Practices Evidence-based Practices Evidence-based Programs & Approaches

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Introduction

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Resources, Toolkits & References

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Prevention Overview

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Highlights of New Jersey’s Prevention System Regional Prevention Coalitions Strategic Prevention Framework Model

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NJ Adverse Childhood Experiences Statewide Action Plan Substance Use Prevention Predictive Outcomes Reporting Tool for NJ

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Prevention Key Concepts Definition of Prevention

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Risk and Protective Factors Universal, Selective & Indicated Populations Environmental Strategies

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Related Factors

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Adverse Childhood Experiences Health Disparities & Social Determinants of Health Mental Health Social Emotional Learning

Introduction

According to Adverse Childhood Experiences: Opportunities to Protect, Prevent Against, and Heal from the Effects of ACEs in New Jersey :

A s part of the Substance Abuse & Mental Health Services Administration’s (SAMHSA) Partnerships for Success (PFS) grant awarded to the State of New Jersey, Department of Human Services, Division of Mental Health and Addiction Services (DMHAS), a key objective is to further strengthen and expand the prevention infrastructure throughout the State of New Jersey. To achieve this goal, DMHAS partnered with the DMHAS-funded Regional Prevention Coalitions (RCs) located throughout New Jersey and the New Jersey Department of Children & Families (DCF), Children’s System of Care (CSOC).

“In New Jersey, where a high percentage of children have been exposed to adversity, the impacts of ACEs, economically and otherwise, are significant. In 2016, more than 40% of children (less than 18 years) in the state had experienced one or more ACEs, and more than 18% of children had experienced at least two. Among the state’s youngest children (under five- years-old), 33% had experienced one or more ACEs. ACEs, however, are not inevitable, nor do they have to determine the destiny of a child who experiences them. ACEs can be prevented, and when they do occur, concrete steps can be taken to help children heal...New Jersey has the potential to become a leader as a trauma-informed, healing-centered state, where children and families thrive, no matter who they are or where they live. Collaborative actions are required to help prevent, protect against, and heal from the effects of Adverse Childhood Experiences (ACEs). ”i

The DMHAS funded Regional Prevention Coalitions (RCs) network has extensive expertise and experience in the utilization of the Strategic Prevention Framework (SPF) and the implementation of evidence-based environmental prevention strategies. DCF’s Children’s System of Care (CSOC), formerly the Division of Child Behavioral Health Services, serves children and adolescents with emotional and behavioral healthcare challenges and their families; children with developmental and intellectual disabilities and their families; and children with substance use challenges and their families. CSOC provides services based on the needs of the child and family in a family-centered, community-based environment. This partnership brings together experts in order to ensure that statewide substance use prevention interventions and programs are brought directly to youth-serving entities that serve those who are at greater risk of substance use and to prevent the onset of and/or reduce the progression of substance use and its related problems.

40% NJ CHILDREN (UNDER AGE 18) WHO EXPERIENCED ONE OR MORE ACE

33% 18%

NJ CHILDREN (UNDER AGE 5) WHO EXPERIENCED ONE OR MORE ACES

This collaboration has two areas of focus: assessing the individual and family risk and protective factors that impact youth substance use in each county and the impact of Adverse Childhood Experiences (ACEs) and their relationship to youth

substance use. The ultimate goal of the partnership is to improve the health and well-being of New Jersey’s youth and to reduce substance use by youth between the ages of 9 and 20.

NJ CHILDREN (UNDER AGE 18) WHO EXPERIENCED TWO OR MORE ACES

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A Note for the Reader: Revised Language

ABUSE VS. USE/MISUSE “Addiction is a chronic but treatable medical condition. Often unintentionally, many people still talk about addiction in ways that are stigmatizing—meaning they use words that can portray someone with a substance use disorder (SUD) in a shameful or negative way and may prevent them from seeking treatment. With simple changes in language, harmful stigma and negativity around SUD can be reduced or avoided.” Following this best practice, words such as “abuse” and other stigmatizing language within this document will be replaced even when it is within a quote or from an outside source as those items were written prior to these important changes in the language we use. When referring to youth use of a substance prior to the legal age of use (21 years of age) as well as the misuse of a substance such as a prescription drug that is being used outside of a prescribed use, we will replace substance “abuse” with substance “use/misuse”. MARIJUANA VS. CANNABIS Please note, as of the date of publication, Governor Murphy signed into law legislation legalizing and regulating cannabis use and possession for adults 21 years and older. Following this, the New Jersey Attorney General made a distinction between the terms marijuana and cannabis referring to “cannabis” when referring to the products sold legally (to those 21 and over) from licensed cannabis businesses, but “marijuana” referring to the drug purchased outside of the regulated market or used by those under 21. Therefore, this document refers to “youth marijuana use” which remains illegal. As such, it will be referred to as “marijuana”.

