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PREVENTION of

DRUG USE and


DRUG USE
DISORDERS

Renato M. Espinoza, MD, MHPEd


Dr Francisco Q. Duque Medical Foundation
Preventive Health and Community Medicine

Goals and Objectives


To understand drug-related problems and their
implications to community health
define terminologies, diagnose drug-related problems

To become effective health workers in the


prevention of drug misuse and associated disorders
discuss multilevel drug abuse preventive measures

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Drug-related
problems are true
masquerades in
clinical practice

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Important Facts
The onset of drug use is most common during the late
childhood and adolescent years.
The onset of drug abuse and dependence is much more
dependent on genetic variation in combination with specific
environmental factors.
Proximal and distal biological, psychological, social and
environmental precursors originating as early as the prenatal
period play a large role in whether experimentation occurs
and use persists.
For some individuals, the initiation of drug misuse and illicit
use of drugs extends beyond adolescence, even in the late
adulthood.

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PHARMACOLOGY OF
DRUGS OF ABUSE
Four processes are important to the development
of drug abuse:
exposure
physical dependence
psychological dependence
tolerance

An understanding of the pharmacological


properties of drugs is essential to the
understanding of drug abuse and dependence and
hence the design of prevention interventions.

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Important processes in
Drug Abuse and
Drug Dependence
1.

Exposure - timing and familial/genetic susceptibility

2.

Physical dependence - adaptive state that manifests itself


as intense physical disturbance when drug use is suspended

3.

Psychological dependence - addiction, condition under


which there is a drive toward periodic or continuous
administration of the drug to produce pleasure or avoid
discomfort

4.

Tolerance - the need for increasingly higher doses of a


drug to recapture the original effects of the drug

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Drug Abuse and


Drug Dependence
Processes of abuse and dependence reflect characteristics of
the drug, the individual user and the context of use.
Among the goals of psychopharmacology, epidemiology and
etiology research is to gain a better understanding of the
processes implicated in the development of dependence based
on the drug, the user and their interactions with one another.
The more reinforcing the drug is the more likely the individual
will seek the drug and abuse it. This is called abuse liability of
the drug.
Drug abuse may result from one exposure only.
example: binge drinking on the first occasion of alcohol use
or driving a vehicle under the influence of an illicit drug.
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Commonly-abused
Group of Drugs
Cannabinoids
Depressants
Dissociative Anesthetics
Hallucinogens
Opioids and Morphine Derivatives
Stimulants
Inhalants
Anabolic Steroids
Over-the-counter (OTC) Drugs
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cannabinoids
from the flowering top of the hemp plant
more than 60 cannabinoids have been isolated
delta-9-THC has been identified as the constituent
responsible for most of the characteristic effects
such as cognition, memory and mood disorders,
motor incoordination, errors in perception,
disorder in the sense of time, feelings of relaxation
and well-being, increased heart rate, differentially
altering standing and supine BP
withdrawal symptoms: irritability, restlessness,
nervousness, decreased appetite, weight loss
street names: hash, resin, MJ, Acapulco gold, pot..
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depressants
A. barbiturates
Share sedative and hypnotic properties
Used medically to produce drowsiness, sleep, muscle relaxation and to
prevent convulsions
Have anesthetic effects
Dose-dependent effects on relaxation, sedation, hypnosis and stupor

B. benzodiazepines
High anxiolytic property and low CNS depressant properties
Relieve anxiety symptoms
Less impaired respiratory, cognitive, attention and motor functions

In general, depressants have complex effects.


Tolerance for and Dependence on the various drugs of this class
generalize within the class and across classes to some opiates and
alcohol, called cross tolerance or cross dependence

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dissociative anesthetics
Includes PCP(phencycline), Ketamine and
Dextromethorphan
PCP
Developed in the 1950s as IV general anesthetic for animals
Sedative and anesthetic effects are trance-like
Patients experience a feeling of out of body
Distorted perception of sight and sound
Feelings of detachment or dissociation from the environment
and self ( not hallucinations )
Mech of action: altering the distribution of the
neurotransmitter GLUTAMATE throughout the brain
Glutamate is involved in the perception of pain responses to
environment and memory

