One of the major questions about addiction is why it takes hold only in some people. The changes in the brain associated with addiction do not progress in the same way in everyone who uses alcohol or drugs. For a wide range of reasons that remain only partially understood, some individuals are able to use alcohol or drugs in moderation and not develop addiction or even milder substance use disorders, whereas others—between 4 and 23 percent depending on the substance—proceed readily from trying a substance to developing a substance use disorder.18
Understanding the factors that raise people’s risk for substance misuse (risk factors) and those that may offer some degree of protection from these risks (protective factors) and then using this knowledge to design interventions aimed at steering people away from substance misuse are the goals of prevention science. Although research has shown strong heritability of substance use disorder,19 we now know that individual, family, community, and environmental risk factors play an important role in both substance misuse and substance use disorders. Being raised in a home in which the parents or other relatives use alcohol or drugs, for example, raises a child’s chances of trying these substances and of developing a substance use disorder.20,21 Living in neighborhoods and going to schools where alcohol and drug use are common, and associating with peers who use substances, are also risk factors.20,22,23
Another important risk factor is age at first use. The earlier people try alcohol or drugs, the more likely they are to develop a substance use disorder. For instance, people who first use alcohol before age 15 are four times more likely to become addicted to alcohol at some time in their lives than are those who have their first drink at age 20 or older.26 Nearly 70 percent of those who try an illicit drug before the age of 13 develop a substance use disorder in the next 7 years, compared with 27 percent of those who first try an illicit drug after the age of 17.27 Although substance misuse problems can develop later in life, preventing or even just delaying young people from trying substances is important for reducing the likelihood of more serious problems later on.
Prevention interventions also aim to support or bolster protective factors, which give people the resources and strengths they need to avoid substance use. Having strong and positive family ties and social connections, being emotionally healthy, and having a feeling that one has control over one’s successes and failures are all protective factors. Being satisfied with one’s life, having a sense of a positive future ahead, and emotional resilience are other examples of protective factors.28
Given the overwhelming tendency for substance use to begin in adolescence (ages 12 to 17) and peak during young adulthood, most prevention interventions have focused on teens and young adults. However, effective prevention policies and programs have been developed across the lifespan, from infancy to adulthood. It is never too early and never too late to prevent substance misuse and substance-related problems. A growing number of interventions designed to reduce risk and enhance protective factors have been scientifically tested and shown to improve substance use and other outcomes. These include interventions for all age groups (including early childhood), for specific ethnic and racial groups, and for groups at high risk for substance misuse, such as youth involved in the criminal justice system. These interventions may focus all individuals in a group (universal interventions) or specifically on at-risk individuals (selective interventions).
Importantly, interventions at the environmental or policy level can also be effective at reducing substance use. This has been shown clearly with alcohol use (especially by minors) and related problems such as drunk driving. Raising alcohol prices; limiting where, when, and to whom alcohol can be sold; raising the legal purchase age; and increasing enforcement of existing alcohol-related laws, such as the minimum legal drinking age (MLDA) of 21 and laws to prevent driving under the influence of alcohol, have successfully reduced negative alcohol-related outcomes where they have been implemented. Higher alcohol taxes have also been shown to reduce alcohol consumption.29 As a growing number of states allow marijuana use recreationally30 or therapeutically, research is ongoing to learn about the effects of these changes and policy levers that may mitigate potential harms, such as increased use by adolescents or impaired driving.
Evidence-based prevention interventions can also address a wider range of potential problems beyond just substance misuse. Alcohol and drug use among adolescents are typically part of a larger spectrum of behavioral problems, including mental disorders, risky and criminal behaviors, and difficulties in school. Many interventions address the common underlying risk factors for these issues and show benefits across these domains, making them powerful and, in many cases, highly cost-effective investments that pay off in reduced health care, law enforcement, and other societal costs.
In summary: Prevention works. However, it must be evidence-based, and there is a need for an ongoing investment in resources and infrastructure to ensure that prevention policies and programs can be implemented faithfully, sustainably, and at sufficient scale to reap the rewards of reduced substance misuse and its consequences in communities.
What is an Intervention?
Intervention here and throughout this Report means a professionally delivered program, service, or policy designed to prevent substance misuse or treat an individual’s substance use disorder. It does not refer to an arranged meeting or confrontation intended to persuade a friend or loved one to quit their substance misuse or enter treatment—the type of “intervention” sometimes depicted on television. Planned surprise confrontations of the latter variety—a model developed in the 1960s, sometimes called the “Johnson Intervention”—have not been demonstrated to be an effective way to engage people in treatment.24 Confrontational approaches in general, though once the norm even in many behavioral treatment settings, have not been found effective and may backfire by heightening resistance and diminishing self-esteem on the part of the targeted individual.25
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18. Anthony, J. C., Warner, L. A., & Kessler, R. C. (1994). Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Experimental and Clinical Psychopharmacology, 2(3), 244-268.
19. Goldman, D., Oroszi, G., & Ducci, F. (2005). The genetics of addictions: Uncovering the genes. Nature Reviews Genetics, 6(7), 521-532.
20. Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112(1), 64-105.
21. Kilpatrick, D. G., Acierno, R., Saunders, B., Resnick, H. S., Best, C. L., & Schnurr, P. P. (2000). Risk factors for adolescent substance abuse and dependence: Data from a national sample. Journal of Consulting and Clinical Psychology, 68(1), 19-30.
22. Mayberry, M. L., Espelage, D. L., & Koenig, B. (2009). Multilevel modeling of direct effects and interactions of peers, parents, school, and community influences on adolescent substance use. Journal of Youth and Adolescence, 38(8), 1038-1049.
23. Marschall-Lévesque, S., Castellanos-Ryan, N., Vitaro, F., & Séguin, J. R. (2014). Moderators of the association between peer and target adolescent substance use. Addictive Behaviors, 39(1), 48-70.
24. Miller, W. R., Meyers, R. J., & Tonigan, J. S. (1999). Engaging the unmotivated in treatment for alcohol problems: A comparison of three strategies for intervention through family members. Journal of Consulting and Clinical Psychology, 67(5), 688-697.
25. White, W. L., & Miller, W. R. (2007). The use of confrontation in addiction treatment: History, science and time for change. Counselor, 8(4), 12-30.
26. Grant, B. F., & Dawson, D. A. (1997). Age at onset of alcohol use and its association with DSM-IV alcohol abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. Journal of Substance Abuse, 9, 103-110.
27. Anthony, J. C., & Petronis, K. R. (1995). Early-onset drug use and risk of later drug problems. Drug and Alcohol Dependence, 40(1), 9-15.
28. Stone, A. L., Becker, L. G., Huber, A. M., & Catalano, R. F. (2012). Review of risk and protective factors of substance use and problem use in emerging adulthood. Addictive Behaviors, 37(7), 747-775.
29. Elder, R. W., Lawrence, B., Ferguson, A., Naimi, T. S., Brewer, R. D., Chattopadhyay, S. K., . . . Task Force on Community Preventive Services. (2010). The effectiveness of tax policy interventions for reducing excessive alcohol consumption and related harms. American Journal of Preventive Medicine, 38(2), 217-229.