Here is a link to Words Matter, a guide to utilizing preferred language when talking about addiction ii : https://www.drugabuse.gov/drug-topics/addiction-science/words-matter- preferred-language-talking-about-addiction

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Prevention Overview E ffective prevention is grounded in science and guided by evidence-based strategies. When prevention is implemented using comprehensive, evidence-based strategies that align with community needs, it is possible – even likely – to prevent the misuse of alcohol, tobacco, marijuana/cannabis, prescription drugs, and other illegal substances. Coalitions across New Jersey and the nation are utilizing the Strategic Prevention Framework (SPF) model to plan and implement programs and interventions that follow these effective strategies. Starting with a comprehensive needs assessment, building community capacity, developing a strategic plan during the planning process, implementing evidence-based initiatives and evaluating your efforts make up the key components of the SPF. Coalitions are the building blocks of effective prevention. The Centers for Disease Control and Prevention (CDC) says, “Prevention should be woven into all aspects of our lives, including where and how we live, learn, work and play. Everyone - government, businesses, educators, healthcare institutions, communities and every single American - has a role in creating a healthier nation.” iii New Jersey’s system of Regional Prevention Coalitions brings together these key sectors to collaborate and implement prevention efforts throughout the communities in which they live, work and play. While some prevention efforts focus on unique interventions for specific drugs such as opiates, many more work to address addiction from a deeper and more upstream perspective. We cannot be singularly focused on the impact of one specific drug. The Trust for America’s Health and Well Being report, The Pain in the Nation: The Drug, Alcohol and Suicide Crises and The Need for a National Resilience Strategy , states, “One thing is clear, there is an immediate need to develop an actionable national response to alcohol and drug misuse and death by suicide. Not only are these urgent health crises across this country, they are indicators of the need to go deeper and to look at underlying causes and opportunities to create an integrated approach to well-being for all people, and especially for those who are at a high risk for experiencing those challenges.” iv prevention should be woven into all aspects of our lives, including where and how we live, learn, work and play. everyone...has a role in creating a healthier nation. “ “

PREVENTION PARABLE (STORY BY: IRVING ZOLA)

Addressing risk factors that affect youth, families and communities can reduce early first use of alcohol and marijuana and the misuse of other drugs such as prescription medications which can be the first step in a person’s path to addiction. We can share this well-known prevention parable to describe and help visualize our work. “Imagine a high waterfall that plunges into a large river. At the bottom of this waterfall, hundreds of people work along the shores of the river trying to save those who have fallen down the waterfall and are drowning in the river. As the people along the shore work frantically to rescue as many as possible, one person looks up at the seemingly never-ending stream of people falling down the waterfall and begins to run upstream. Another rescuer hollers, ‘Where are you going? There are so many people that need help here.’ To which the person replies, ‘I’m going upstream to find out why so many people are falling into the river.” v

Prevention happens all along the water’s edge, but it is often challenging to describe the importance of upstream efforts. Upstream refers to work that is needed to address the risk factors, social determinants of health and other contexts such as adverse childhood experiences that may lead to substance use and its negative consequences. Prevention strategies that can positively impact people where they work, live, play, and pray as well as building skills and other protective factors to support wellness must be implemented upstream. As an example, if a young person is incarcerated and services are provided in jail, sometimes for the first time, though

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This prevention overview highlights just some of research that demonstrates the importance of implementing evidence-based prevention strategies and programs within all spheres of a child’s life. This toolkit highlights the research that informs and directs prevention work in New Jersey. It also introduces key concepts to educate those working with youth, their families and the communities in which they live, learn, and play.

important, what we are dealing with are the results of downstream thinking only; thinking upstream means making earlier strategic decisions about how we want our community to look and how to support youth, families and communities through effective prevention policies, programs and interventions. Upstream prevention enables people to experience physical, mental, and social well-being. Though the research on Adverse Childhood Experiences (ACEs) dates back to 1995, it was recently discovered that ACEs affect not only children’s emotional development but also their long-term physical health. As an example, parents with a substance use disorder can cause ACEs in their child’s life and youth who experience ACEs are at higher risk of addiction. Because of this close intersection, key stakeholders across New Jersey have come together to identify prevention strategies and programs that are working to prevent ACEs from occurring in children’s lives as well as collaborating to provide supportive environments for children who have already experienced ACEs. This dual approach allows specific programs to address ACEs while also educating providers across systems about these experiences that can have a negative impact on children, parents, and communities.

Young people exposed to Adverse Childhood Experiences (stressful, traumatic events) are more likely to develop substance use disorders as adults. vi

emotional abuse & neglect

Children whose parents misuse drugs or alcohol are also at increased risk of experiencing other ACEs, including emotional abuse and neglect. vii

early alcohol use

ACEs often lead to an earlier age of initiation of alcohol use, viii a greater likelihood of serious problems with drugs ix and increased odds of attempting suicide. x

lower academic achievement

ACEs are also linked to social, emotional and cognitive impairment, lower academic achievement and lower educational attainment. xi

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Highlights of New Jersey’s Prevention System T he Regional Prevention Coalitions are working together to reduce the use and misuse of alcohol and other drugs among the residents of New Jersey. These coalitions are committed to collaborating with community partners, including but not limited to youth- serving organizations, Municipal Alliances, law enforcement partners, faith-based organizations, schools, treatment agencies, elected officials, health departments, healthcare providers and other local level community entities to make New Jersey a healthier place to live. REGIONAL PREVENTION COALITIONS

Your local Regional Prevention Coalitions can provide training and technical assistance on the use of this toolkit and guide you in learning more about resources to support your efforts in im- plementing evidence-based programs, policies, and interventions that directly relate to the youth in your region.