KETAMINE
Developed in 1963
Injectable liquid form
Evaporated into an odorless and tasteless powder and it is
used as date rape drug
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hallucinogens
No acceptable medical use
Includes: mescaline, psilocin and LSD
Effects: distortion of perception, produce
hallucinations, illusions and profound alteration of
mood
Also called psychotomimetics or psychedelics
Their effects reflect the activity at receptors of
the serotogenic and cholinergic systems
Tolerance occurs after repeated use

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opioids and morphine


Effects: analgesia, sedation, euphoria
Mech of action: stimulation of the higher centers
of the brain and slow down the activity of the CNS
Opiod refers to the natural drugs produced from
the opium poppy such as opium, morphine and
codeine
Semi-synthetic opiates: heroine and methadone
Medical uses: pain management, diarrhea, cough
These group of drugs are highly addictive

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stimulants
Excitatory in recognition of their main effects in the CNS
Increases the levels of dopamine and decreases inhibitory
neurotransmitter
Includes cocaine, amphetamines, and methylphenidate
In low doses, are associated with feelings of increased
alertness, euphoria, vigor, motor activity, and appetite
suppression
At high doses, they produce convulsions, changes in thought
characterized on continuum from hyper-vigilance to suspicion
to paranoia, amphetamine and cocaine induced psychoses,
paranoid ideation, or toxic cardiovascular symptoms
Cocaine, when combined with alcohol, produces the lethal
cocaethylene.

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inhalants
Diverse group of chemicals that easily evaporates
Examples: aerosols, gases, hydrocarbon inhalants such as
solvents, gasoline and paint thinner
When vapors are inhaled and exhaled air is rebreathed,
intoxication is produced. Vapors of liquid solvents can be sniffed
directly from a container, may be poured on a rag and held over
the mouth, or may be emptied into a rag that is held over the
mouth and nose for inhalation
Mech of action: inhaled vapors enter the bloodstream rapidly
and are distributed to liver and brain and are absorbed quickly
into the CNS depressing many bodily functions
Generally they are categorized as CNS depressants. In moderate
doses, they produce similar effects to that caused by alcohol:
Giddiness, Disinhibition and Muscle Weakness
Lack of Coordination, Slowed Reflexes and Slurred
Speech
High doses can cause severe breathing failure and death
Chronic abuse lead to irreversible liver or brain damage and
other health problems.

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over-the-counter (OTC) drugs


Include variety of preparations with which people self
treat for minor ailments from the common cold to pain
relief or to improve performance in some way
Examples: stimulants, sleep enhancers, weight control
products
Most of these products come in combination of drugs
that interact with one another to produce the most
positive effect
If taken as directed, they are relatively safe
Long term and excessive dosages will produce varied
health problems from anxiety to GI and CV
complications
Dextromethorphan, when abused, would produce
effects similar to the dissociative anesthetic effects of
PCP and ketamine
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other compounds
Are group of drugs that do not fall into the
above categories
Examples: anabolic steroids, male sex
hormones
Medical uses:
Delayed puberty, when the body produce very low
amounts of testosterone
Treating body wasting in AIDS and related diseases

Health consequences associated with abuse:


Reduced sperm production, shrinking of the testicles,
impotence, difficulty and painful urination, baldness
and irreversible breast enlargement in males
Development of masculine characteristics like
decreased body fat and breast size, deepening of the
voice, excessive body hair, and loss of scalp hair in
females
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other compounds
Anabolic steroids are injected, taken orally or are rubbed into
the skin in an ointment form
The use of these substances are widespread among athletes
motivated by the desire to build muscle and improve
performance
Most abusers take doses of up to 100x greater than a
therapeutic dose
Health consequences associated with abuse:
For adolescents of both genders, abuse can result in
termination of the growth spurt thus permanently
stunting growth
Other severe health, social, and psychological
consequences occur for abusers of both genders at all
ages, include:
Clotting
Liver cysts and cancer
Cholesterol changes
Heightened aggression
Depressed mood
Insomnia
Loss of appetite
Muscle and joint pains
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Summary of Hallmarks
Aggressive or overactive
behavior, giggling, silliness,
euphoria, rapid speech,
confused thinking, no appetite,
extreme fatigue, dry mouth,
shakiness

