Prevent the use of a drug before it has begun -- This prevention is approached during the abstinence phase of drug abuse.

Prevent further use, after a substance has been used -- This goal is applied to stop the further use of a substance, often occurring during the experimentation through social use phases of drug use.

Reverse the progression of substance abuse and restore the health of abusing persons -- This approach is more applicable to those who have become chronic addicts of substances.

Provide the user with resistance (will), education (decision-making), and conflict resolution (alternative to drug abuse) to prevent return to substance abuse -- This approach is most applicable with persons who were severely addicted but have gone through an abstinent phase and are not currently using or abusing the substance.

The third approach is often accomplished in clinics, in tandem with a medical withdrawal from the substance (for example a methadone clinic for heroin abuse).  As the health of the person is improved many of the same educational information may be provided to the patient.  Additionally, the counselling component discussed below may also play a major role in accomplishing the goals of this approach to drug prevention.

The fourth goal is most often accomplished through psychological approaches of substance abuse treatment.  This may be accomplished by a variety of methods including individual counselling sessions, support groups, and half-way houses.  It is often easier for a former abuser to stay "clean" if there are persons who are experiencing the same physical temptations, problems, and fears nearby, with whom the patient may confide, talk, and seek information or solace.

Another component of prevention, which is applicable to all of the aspects noted above but especially important in youth, is to provide alternatives to substance abuse.  This may take many forms including "drug-free" parties, sports, group activities.  For youth, these types of activities may include school sports or organisations, scouts, church, or community sponsored events.  Alternatives to substance abuse are also important in former abusers and adults who are recovering addicts.

Prevention Methods

Supply Reduction -- The goal of this  approach to prevention is simply to remove the drugs so that there will be no source for abuse.  This may be accomplished through legislation (the ultimate example of this approach was prohibition in the first half of this century) that entails stiff penalties for possession and/or use.  The fear of penalty may cause some persons to abstain from drug use.  A second approach to supply reduction is interdiction in import and distribution of illegal substances.  This is currently accomplished by policing action of local and federal law enforcement (including the FBI, DEA) and the military (especially the Coast Guard).  A strong argument against supply reduction as the only means of preventing drug abuse is the cost involved.  As the only means of preventing drug abuse, it is not especially cost effective for society and consequently (since each citizen is a taxpayer) for the population of a country.  Therefore, a second approach to decrease drug use is needed.

Demand Reduction -- If the goals of prevention as outlined above are accomplished, the drug use would either never happen or would not begin again.  The success of the four goals noted above are an integral component of demand reduction.  This approach to prevention may be considered by one of three methods.

Primary Prevention involves the educational and alternative approach discussed above to prevent drug use from ever starting.  (Goal Number 1, from above)

Secondary Prevention involves the same techniques, but targeted for those already using substances (Goal Number 2, from above).  This method of prevention is often confounded by the fact that users (especially early or younger users) often utilise concealment to hide their substance abuse and are often in denial of their substance abuse.

Tertiary Prevention aims to restore health and prevent further use (Goal Number 3).  This should always be followed by Goal Number 4, to provide support for the former abuser.

Harm Reduction -- This approach to prevention of drug use is the most controversial.  Some opponents claim that rather than prevent drug use, harm reduction actually promotes it.  The goal for harm reduction is to reduce the extent of damage that may occur as a result of substance abuse.  Examples of harm reduction include providing sterile (clean) syringes to users (to lessen the risk or diseases such as AIDS or hepatitis that may be spread by repeated use of needles by more than one individual, to decrease the risk of infection, and to decrease contamination), methadone maintenance programs (to prevent withdrawal and therefore prevent further use of heroin), designated drivers, encouraging eating when drinking (to decrease the rate of ethanol absorption), or the use of low-tar, filtered cigarettes (to reduce the risk of cancer).  This approach is designed to at least limit the health consequences of drug use, which will decrease the impact on the cost of health care by society for drug-related injury and illness.

Two very powerful challenges to any attempt at drug use prevention include the dual nature of American society ("legal" drugs such as ethanol and tobacco -- these are perceived as o.k. for use and subsequently become abused -- and the impression that if it is allowable for these agents then the use of illegal substances should be permissible as well) and the funding (any approach to prevent drug use is costly, whether it is paying law enforcement officials, prison upkeep, state-funded clinics, or state-supplies syringes -- any of these approaches may be limited by the monies available).

Age of first use -- First time substance abusers are younger and younger in recent years.  By 1995, the use of marijuana by 8th graders in a Michigan school district had increased from 6% to 16% in a four year period.  Additionally, drug test on juveniles arrested indicated that positive drug use (excluding alcohol) had increased from 22% in 1990 to 42% in 1994.  Regardless of age, the susceptibility of the person to abuse drugs is a complex combination of many events, as described early in this course.  Therefore, the elderly are at just as great a risk of continued drug abuse, although they, as an age-group, more often abuse legitimately prescribed prescription drugs or ethanol rather than illegal street substances.