For Regional Prevention Coalition contact information, visit https://www.njpn.org/regional- prevention-coalitions.

REGIONAL PREVENTION COALITIONS

• Atlantic County – Join Together Atlantic County • Cape May County – Cape May County Healthy Community Coalition • Bergen County – Bergen County Prevention Coalition • Burlington County – Burlington County Coalition for Healthy Communities • Camden County – Community Alliance Network (CAN) Drug Free Community Coalition • Cumberland & Salem Counties – Salem-Cumberland Regional Action Toward Community Health (SCRATCH) • Essex County – Alcohol & Drug Abuse Prevention Team (ADAPT) • Gloucester County – Gloucester County Regional Substance Abuse Prevention Coalition (GRASP) • Hudson County – Hudson County Coalition for a Drug-Free Community • Hunterdon & Somerset Counties – Safe Communities Coalition of Hunterdon and Somerset County • Mercer County – Prevention Coalition of Mercer County • Middlesex County – The Coalition for Healthy Communities • Monmouth County – Prevention Coalition of Monmouth County • Morris County – Community Coalition for a Safe and Healthy Morris • Ocean County – DART Prevention Coalition • Passaic County – United for Prevention in Passaic County (UPinPC) • Sussex & Warren Counties – Coalition for Healthy and Safe Communities • Union County - Prevention Links

The Regional Prevention Coalitions focus on New Jersey’s state priorities including:

Reducing underage drinking

state 5

Reducing the use of illegal substances including opioids

Reducing tobacco/ vaping use among youth

priorities

Reducing prescription medication misuse across the lifespan

Reducing youth use of marijuana/cannabis

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Regional Prevention Coalitions have been guiding the implementation and use of effective prevention strategies based on their proficiency in using SAMHSA’s SPF model. Below are the five key steps to the SPF model: STRATEGIC PREVENTION FRAMEWORK Assessment involves gathering and using data to identify a priority problem, factors influencing this problem, and resources and readiness to address it. Step 2 Capacity involves building resources and readiness to address the priority problem and its associated factors. Step 3 Planning involves developing a comprehensive plan that details prevention priorities, programs and practices selected to address them, and anticipated outcomes. Step 4 Implementation involves moving the prevention plan into action by fine-tuning selected programs and practices and delivering them as intended. Step 5 Evaluation involves examining how programs and practices are working and using lessons learned to improve them and the plan overall. In addition to the five key steps outlined above, cultural competence and sustainability are integral in the process: Step 1

The following table provides a deeper description of the SPF steps and the core competencies needed for each. xii

CORE COMPETENCIES

DOMAIN

DEFINITION

Assessment is an ongoing process that can include regular and systematic collection, assembly, analysis, and distribution of information on the needs, resources, and community readiness of the population to be served.

• Data gathering • Needs and resource identification • Problem definition • Analysis

Assesment

• Collaboration • Organizational advocacy • Organizational cultural proficiency

Capacity building is a long-term continuing process that involves mobilizing human, organizational, and financial resources to promote and sustain intended outcomes.

Capacity

• Cultural Competence is the ability of an individual or an organization to interact effectively with members of diverse population groups. • Sustainability is the capacity of a community to produce and maintain positive prevention outcomes after initial funding ends and over time.

• Collaborative planning • Cultural inclusion • Systematic thinking • Evidence-informed approaches • Facilitation • Strategic planning

Effective planning involves developing measurable goals and objectives in response to assessment of needs and assets; identifying strategies that are based on knowledge derived from theory, evidence, and practice; and developing logic models that include realistic outcomes and relevant policies, practices, and programs. Implementation is focused on carrying out the various components of the prevention plan in an effective, efficient, culturally sensitive, and ethical manner, as well as identifying and overcoming any potential barriers. Stakeholders and organizations detail the evidence-informed programs, processes, policies, and practices that need to be undertaken, develop specific timelines, and decide on ongoing program evaluation needs. Evaluation determines the reach, effectiveness, and impact of the implementation of the strategic plan and of the programs, processes, policies, and practices. Use appropriate evaluation methods to support improvements, sustainability, and dissemination in a continuous iterative process.

Cultural competence and sustainability should be considered at all steps of the SPF process and are integral to its success in reaching the target population and making a continual impact.

Planning

• Cultural responsiveness • Collaboration • Change management

Implementation

• Culturally informed evaluation approach • Data interpretation and use

Evaluation

Recently, SAMHSA developed the Prevention Core Competencies document to guide our field on the knowledge, skills, and abilities needed to implement evidence-based prevention services. Within this document, SAMHSA highlights the key professional skills needed to implement the SPF.