Jars of pills of
varying colors,
chain smoking

Hypertension, death
from overdose,
hallucinations,
methamphetamines
cause temporary
psychosis

Barbiturates

Drowsiness, stupor, dullness,


slurred speech, drunk
appearance, vomiting

Pills of various
colors

Death from overdose or as


a result from withdrawal
addictions, convulsions

Cannabis/Marijuan
a

Initial euphoria, floating feeling,


sleepiness, lethargy, wandering
mind, enlarged pupils, lack of
coordination, craving for sweets,
changes of appetite, memory
difficulty

Strong odor of burnt


leaves, small seeds
in pocket lining,
cigarette paper,
discolored fingers

Inducement to take
stronger narcotics, recent
medical findings reveal
that prolonged usage
causes cognitive defects

Ecstacy
(methylenedioxymethamphetamine)

Anxiety, panic, sweating, loving


feelings, jaw clenching, teeth
grinding, bizarre overactive
behavior, hallucinations,
increased heart rate, BP and
body temperature, feelings of
confidence, happiness and love

Small tablets of
various colors,
shapes, sizes and
designs, also comes
in capsule or
powder

Convulsions, risk of death


from heart attack,
cerebral hemorrhage,
hyperthermia, fluid
imbalance with
hyponatremia, acute
kidney failure, DIC, liver
toxicity

Amphetamines
(including
methamphetamines)

Fantasy (gamma
Relaxation and
hydroxybutyrate) drowsiness, dizziness,
relaxed
inhibition/euphoria,
increased sexual
arousal, impaired
mobilituy and speech

Colorless
liquid
Also powder
and capsules

Tremors and
shaking, amnesia,
coma, convulsions,
deah from high
doses

Glue sniffing

Aggression and
violence, drunk
appearance, slurred
speech, dreamy or
blank expression

Tubes of glue,
glue smears,
large paper or
plastic bags or
handkerchiefs

Lung/brain/liver
damage, death thru
suffocation or
choking

LSD

Severe hallucinations,
feelings of
detachment,
incoherent speech,
cold hands and feet,
vomiting, laughing and
crying

Cube sugar
with
discoloration
in centre,
strong body
odor, small
tube of liquid

Suicidal tendencies,
unpredictable
behavior, chronic
exposure causes
brain damage, LSD
causes chromosomal
breakdown

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Narcotics
a) Opioids
(heroin)

Stupor/drowsiness,
marks on body,
watery eyes, loss of
appetite, running
nose, narrowed
pupils, loss of sex
drive

Needle or
hypodermic
syringe, cotton,
tourniquet. string,
rope, belt, burnt
bottle, caps or
spoons, bloodstain
on shirt sleeves,
glass in envelopes

Death from overdose,


mental deterioration,
destruction of brain
and liver, hepatitis,
embolisms

B) Cocaine

Similar effects to
amphetamines
(muscle pains,
irritability, paranoia,
hyperactivity, jerky
movements
euphoria, dilated
pupils

Powder: in
microwave ovens;
inhaled or injected

Hallucinations, death
from overdose
_sudden death from
arrhythmias, seizures,
mental disorders,
severe respiratory
problems

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STREET DRUG DICTIONARY


AMPHETAMINES (uppers)
Benzedrine
Dexedrine
Methedrine
Drinamyl

AMPHETAMINE
DERIVATIVES
Ecstacy
Crack
Crank
HALLUCINOGENS
LSD
Cannabis (Indian hemp)
1. Hashish (the resin)
2. Marijuana (leaves)
Cigarettes
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Smoking pot

Roses, beanies, peaches


Dexies, speed, hearts, pep pills, fast, go-ee, uppers
Meth, crystals, white light, ice, whiz
Purple hearts, goof balls

E, eggs, eckies, XTC, the love drug, mitsubishis, MDMA, vitamin E,


X, Adam, death
Crack, split, base/space base (with phencyclidine)
Crystal M, crank

Acid, blue cheer, strawberry fields, barrels, sunshine, pentagons,


purple haze, peace pills, blu light, trips
Hash, resin
Pot, tea, grass, hay, weed, locoweed, Mary Jane, rope, bong, jive,
Acapulco gold
Reefers, sticks, muggles, joints, spliffies, head, smoko, ganga
Blow a sick, blast a joint, blow, get high, get stoned
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NARCOTICS
Morphine