Race and Class -- Categorising drug use by race or class is extremely difficult if not impossible.  The use and abuse patterns vary widely over different metropolitan areas and when comparing urban to rural areas.  One California study indicated that the three top races that abused drugs were Caucasians, Hispanics, and Asians.  However, this cannot be considered representative of the nation as a whole, since there are distinct population differences between that one state and the nation in general.  Class is just as difficult to pigeonhole with regards to substance abuse since there are high rates of use among highly educated persons and professionals such as health care providers, clergy, and law enforcement officials as well as the typical perception of shiftless, good-for-nothing bums, inner-city kids, or the homeless that is often portrayed by Hollywood.

Pregnancy and Drug Use -- The potential harm from ethanol during pregnancy has been described previously.  However, other drugs may be just as dangerous if taken during pregnancy.

Cocaine and Amphetamines -- The use of these stimulants during pregnancy may result in the birth of an addicted infant.  Withdrawal of the infant is often severe and may even cause seizures and death.  Birth defects that may occur with these stimulants include stunted growth (including small heads), genito-urinary tract abnormalities, intestinal disease, and behavioural effects (including sleep abnormalities and breathing problems).  These infants also demonstrated a higher death rate from sudden infant death syndrome (SIDS or crib death) that infants born to drug-free mothers.

Opioids -- Use of these compounds, such as heroin, increases the risk for miscarriages, stillbirth, and severe infection (from the use of dirty needles).  Birth abnormalities include premature delivery, low birth weight, and decreased strength of the newborn.

Marijuana -- Use of marijuana may cause low infant birth weight, premature delivery, and birth defects, including CNS effects such as abnormal responses to light and visual stimuli and increased crying.  Other complications include difficult or prolonged labour and abnormal bleeding.

Tobacco -- Women who are heavy smokers are at a greater risk of miscarriage.  Stillbirths are also more common among heavy smokers.  Neonatal effects include low birth weight, cleft palate, heart defects, behavioural effects (decreased suckling response), and depressed immune system in the infant.

Drug Use in High Schools
In order of popularity, the most commonly abused substances are alcohol, tobacco, and marijuana (with 51%, 34%, and 21% respectively of high school seniors using these product within a 1 month period, by one 1995 study).  The next highest use was hallucinogens (at 4%).  This trend has been surprisingly consistent over a 20 year period, with relative amount used constant within the same time period.
Much of the initial use of drugs in high school results from curiosity and experimentation.  This is confounded by the typical rebellious spirit of teens and their notion of immortality ("I'm going to live forever" attitude).  This combination of inexperience and lack of concern often results in inappropriate use of frequent intoxication.

Once abuse has progressed to the addictive stage, the other effects of drug use in high school are those that occur with any user, including the increased risk of criminal activity or behaviour, and the impact on emotional maturity, with the student seeking solace or answers from the substance rather than the problem.  The latter is an especial concern with high schoolers, since they are often just learning to cope emotionally with life situations during their adolescent years.

Risks that may contribute to the use of substance by the high school student include

teen pregnancy, dropping out of school, living below poverty level, emotional or mental disease, previous criminal records, lack of self esteem, peer pressure, lack of school policies and procedures, or family background that tolerates or supports substance use.  Any of these factors may increase the risk of that student abusing one or more substances.
Alternately, there are four factors that, if established by age 12, will decrease the risk of substance abuse.  These include
a strong sense of family participation and involvement
an established personal position on substance abuse and an understanding of why that position was taken
strong spiritual sense and community involvement
attachment to a clean, sober, adult role model, other than a parent

Prevention for School-Age Children
Primary Prevention -- Should begin as early as kindergarten

Secondary Prevention -- Schools should have clear and strict policies on substance abuse with subsidiary crises intervention, referral, follow up, aftercare, and support programs, especially in high schools

Tertiary Prevention -- Student assistance programs such as teen-Al/Anon and other similar groups.

 

Drug Use in College
Again, alcohol is the primary substance of abuse among college students.  Various studies indicate that anywhere from 80-90% of college students drink some alcohol.  Often this presents as binge drinking

As college student, the opportunities for more open use of drugs are greater, but the responsibilities are also greater.  This has lead some people to refer to the concept of "second hand drinking".  This refers to the effects of alcohol use on those who are not drinking.  It may include those persons who are the object of assault (fights, rape, et c.); persons who must look after and clean up after friends who are drinking; and persons who are indirectly affected by the drinking (i.e. the neighbor that is trying to study but cannot, because of the party next door, causing poor exam performance).