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NEW JERSEY’S ADVERSE CHILDHOOD EXPERIENCES STATEWIDE ACTION PLAN

“Estimates of the prevalence of Adverse Childhood Experiences range from 61-67 percent. In 2016, over 40 percent of children in New Jersey — more than 782,000 — were estimated to have experienced at least one ACE, and 18 percent were estimated to have experienced multiple ACEs. Among the state’s youngest children (under five years old), 33 percent experienced one or more ACEs. Consistent with national findings, rates of exposure to adverse experiences are higher in New Jersey for children and families of color and for children living in poverty than for their non- Hispanic white and more financially secure counterparts.” xiii The landmark ACE study, conducted by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente, focused on the 10 categories of ACEs listed below. xiv

In 2019, the New Jersey ACEs Collaborative, an alliance of DCF and three New Jersey philanthropic organizations, the Burke Foundation, The Nicholson Foundation, and the Turrell Fund, released Adverse Childhood Experiences: Opportunities to Prevent, Protect Against, and Heal from the Effects of ACEs in New Jersey . In response to the comprehensive report, the Office of Resilience was created in June of 2020 and is housed within the New Jersey Department of Children and Families. The purpose of the office is to host, coordinate, and facilitate statewide initiatives related to raising the awareness and creating opportunities to eradicate Adverse Childhood Experiences (ACEs) through grassroots and community-led efforts, technical assistance, and strategic support for organizations already pursuing this work. In February 2021, the Office of Resilience released the NJ ACEs Statewide Action Plan . The plan outlines the following Five Core Strategies to address ACEs in New Jersey:

ADVERSE CHILDHOOD EXPERIENCES ARE COMMON

5

Household Dysfunction Substance Abuse

27% 23% 17% 13%

Achieve Trauma-Informed & Healing- Centered State Designation

5 core strategies TO ADDRESS ACES IN NJ

Parental Separation/Divorce

10 total aces

Mental Illness Battered Mothers Criminal Behavior

6%

2 3

Neglect

Conduct an ACEs Public Awareness & Mobilization Campaign

Emotional Physcial

15% 10%

Abuse

Emotional Physical

11% 28% 21%

Maintain Community-Driven Policy & Funding Priorities

Sexual

Promote Trauma- Informed/ Healing-Centered Services & Supports

Provide Cross-Sector ACEs Training

SOURCE: ADOPTED FROM ACE INTERFACE, 2015

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risk perception interventions, early initiation and identification programs, counter-marketing, marketing restrictions, and laws to impact supply (e.g., outlet density laws).

The high prevalence of ACEs among our youth and the cross intersection with substance use makes ACEs an important consideration in planning and implementing effective prevention programs.

SALE

Please find the full NJ ACEs Statewide Action Plan here: https://www.nj.gov/dcf/documents/NJ.ACEs.Action.Plan.2021.pdf

POINT OF SALE

LAWS TO IMPACT SUPPLY

More information on the research behind ACEs is found below in Section 5

SOCIAL AVAILABILITY

areas to implement PREVENTION STRATEGIES

SUBSTANCE USE PREVENTION PREDICTIVE OUTCOMES REPORTING TOOL FOR NEW JERSEY

EARLY INTERVENTION PROGRAMS

In partnership with RWJBarnabas Health Institute for Prevention & Recovery, the New Jersey Prevention Network and RTI International, through funding from the DMHAS, a predictive modeling tool entitled SUPPORT-NJ (Substance Use Prevention Predictive Outcomes Reporting Tool for New Jersey) was developed. SUPPORT NJ combines evidence on the potential impact of substance use prevention strategies with data on substance use prevalence, incidence, and impacts for the state and its individual counties to simulate the potential predictive impact of implementing certain evidence-based strategies or combinations of strategies for New Jersey’s youth and young adults.

RISK PERCEPTION

LEGAL CONSEQUENCES

COUNTER-MARKETING & MARKETING RESTRICTIONS

SUPPORT NJ was created to assess the impact of these strategies on alcohol and marijuana use, heavy use, and associated outcomes. The model tracks the experiences of simulated individuals - defined by gender and age group - for up to five years as they transition among four mutually- exclusive states: 1) no use, 2) non-heavy use, 3) heavy use, and 4) former use. The model considers the outcomes/consequences including missed school days, hospitalizations and emergency department visits, and arrests with different probabilities based on their age, gender, and current drug use state. xv The Regional Prevention Coalitions can use the SUPPORT NJ tool to direct planning to the most impactful strategies to be implemented within a community or county.