Morh, Miss, Emma

Heroin

H, big H, Harry, GOM (Gods own medicine), crap, junk,


horse dynamite(high-grade heroine), lemonade(low-grade
heroine), _Injection of dissolved powder: mainlining,
blast, smack, _Inhalation of powder: sniffing

Cocaine

Coke, snow, lady of the streets, nose candy, ICE, snort

H&C

Speed balls

MISCELLANEO
US
Fantasy
Barbiturates
Benzodiazepines
Ketamine
Solvents
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GBH (grievous bodily harm), liquid G, liquid ecstacy, liquid X


Devils barbies, goof balls
Rowies, moggies
K. Vitamin K, special K, K hole
Chroming

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EPIDEMIOLOGY OF
DRUG USE
Understanding the nature, extent and patterns of
use and abuse of psychoactive drugs and
compounds is a necessary prerequisite to the
development of efficacious and effective
prevention interventions.
Understanding the causal factors that lead to
exposure, initiation, progression, and maintenance
of drug abuse is fundamental to the advancement
of prevention strategies.
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ETIOLOGY of Drug Use


Substance use, abuse, and dependence result from a

complex interactions between biological,


psychological, and sociologic factors such as the interaction
styles of individuals, family members, peers, and other
significant others in combination with features of the social
context or environment.
The life course bio-psycho-social developmental
perspective suggests that the individual and
environmental factors interact to increase or reduce
vulnerability to drug use, abuse, dependence, and associated
problem behaviors.
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ETIOLOGY of Drug Use


Vulnerability occurs at many points along the life
course and peaks at critical life situations:
BIOLOGICAL TRANSITIONS - puberty
NORMATIVE TRANSITIONS - moving from elementary to
high school

SOCIAL TRANSITIONS - dating


TRAUMATIC TRANSITIONS - death of a parent

Vulnerability involves dynamic intrapersonal,


interpersonal and environmental influences.
A meta-theoretical perspective provides a broad
view of the complex forces and interactions that
influence developmental and problem behaviors.
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MACROSYSTEM
ATTITUDES AND IDEOLOGIES OF THE CULTURE
EXOSYSTEM EXTENDED
FAMILY
MESOSYSTEM

MICROSYSTEM
FRIENDS
OF FAMILY

NEIGHBORS

FAMILY

SCHOOL

HEALTH
SERVICES

MASS
MEDIA

PEERS

CHILD

CHURCH

NEIGHBORHOOD

GROUP

PLAY AREA

LEGAL
SERVICES

DAYCARE CENTER

SOCIAL WELFARE
SERVICES

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BRONFENBRENNER
BRONFENBRENNERS FOUR ECOLOGICAL
SETTINGS FOR DEVELOPMENTAL CHANGES

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THEORETICAL
PERSPECTIVES
Interventions based on discrete theoretical
perspectives will guide the development of the
content, length of exposure, and for whom these
interventions work.
Theoretical perspectives predict differential drug
use trajectories and elucidate developmentally
grounded mediators.
These also provide the basis of a comprehensive
evaluation design.
The 3 commonly used theories in prevention:
1. BEHAVIORAL THEORY
2. SOCIAL LEARNING THEORY
3. SOCIAL COGNITIVE THEORY
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Behavioral Theory
Includes information processing
Places emphasis on learning skills and knowledge
Assumes that behavior is based on cognition rather than
external forces
Major Foci:
Learning occurs thru making cognitive connections between
stimuli and responses
When learning is rewarded, especially in close temporal
proximity to the response, the connections are reinforced
Active participation in the learning process is critical
Steps are delineated that begin with successive approximations
to the parts with increasing accuracy over time
Success of learning is done with repetitions, reinforcement and
raising standards
Behaviors that are not reinforced are not learned
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Social Learning Theory


Emphasizes learning that occurs within social contexts:
Family, School, Neighborhood, Community