Prevent of Drug Use in College -- Normative assessment has proven beneficial in reducing college-related substance abuse.  If the preconceived notion of a student is that all college student get roaring drunk every night, then that student will likely conform to that behaviour.  If, however, they are educated that this is NOT normal behaviour, they will moderate their behaviour to match the norm.  Similarly, if a student associates with heavy drinkers, he/she will accept it as the norm and follow suit.  However, if they are shown that their ""crowd" does not represent the student body, use often declines.  Other approaches include campus regulation limiting or restricting the use of substances on campus, drug-free dorms, and strict policies and procedures (refer to secondary prevention as described for high schools above).
 

Drugs and Sex -- Many of the effects of drugs on sexual desire, performance, and reproduction have been discussed previously.  In addition to the direct effects of a specific drug on sex, recall that many drugs, through their disinhibitory effects, may cause abnormal behaviour that may result in sexual assault or unprotected sex.  This can lead to criminal prosecution or disease (AIDS, gonorrhea, syphilis, chlamydial infections).  Also, recall that many diseases (AIDS, hepatitis) may be transmitted by unclean needles that are shared by drug users.

Drugs and The Workplace
The use/abuse of substances can result in millions of dollars either lost or expended in the workplace.  A 1995 study indicated that as much as $140 billion dollars was spent in the U.S.A. as a direct result of drug use or abuse.

Loss of productivity -- an abuser is more often tardy, absent (and absent for extended periods), likely to make mistakes, likely to have lower output, and likely to have a greater number of grievance hearings

Medical costs -- abusers also experience more job-related accidents, have more sick leave, overutilise health insurance, and file more worker's compensation claims, all of which directly increase medical costs and increase the insurance premiums for the company and fellow workers as well as endanger the health and safety of fellow workers.

Legal costs -- increased legal costs associated with substance abuse include increased pilferage, theft, and embezzlement, increase cost of company security, increased numbers of lawsuits, loss of customer goodwill and negative publicity.

Probably the most dramatic improvement in substance abuse for a particular workplace has been in the military.  At one time, substance abuse was quite high among military personnel.  However, required drug testing, stiff penalties (dishonourable discharge and possible prosecution) lead to a zero tolerance for substance abuse.  The apparent radical measures taken by the military is not practicable for most workplaces, but do stress the improvement that is possible.

Drug testing has become commonplace in many workplaces.  There are three primary methods used to test for drugs:

Chromatography (Primarily Thin Layer Chromatography or TLC) -- This is a fairly sensitive test for many drugs and will indicate the amount of drug that is present in the sample.  However, it is not able to distinguish between drugs that are very similar in their chemical structure.

Enzyme Multiplied Immunoassay Techniques (EMIT) -- This method is extremely sensitive and may be run very quickly.  It cannot determine the amount or concentration of drug that is present, only that it is present in some amount.  Additionally, a separate test must be done for each drug to be tested.  It may also give false positive readings (the over-the-counter pain reliever ibuprofen may test positive for marijuana; Vicks inhaler may test positive for methamphetamine).  It is also so sensitive that second-hand marijuana smoke or a poppyseed muffin may also give a positive for marijuana or heroin respectively.

Gas Chromatography/Mass Spectrometry (GC/MS) -- This is probably the best method for drug tests.  It is highly accurate, sensitive, and may test for many drugs simultaneously.  Additionally, it can distinguish between closely related chemical compounds.  It is expensive and required sophisticated equipment and highly trained technicians for proper use of the equipment.

Detection Period -- The time (after ingestion of a substance) that it is still detectable is determined by a number of factors, including its rate of absorption, metabolism, distribution, elimination, excretion, and the specific method of testing.  Typically, there is a latency period, required for absorption, that must pass before the drug can be detected in the blood or especially the urine.

Typical detection periods include (the time after the last dose at which the drug is still detectable)
alcohol -- 12-24 hr
amphetamines -- 2-4 days
cocaine -- 12-72 hr
marijuana
casual use (up to 4 cigarettes/week) -- 5-7 days
daily use -- 10-15 days
chronic, heavy use -- 1-2 months
heroin -- 2-4 days
PCP
casual use -- 2-7 days
chronic, heavy use -- several months

False positive results may occur (as described above for GC/MS).  Consequences of false positive include improper termination from jobs and/or prosecution for drug use when no use occurred.  (A second consequence would be lawsuits that result from the improper termination or arrest!)   Very often, when a test comes back positive, the testing facility will run a second alternate test to confirm the original finding.  It is rare to get two false positives using two different testing methods.

False negative results (when the test say no drug was present when actually it was), may also occur.  This is often a function of the sensitivity of the test (the less sensitive the method, the more false negatives that may occur).  The consequences of false negatives include users not being discovered, which could ultimately result in personal danger or damage to themselves or others.

Errors may also arise from mishandling of samples.  This most often represents sloppy laboratory practices and should not be tolerated by the laboratory supervisor or the contract holders for the testing to be performed.