SUPPORT NJ is a microsimulation model of alcohol and marijuana use that allows coalitions to explore the impacts from a monthly lens through a 5-year period of the implementation of evidence-based individual and community-level interventions. Through a thorough search of available research and evidence of effectiveness, taking into consideration individuals aged 13 to 25 years old, several categories of strategies are highlighted within this model: point of sale interventions, legal consequences, social availability interventions,

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Prevention Key Concepts

Childhood Experiences (ACEs), and employment status. Individual-level risk factors may include a person’s genetic predisposition to addiction or exposure to alcohol prenatally. Individual-level protective factors might include positive self-image, self-control, or social competence.” xvi

DEFINITION OF PREVENTION T he word prevention is defined as “to stop something before it happens.” From a public health standpoint, prevention is the work done with individuals, families, communities, and even nations to stop or reduce the incidence and/or impact of something negative on health and safety. When we place a traffic signal at a busy intersection, we prevent car crashes. When we stop factories from dumping carcinogens into a stream that feeds a reservoir, we prevent the increase in certain types of cancer. Substance use/misuse prevention is no different. The implementation of evidence-based practices and strategies refers to the efforts we make to reduce or eliminate the misuse of substances – alcohol, tobacco, marijuana/cannabis, prescription drugs, illegal drugs – and the impact of those substances on individuals, families, communities, and yes, even nations. Evidence-based substance use/misuse prevention is a collection of strategies, initiatives, and programs that research has shown effectively reduces substance use/misuse and its related impact when implemented. Examples of the effectiveness of evidence-based strategies can be seen when the drinking age went from 18 to 21. This increase in the minimum drinking age, in combination with seatbelt mandates and increased enforcement, prevented tens of thousands of alcohol-related car crash deaths. Additionally, increased regulation of the tobacco industry, in combination with broad community education, increased tobacco taxes and changes to age of sale laws, reduced the percentage of underage smokers in the United States by over 60%. RISK & PROTECTIVE FACTORS As we introduced the idea of upstream prevention, we began to address the many risk factors that put youth at higher risk for a substance use disorder as well as the protective factors that support youth. Prevention works to reduce these risk factors when possible and to increase protective factors. According to SAMHSA:

The following list provides some examples of the individual, family, school, and community risk factors that are known to be associated with a higher likelihood of developing a substance use disorder. These risk factors are those areas that can and should be addressed upstream to prevent the negative impacts that can occur downstream if left unaddressed.

RISK FACTORS INDIVIDUAL BASED

• Parental drug/alcohol use • Depression • Anxiety • Early substance use • Emotional problems in childhood • Sexual abuse • Early aggressive behavior

RISK FACTORS FAMILY BASED

• Parental drug/alcohol use • Substance use among parents or siblings • Inadequate supervision and monitoring • Child abuse/maltreatment • Parental favorable attitudes toward alcohol and/or drugs • Marital conflicts • Parental depression

RISK FACTORS SCHOOL/COMMUNITY

“Risk factors are characteristics at the biological, psychological, family, community, or cultural level that precede and are associated with a higher likelihood of negative outcomes. Protective factors are characteristics associated with a lower likelihood of negative outcomes or that reduce a risk factor’s impact. Protective factors may be seen as positive countering events. Some risk and protective factors are fixed: they don’t change over time. Other risk and protective factors are considered variable and can change over time. Variable risk factors include income level, peer group, Adverse

• Peer rejection • Substance using peers • Loss of close relationship or friends • Poor academic achievement • School violence • Societal/community norms about alcohol and drug use

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Targeting only one context when addressing a person’s risk or protective factors is unlikely to be successful because people don’t exist in isolation. For example:

For examples of protective factors and how they may be different in each community, please visit: https://cadcaworkstation.org/public/hawaii-pacific/Shared%20Resources/ Evidence%20Based%20Environmental%20Strategies/SAMHSA%20-%20 Marijuana%20Prevention%20Resources.pdf For more information on risk and protective factors, please visit: https://www.samhsa.gov/sites/default/files/20190718-samhsa-risk-protec- tive-factors.pdf SAMHSA’s Risk & Protective Factors Pamphlet: https://documentcloud.adobe.com/link/review?uri=urn:aa- id:scds:US:84b858e4-2393-4f5d-9f2c-a1c747537c6e

society

communities

Relationships

In relationships , risk factors include parents who use drugs and alcohol or suffer from mental illness, child abuse and maltreatment, and inadequate supervision. In this context, positive parental involvement is an example of a protective factor.

In society , risk factors can include norms and laws favorable to substance use, as well as racism and a lack of economic opportunity. Protective factors

In communities , risk factors include neighborhood poverty and violence. Here, protective factors could include the availability of faith-based resources and after-school activities.

UNIVERSAL, SELECTIVE & INDICATED POPULATIONS The Institute of Medicine defines the various classifications of prevention based on the risks associated with the populations that help to identify the various levels of prevention service needs to consider in identifying the appropriate strategy, program or intervention to select, as listed below.

in this context would include

hate crime laws or policies limiting the availability of alcohol.