The basic premise is that people learn from interacting with and
observing other people.
People who are most salient to the learner tend to have the most
impact on both social knowledge and behaviors.
Social learning that translates to changes in behavior occurs thru
modeling and initiation.
Not all social learning result in behavior change.
Behavior itself can be reinforcing thru sensory stimulation that is
satisfying.
When behavior is modeled or imitated, it is more likely to become
integrated to individuals repertoire of behaviors and if positively
and strongly reinforced leads to vicarious connection to the persons
learning.
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Social Cognitive Theory


Is an offshoot of social learning theory emphasizing the
cognitive processes that occur during learning.
Attention is a critical cognitive feature of this paradigm in
that it is associated with expectation of rewards or negative
consequences.
Individuals develop cognitive expectation about associated
behavioral consequences based on verbal and nonverbal
reactions they have experienced.
Other cognitive strategies related to the development of
behaviors include:

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SKILLS
SELF-MONITORING
SELF-TALK
SELF-REINFORCEMENT
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RISK and
PROTECTIVE FACTORS
The bio-psycho-social perspective and theories related to
prevention implicitly recognize the role of risk and protective
factors in shaping developmental trajectories.
Basic Concept: risk is associated with increased vulnerability,
whereas protection is associated with decreased vulnerability to
disease.
This paradigm has been adapted for behaviorally-based diseases
with one major caveat:
For many medical conditions a single source is associated with causation,
whereas with psychosocial health issues, multiple factors are associated
with disease causation

The perspective places the individual at the center because so


much of what occurs during the developmental process is
determined by individual characteristics such as temperament,
learning and communication styles and genetic vulnerability to
disease.

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RISK and
PROTECTIVE FACTORS
The study of behavioral genetics provides a framework for
one line of etiologic investigation of risk and protective
factors.
The genetic and environmental factors to behavioral
outcomes have been demonstrated to be related to familial
influences.
A trajectory captures how individual children adapt either
positively or negatively to their circumstances and is affected
by intrapersonal, interpersonal, and environmental factors
encountered at different developmental stages over the life
course.

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RISK and
PROTECTIVE FACTORS
Many types of these risk and protective factors occur at all
levels of human ecosystem and have varied potency of
influence and effects to different individuals at particular
developmental stages.
Some factors can be dynamic (socioeconomic) and others
cannot be changed at all (gender and genetic vulnerability).
Risk and protective factors operate in 5 contexts:
INDIVIDUAL, FAMILY, PEER, SCHOOL and COMMUNITY

Not all individuals at heightened risk actually use or abuse


drugs. Strong extra-familial support systems is a protective
factor to a young person with a strong family history of
substance abuse and a chaotic home environment.

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RISK and
PROTECTIVE FACTORS
In most cases, risk and protective factors are independent of each
other and operate in a continuum.
Childrens earliest interactions occur within the family and factors
that affect early development are crucial to the development.
Families foster optimal development when strong bonds are
established between parents and the child:

Parents involvement in childs activities


Childs emotional and material needs are met by parents
Firm, clear, and consistent limits for behavior
Rules are enforced in non-hostile, matter-of-fact manner

One of the most well-delineated risk trajectories for subsequent


substance abuse is out-of-control aggressive behavior in very young
children.
Other factors that may initiate drug use:
Drug availability
Perception that drug abuse is accepted
Inflated misperceptions about the extent to which same-age peers
use drugs
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Risk factors

Context

Protective
factors

Early aggressive
behavior

individual

Lack of parental
supervision

family

Substance abuse

peer

Academic
competence

Drug availability

school

Anti-drug use
policies

Poverty

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community

Impulse control

Parental monitoring

Strong neighborhood
attachment

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PREVENTION INTERVENTIONS
Prevention interventions approach the relaying of information
concerning classes of drug in several ways:
1.

For general populations of young children, little or no information


on drugs of abuse is given, instead they concentrate on skills
development or other proven prevention strategies.

2.

Other interventions concentrate on targeting a specific group of


drugs for a specific population. Drugs to target are determined
through epidemiologic studies of the population of interest.

3.

