Substance Misuse: Prevention and Harm Reduction

More than 90,000 Americans died from drug overdoses in 2020 – a record-breaking 30% increase from 2019. In addition to the devastating effects on individuals and their families, alcohol, tobacco, and illicit drug misuse costs the U.S. a staggering $740 billion annually. Effective, evidence-based substance misuse prevention and harm reduction programs can save lives and money, as well as alleviate suffering. This informational brief describes the three levels of prevention and identifies related prevention and harm reduction programs while considering diversity and equity issues.

Prevention Programs

Prevention programs include primary prevention (i.e., universal to reduce risk in a broad population), secondary prevention (i.e., for those at-risk), and tertiary prevention (i.e., to prevent relapse). A number of prevention programs have shown to be effective. However, not all individuals have access to such programs. People with minoritized identities (including Black, Indigenous, people of color, and those who identify as LGBTQ+) are more likely to be criminally prosecuted, as opposed to being referred to prevention or treatment services, for substance use disorders. Further, prevention and harm reduction programs are lacking in rural communities. Please note the example programs listed below are alphabetized and not listed in any preferential order.

Primary Prevention is universal, offered to an entire population regardless of known risk. Some example programs, including ones tested with specific populations, are:

• Communities that Care: develops a coalition of key stakeholders who examine data to identify risks in their community and implement appropriate, effective prevention programs;
• Culturally Grounded Life Skills for Youth Curriculum: was originally developed for northwest tribal communities and has been adapted for use by other tribal communities;
• Familias Unidas: a family-centered, multi-level prevention intervention for Hispanic youth and their families;
• PAX Good Behavior Game: a classroom-based game where students help devise the rules and rewards, allowing them to begin to identify what is best for them; this teaches self-regulation to benefit self and others;
• PROSPER: coordinates communities’ high-quality implementation of evidence-based services involving families and schools. Example programs coordinated by PROSPER include LifeSkills Training and Guiding Good Choices;
• Strong African American Families: builds on the strengths of African American families and supports parents and youth during the transition from early adolescence to the teen years to decrease risky behaviors.

Secondary Prevention provides support to help prevent relapse among people with substance use disorders. Examples include:

• Collegiate Recovery Centers: provide opportunities for individuals to engage in recovery community activities and receive supportive care from peers and providers;
• Community-based aftercare programs (e.g., 12 step programs and peer support);
• Recovery High Schools: offer opportunities for youth with substance use disorders to receive education in a substance-free environment.

Harm Reduction

Harm reduction efforts aim to reduce the damaging consequences of substance abuse. Examples of harm reduction include:

• Doula programs: support pregnant people who are using drugs to improve the likelihood of treatment initiation and improve health outcomes for parents and babies;
• Harm reduction education and supply provision: education and supplies (e.g., fentanyl test strips and Narcan) can be provided to people who are unhoused, syringe exchange clients, and high school and college students to reverse overdose and prevent death;
• Housing First: provides housing for people regardless of whether they are currently using substances or have other behavioral health problems;
• Peer support services: offer services and support to people who are actively using substances; these services are often not reimbursable by Medicaid but can improve access to harm reduction services;
• Syringe exchange programs: provide unused syringes and other services to people who inject drugs to prevent the transmission of infectious diseases; additional services (e.g., testing, vaccines, reproductive health services) can be nested within syringe exchange programs to provide additional opportunities to prevent the transmission of infectious diseases.

Considerations for policymakers

There are prevention and harm reduction programs for substance misuse that are effective and based in evidence. However, it is important for policymakers to also consider individuals’ level of access to these programs. Access to prevention and treatment services is notably more challenging for individuals who have socioeconomic disadvantage, childcare responsibilities, justice system involvement, foster care involvement, and/or co-morbid mental health challenges as well as those who are pregnant or live in rural areas. An additional consideration is whether the program has been tested with the intended population.