Research shows the more risk factors that exist, the higher rates of substance use disorder and other negative outcomes. Please note, many of these risk factors intersect with ACEs and can also increase the risk of negative mental health outcomes. Prevention strategies provide interventions that target multiple, not single, factors. For example, effective parenting has been shown to mediate the effects of multiple risk factors, including poverty, divorce, parental bereavement, and parental mental illness. The more we understand how risk and protective factors interact, the better prepared we will be to develop appropriate interventions. xvii

INSTITUTE OF MEDICINE CLASSIFICATION OF PREVENTION

Universal interventions address the entire population to delay or prevent substance misuse UNIVERSAL SELECTIVE Selective interventions target subpopulations at increased risk of substance use disorder INDICATED Indicated interventions target individuals who are using substances and are at risk of developing a substance use disorder

Shared Risk & Protective Factors

Substance Use Disorders Risk & Protective Factors

Mental Illness Risk & Protective Factors

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Universal

A Universal prevention strategy addresses the entire population (national, local community, school, and neighborhood) with messages and programs aimed at preventing or delaying the use of alcohol, tobacco, and other drugs. For example, it would include the general population and subgroups such as pregnant women, children, adolescents, and the elderly. The mission of universal prevention is to prevent the problem. All members of the population share the same general risk for substance [misuse] although the risk may vary greatly among individuals. Universal prevention programs are delivered to large groups without any prior screening for substance misuse risk. The entire population is assessed as at-risk for substance misuse and capable of benefiting from prevention programs.

Target: High-risk Individuals

INDICATED

SELECTIVE

Target: Subgroups

UNIVERSAL

Target: Entire Population

Selective

Selective prevention strategies target subsets of the total population that are deemed to be at risk for substance use/misuse by virtue of their membership in a particular population segment - for example, children of adult alcoholics, dropouts, or students who are failing academically. Risk groups may be identified based on biological, psychological, social, or environmental risk factors known to be associated with substance use/misuse (IOM 1994). Targeted subgroups may be defined by age, gender, family history, place of residence such as high drug-use or low-income neighborhoods, and victimization by physical and/or sexual abuse. Selective prevention targets the entire subgroup regardless of the degree of risk of any individual within the group. One individual in the subgroup may not be at personal risk for substance use/ misuse, while another person in the same subgroup may be misusing substances. The selective prevention program is presented to the entire subgroup because the subgroup is at higher risk for substance use/misuse than the general population. An individual’s personal risk is not specifically assessed or identified and is based solely on a presumption given his or her membership in the at-risk subgroup.

UNIVERSAL PREVENTION

Universal Direct Interventions directly serve an identifiable group of participants who have not been identified on the basis of individual risk (e.g., school curriculum, after school program, parenting class). This also could include interventions involving interpersonal and ongoing/repeated contact (e.g., coalitions).

Universal Indirect Interventions support population-based programs and environmental strategies (e.g., establishing alcohol tobacco drug education (ATOD) policies, modifying ATOD advertising practices). This also could include interventions involving programs and policies implemented by coalitions.

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ENVIRONMENTAL STRATEGIES

Indicated

Indicated prevention strategies are designed to prevent the onset of substance use disorder in individuals who do not meet DSM-V criteria for addiction, but who are showing early danger signs, such as failing grades and

According to the Northeast & Caribbean Prevention Technology Transfer Center (Center for Prevention Science, School of Social Work, Rutgers University, New Brunswick, NJ under a cooperative agreement from the Substance Abuse and Mental Health Services Administration), environmental prevention strategies are “interventions that modify or change the environment in which individuals make choices. The focus of environmental strategies is to change the environment in ways that encourage people to make healthy choices.” xix THE FOCUS OF ENVIRONMENTAL STRATEGIES IS TO CHANGE THE ENVIRONMENT IN WAYS THAT ENCOURAGE PEOPLE TO MAKE HEALTHY CHOICES. “ “ Individual strategies focus directly on changing the individual’s knowledge, attitudes, and behaviors (KAB). Environmental strategies, rooted in public health, address population level or community-wide change. For example, if we teach children in schools that alcohol, tobacco, and other drugs are harmful (individual strategy focus), but those same children walk out of their school and into a world of advertising/media that glamorizes the fun side of substance use, shops that sell products to minors without checking ID, bars on every corner that allow public/outdoor use, and enforcement efforts that largely ignore these things, then the environment (or community) that surrounds them teaches them the opposite. Changing these environmental factors (i.e., using environmental strategies) in the world around these children impacts the entire population or community.

consumption of alcohol and/or other drugs.

The mission of indicated prevention is to identify individuals who are exhibiting early signs of substance use/misuse and other problem behaviors associated with substance use/misuse and to target them with special programs. The individuals are exhibiting substance use/ misuse-like behavior, but at a subclinical level (IOM 1994). Indicated prevention approaches are used for individuals who may or may not be using substances, but exhibit risk factors that increase their chances of developing a substance use disorder.

