Prevention Can Be Treatment at a Different Time

It’s always better to prevent illness than try to treat it after disease develops and progresses. While most people who use substances do not go on to develop a substance use disorder, the impact of opioid and stimulant use disorders on health, relationships, and quality of life can be devastating. And although relatively few who misuse opioids develop a severe use disorder (about 1% of Americans), no matter who that 1 in 100 individuals is … it’s one too many.

Prevention is a powerful tool for saving lives. The Helping to End Addiction Long-term^® Initiative, or NIH HEAL Initiative^®, is using a range of strategies to find out how to implement effective prevention programs into community settings like schools, the justice system, the child welfare system, primary care and emergency departments, and other places where people live and work.

Identifying Risk

Many health problems do not develop out of the blue. Chronic conditions like diabetes, cancer, and high blood pressure often show warning signs that show up in blood tests, mammograms, and other routine health screenings. Toward effective screening for opioid misuse and its known risk factors, HEAL-funded scientists are looking for ways to identify people who are at increased risk for developing opioid use disorder and getting early help to mitigate those risks.

As children progress through developmental stages, some stages are associated with additional risk for beginning to use substances, including opioids: the teenage and young adult years are times of transition involving changes to the brain and social surroundings (like leaving home and school). Earlier developmental stages are also important. Adverse childhood experiences also add risk. These may include abuse and/or neglect, social isolation, discrimination, as well as lack of nutritious food and safe housing,

What about looking much earlier in life?

Research shows that the path to future substance use can begin as early as the toddler years. During this developmental period, parents teach children how to follow rules and develop appropriate social skills. Behavioral problems can develop during this time if children do not get help controlling impulses and focusing on tasks important to success in school and relationships with peers and teachers.

Scientists are exploring how to identify childhood risk for later opioid use. They have learned that aggressive behavior as early as first grade is associated with opioid use 15 to 20 years later. They have also learned that girls who had higher than normal attention problems in first grade were more likely to misuse prescription opioids later in life. These findings, from HEAL researchers Jill Rabinowitz, Ph.D., and Nicholas Ialongo, Ph.D., of Johns Hopkins Bloomberg School of Public Health and researchers at Wake Forest School of Medicine, involved analyzing data that has been collected from three groups, or cohorts, of about 1,600 children from predominantly African American, low to lower middle-income areas in Baltimore, Maryland.

This overall research project has been going on for a long time. Beginning in the mid-1980s and early 1990s, and in partnership with the Baltimore City school system, scientists have been following these groups of children, who now range in age from their mid-30s to their early 40s. HEAL research shows that adolescents in these groups who reported using cannabis and tobacco more frequently at age 14 were more likely to report having used opioids by age 19, although several other risk factors emerge in the teen years that play a role.

These and other results point to windows of opportunity for delivering interventions to reduce risk. The Baltimore team as well as several research groups across the country have been testing various early elementary school-based interventions to prevent harmful outcomes like substance misuse. Collectively, this research suggests that preventive interventions that focus on working with teachers and parents on promoting children’s social skills and reducing aggressive-disruptive behavior in the early elementary school years may reduce the likelihood of substance misuse in adolescence and emerging adulthood.

We don’t yet know the extent to which such interventions will prevent opioid misuse and addiction, given the limited amount of long-term data from randomized trials of early elementary school-based preventive interventions targeting later substance misuse. But these approaches could be part of a multi-faceted roadmap for preventing opioid misuse and addiction across the life span and protecting children from harm in adulthood.

Transitions are Times of Opportunity

Mental illness is also a risk factor for misuse of substances, including opioids. Up to 20% of adult mental illness begins in childhood.

“Prevention can be treatment at a different time,” explains HEAL researcher Timothy Wilens, M.D., a child and adolescent psychiatrist at Mass General Hospital in Boston, Massachusetts. He has been treating childhood psychiatric disorders, substance use disorder, and other addictive disorders for many years after seeing the value of prevention for substance misuse, Wilens explains.

“I woke up one day almost like a thoracic surgeon who says, ‘I’m tired of just doing bypass surgeries and knowing that the next generation of people not eating well, not exercising, not controlling their diabetes, will need surgery’ … for kids using substances, what if we could prevent bad outcomes from ever happening?”

With HEAL funding, Wilens and Amy Yule, M.D., of Boston University School of Medicine are focusing on mental health treatment in children and teens as a potential strategy for preventing opioid misuse and other substance use issues. We still do not know whether psychiatric treatments can prevent use of opioids and other substances. That's despite the well-known links between mental illness and substance use amplified by tragic news stories of individuals battling these conditions who die by suicide or from a fatal overdose.

Wilen’s and Yule’s current HEAL research draws from their previous studies showing that treating children with attention-deficit/hyperactivity disorder (ideally by age 9) prevents them from using substances later in life. It may seem surprising, but no one has scientifically tested questions about children with behavioral disorders like: “How long did you get mental health treatment, what was that treatment, and did you develop substance use over time? Did you develop opioid use disorder?”

One way to answer these questions is by asking youth directly, which the HEAL research team is doing through in-depth surveys of about 500 patients they are following over time in their behavioral health clinics. To reach far more people, though, the HEAL team is also using an innovative approach – Big Data analytics. They have designed computer algorithms to comb through thousands of electronic health records to look for connections between treating a psychiatric disorder (for example, depression, anxiety, or bipolar disorder) and opioid and other substance use. The ultimate goal is to define scenarios for treatment. That is, when and how much psychiatric medication, counseling, or both might keep teens from using opioids that could put them at risk for addiction or overdose.

We know mental illness needs to be treated,” says Wilens, “but [we don’t know] how much do you have to treat so that you reduce substance use risk. For example, do I treat to reduce symptoms by 30%, by 50%?”

The details matter. Answers to those questions, explains Wilens, are what providers need to know precisely how to use the power of prevention through early treatment.

Effective prevention, thus, may involve psychiatric medications to treat depression. Wilens and Yule have found that about 30% of children with depression develop a substance use disorder later in life. Pending the results of this HEAL research, effective prevention for use of substances including opioids may also involve behavioral or group-based therapy.

Prevention Across the Lifespan

Prevention interventions might target vulnerable moments in life: like early childhood when socialization begins, adolescence when peers have an outsized effect on development, and early adulthood – when the guardrails of childhood break down and real-world expectations for success come due. Not everyone is prepared for these big changes, and social context such as lack of access to basic needs like housing, nutritious food, and healthy relationships can add substantial risk.

Several HEAL prevention research studies pdf  16.04 MB are evaluating prevention strategies that have been used in other settings to see if they hold up for preventing opioid use. Projects currently under way are designing prevention interventions within existing community structures like the child welfare system, justice settings, or with Indigenous communities who have felt effects of the opioid and overdose crisis.

To learn more, see “Embedding Opioid Prevention into Everyday Life” and “HEALing in Advance: About the HEAL Preventing Opioid Use Disorder Research Program.”