Indicated prevention programs address risk factors associated with the individual, such as conduct disorders, and alienation from parents, school, and positive peer groups. Less emphasis is placed on assessing or addressing environmental influences, such as community values. The aim of indicated prevention programs is not only the reduction in first time substance use, but also reduction in the length of time the signs continue, delay of onset of a substance use disorder, and reduction in the severity of a substance use disorder. Individuals can be referred to indicated prevention programs by parents, teachers, school counselors, school nurses, youth workers, friends, or the courts. Young people may volunteer to participate in indicated prevention programs. NOTE: In most cases, indicated strategies would be the most appropriate strategies for youth already involved with the juvenile justice system. xviii

For more information from the National Academy of Medicine, please visit: https://nam.edu/perspectives-2015-unleashing-the-power-of-prevention/

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Some of the known benefits of environmental prevention strategies include: 1) proven effectiveness in reducing the incidence and impact of substance use/misuse; 2) impact on a broader population than individual strategies; and 3) their cost effectiveness. Comprehensive prevention refers to the use of environmental strategies in concert with individual strategies in a thoughtful manner, based on the needs of the community. For example, an evidence-based early intervention program that addresses risk and protective factors of children who have experienced multiple ACEs – a needed individual strategy – implemented in conjunction with broader, community-wide policy initiatives aimed at reducing poverty/ increasing access to healthcare and mental health services – an environmental approach – will have greater impact than if one of these strategies was implemented without the other. Environmental prevention strategies have been described by Community Anti-Drug Coalitions of America (CADCA) as the “Seven Strategies for Community Change,” endorsed by New Jersey’s prevention system. This framework has been a guide to categorizing prevention strategies as well as a guide to encouraging a multi-strategy approach to addressing community needs.

4 Enhancing Access/Reducing Barriers Improving systems and processes to increase the ease, ability, and opportunity to utilize those systems and services (e.g., assuring healthcare, childcare, transportation, housing, justice, education, safety, special needs, and cultural and language sensitivity). 5 Changing Consequences (Incentives/Disincentives) Increasing or decreasing the probability of a specific behavior that reduces risk or enhances protection by altering the consequences for performing that behavior (e.g., increasing public recognition for desired behavior, individual and business rewards, taxes, citations, fines, and revocations/loss of privileges).

6 Physical Design Changing the physical design or structure of the environment to reduce risk or enhance protection (parks, landscapes, signage, lighting, and outlet density).

CADCA SEVEN STRATEGIES FOR COMMUNITY CHANGE

1 Providing Information

Educational presentations, workshops or seminars or other presentations of data, (e.g., public announcements, brochures, dissemination, billboards, community meetings, forums, and web-based communication). 2 Enhancing Skills Workshops, seminars or other activities designed to increase the skills of participants, members and staff needed to achieve population-level outcomes (e.g., training technical assistance, distance learning, strategic planning retreats, and curricula development). 3 Providing Support Creating opportunities to support people to participate in activities that reduce risk or enhance protection (e.g., providing alternative activities, mentoring, referrals, and support groups or clubs).

7 Modifying/Changing Policy Formal change in written procedures, by-laws, proclamations, rules or laws with written documentation and/or voting procedures (e.g., workplace initiatives, law enforcement procedures and practices, public policy actions, system change within government, communities and organizations).

Evidence-based approaches can be guided by CADCA’s Strategy for Community Change: http://aodpartnership.org/wp-content/uploads/2016/03/seven- strategies-for-community-change.pdf

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APPLYING THE CADCA STRATEGIES

ENHANCE skills

Tobacco : Implementing a comprehensive youth empowerment program, REBEL (Reaching Everyone By Exposing Lies), in middle, high school and college to teach advocacy skills. Teach youth to recognize the lies of the tobacco industry. Alcohol : Prevention agency provides Life Skills training to all 6, 7, and 8th grade classes, enhancing the teens’ decision-making skills. They also provide Responsible Beverage Server Training to retailers in the community to reduce sales to underage youth.

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provide support

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Tobacco : Promote no-cost/low-cost tobacco cessation programs for youth and adults. Alcohol : Community recreation centers host drug-free activities for youth each night and provide adult mentoring opportunities for teens.

Reflecting back to our prevention parable story, we need to look upstream at the risk factors in play among youth, families and communities to determine why people are falling into the river. Once the risks have been identified, strategies need to be implemented to create a supportive environment with programs, policies and initiatives that reduce the risks. Tobacco use and underage drinking are reasons why youth fall into the river, but over the last 20 years, prevention efforts have reduced youth use rates significantly with evidence-based, multi-strategy approaches. Prevention is more than “providing information” and is a comprehensive public health model which combines individual, family and community-based strategies that work together. These combine to improve individual knowledge, attitudes and behaviors as well as change policies and laws that positively impact the environment in which youth live, learn, and play. Looking upstream at the individual and community risk factors -and working to improve them before more serious problems occur - is what makes prevention work. The CADCA strategies guide prevention efforts to address these issues in a coordinated and comprehensive approach to make true community change that “builds stronger fences” to reduce the number of youth falling into the river. Here are examples of strategies within each CADCA Strategy category that have been utilized to reduce the use rates and community impact of youth tobacco and alcohol use.

While all of these efforts prevent people from falling in the river, their impact is largely confined to those who live in the community currently and are not long-term or sustainable. The following environmental strategies make population-level change for both current and future residents.

Access & Barriers Tobacco : Increase Medicaid and other insurance coverage for Nicotine Replacement Therapy (NRT) medications and access to over-the-counter NRT options. Alcohol : Prevention agency provides transportation to a Strengthening Families Program to allow easier access to evidence-based programs.

change consequences

Tobacco : 2007 Motion Picture Association restricts tobacco use in films; Tobacco Master Settlement Agreement holds tobacco industry accountable for the health impact of their products and also creates numerous limits around product advertising. Alcohol : Law passes that increases fines for the sale of alcohol to minors which deters retailers and bars from selling to minors and increases their compliance efforts to avoid the fines.

provide information

Tobacco : Youth education on the dangers of tobacco use highlighting early findings from the Surgeon General’s report and the tobacco industry’s manipulation of teens. Alcohol : Coalitions host Town Hall meetings and highlight the dangers of underage drinking with data on current teen alcohol use in the community.

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change physical design

Tobacco : After extensive advocacy by REBEL youth and Tobacco Coalitions, NJ passes the New Jersey Smoke-Free Air Act which makes all public indoor spaces smoke-free. Local advocacy continues to increase smoke-free outdoor recreational areas. Alcohol : New signage is created for all retailers and bars to post that communicates the drinking age is 21. A municipality passes a “Content Neutral Advertising” ordinance which is a law restricting any advertisements in store windows. This eliminates alcohol advertising visible to youth walking to school.

modify policy

Tobacco : In 2018 and 2019 (New Jersey and the US, respectively), the legal tobacco age of sale is raised to 21. (Tobacco 21) Alcohol : The law is changed to now allow Compliance Checks to be implemented which holds retailers accountable if they sell to minors.

Through this multi-strategy approach, applied consistently over time, we have prevented people from “falling into the river” not only today, but for generations to come. Evidence-based individual and community-based environmental prevention strategies do work, but they require time and constant vigilance. While US smoking rates have declined steadily from their peak of 45% in 1954, the death rate from tobacco-related illnesses did not level off and start to decrease until 1993. Today the rate of smoking among US adults stands at 15%.

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Related Factors

Illicit Drug Use

• Lifetime illicit drug use, ever having a drug problem, and self-reported addiction (Dube et al, 2003) xx

ADVERSE CHILDHOOD EXPERIENCES

According to SAMHSA, research has also demonstrated a strong graded relationship between ACEs and related behavioral problems, such as the following: • Increased risk of suicide attempts, including attempts by men and women, as well as attempts during adolescence and adulthood (Dube et al, 2004)

A dverse Childhood Experiences (ACEs) are stressful or traumatic experiences, including abuse, neglect, and a range of household dysfunction such as witnessing domestic violence, or growing up with substance use, mental illness, parental discord, or crime in the home. ACEs are strongly related to development and prevalence of a wide range of health problems, including substance use, throughout the lifespan. When children are exposed to chronic stressful events, neurodevelopment can be disrupted. Disruption in early development of the nervous system may impede a child’s ability to cope with negative or disruptive emotions and contribute to emotional and cognitive impairment. Over time, and often during adolescence, the child adopts coping mechanisms, such as substance use. Eventually, this contributes to disease, disability and social problems, as well as premature mortality. When children are exposed to chronic stressful events, neurodevelopment can be disrupted. “ “ The relationship of ACEs to substance use and related behavioral health problems research has demonstrated a strong graded (i.e., dose-response) relationship between ACEs and a variety of substance-related behaviors, including:

• Lifetime depressive episodes (Chapman et al, 2004) • Sleep disturbances in adults (Chapman et al, 2011) • Sexual risk behaviors (Hillis et al, 2001) • Teen pregnancy (Hillis et al, 2004)

STRATEGIES TO STRENGTHEN PREVENTION EFFORTS

• Collecting state- and county-level ACE data to drive local decision making (e.g., by incorporating ACEs indicators into Behavioral Risk Factors Surveillance Systems) • Increasing awareness of ACEs among state- and community-level prevention practitioners, emphasizing the relevance of ACEs to multiple behavioral health disciplines • Including ACEs among the primary risk and protective factors considered when engaging in prevention planning efforts • Selecting and implementing programs, policies, and strategies designed to address ACEs, including efforts focusing on reducing intergeneration transmission of ACEs • Using ACEs research and local ACEs data to identify groups of people who may be at higher risk for substance use/misuse and related behavioral health problems xxi Because ACEs are common and strongly related to a variety of substance use/misuse and related behavioral health outcomes, the prevention of ACES and the early identification of those who experience ACEs could prevent a number of negative consequences and have a significant impact on a range of critical health problems. Specifically, practitioners can thus strengthen their prevention efforts by:

• Early initiation of alcohol use. For states, tribes, and jurisdictions focusing on underage drinking, these results suggest the importance of addressing ACEs as one component of preventing underage drinking, as responses to underage drinking may not be effective unless they help youth recognize and cope with stressors of abuse, domestic violence and other adverse experiences (Dube et al, 2006) • Problem drinking behavior into adulthood (Dube et al, 2002) Alcohol Smoking • Increased likelihood of early smoking initiation (Anda et al, 1999)) • Continued smoking, heavy smoking during adulthood (Ford et al, 2011)

• Prescription drug misuse (Anda et al, 2008) Prescription Drug Misuse

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