Some interventions target one specific drug that is a serious


problem for a specific population.
Example, steroid abuse among athletes

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PROGRAMMES and
STRATEGIES
Programmes and Strategies are effective if they are related
to pertinent social contexts with some attention to
developmental timing.
At the intrapersonal level, the most important strategies are
those that build skills and competencies:

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Learning to conform to rules


Behave in prosocial ways
Identify and appropriately express feelings
Control of impulses
Academic competence
Social resistance
Social emotional learning
Normative education

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Family-based
Interventions
One universal program teaches the important
strategy of reinforcing appropriate behaviors that
the child naturally expresses and ignoring
inappropriate behaviors.
As mentioned, transitions are points of
vulnerability so that they are major periods of risk.
Birth of the first-born baby, parenting a special
child, expectations for academic and social
performance are but some of the reality issues
inside the family which need to be addressed so
that harmony at home is restored.

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School-based
Interventions
At school, a number of programmes and strategies have also
been demonstrated to make for successful transitions and
academic careers.
One important strategy is classroom management which
trains teachers in building plans for rewarding positive
behaviors and over time has the effect of reducing the bulk
of negative classroom behaviors.
Learning is the primary goal and the primary source of
reward.
Teachers are trained to use consistent, easy to learn routines
that are fun for the children.

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School-based
Interventions
The environmental change strategy transforms the
classroom from one centered on reducing negative behaviors
to one focused on promoting positive behaviors and learning.
The social emotional learning strategy helps the
children to identify their feelings such as frustration or anger
and then provides them tools to manage these feelings.
Developing social emotional awareness at a very young age has long term positive effects
on academic and social performance across the school years and into adulthood

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School-based
Interventions
Promotion of academic competence is another type
of school-based intervention that have the most profound
effects in fostering a positive attitude toward learning, a
sense of accomplishment and understanding of the basics
necessary for future learning.

Resistance skills training is based on the social


learning theory and stresses the importance of social factors
in the initiation of drug use. The paradigm focuses on
teaching youth skills to handle peer pressure to experiment
with drugs.
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School-based
Interventions
Normative education is another strategy that have some
positive effects but only when used in conjunction with skills
development strategies.

The goal is to correct misperceived positive norms about the actual


use and acceptance of drug use.

It reinforces the perception of the school as a safe and nurturing


environment.

Actual survey is done to compare the students perceptions of drug


use and acceptance among their peers and their own drug use.

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Community-based
Interventions
At the community level and beyond, prevention
strategies typically involve policy and media
interventions.
Policy interventions:
Training shopkeepers to request for identification from
purchasers of tobacco and alcohol products
Refusal of sales to those that do not meet the minimum age
requirements

Media interventions:
Offering of alternative activities to high sensation seeking
personality traits, such as rock climbing
Spots were aired in one community then compared to the
second community not receiving media spots
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Program Delivery
Delivery refers to the way in which the plan or strategy is
implemented with the target population.
the skills/competency development interventions are the
most potent in terms of effectiveness in contrast to the fear
arousal strategy which have been demonstrated to be least
effective.
Dosage is critical.. active ingredients of the intervention
must be delivered and received for it to have the desired
effect, booster sessions are important.
Efforts at the individual, family, school, and community
levels should reinforce one another and must always be
consistent.
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KEY MESSAGES to the


HEALTH CARE PROVIDERS
Health care workers have the unique opportunity to interact one-onone with patients about their health behaviors.
REDUCE INITIATION OF DRUG USE
ABORT THE PROGRESSION OF THE DRUG USE DISORDER

Life transitions are critical periods for patient screening


SCHOOL PHYSICALS
PREGNANCY EXAMINATIONS

Research is on-going in the development of other tools to reduce


drug use and substance abuse.
One approach being investigated is the the use of technology-based tools to
screen for potential drug-related problem behaviors.

The goals of developing and testing these tools are to involve the
primary care physicians in:
IDENTIFYING PATIENTS AT RISK
PROVIDING BRIEF INTERVENTIONS
POTENTIALLY PROVIDING REFERRALS
for more intensive interventions
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SUMMARY
pharmacology of drugs of abuse
processes of abuse and dependence
commonly abused drugs
prevention interventions

epidemiology of drug use


etiology

Bronfenbrenners 4 ecological settings for developmental change


Behavioral theory
Social learning theory
Social cognitive theory

risk and protective factors


The Five Contexts

programs and strategies


Family-based interventions
School-based interventions
Community-based interventions

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Drug use and


drug use disorders
interfere with the
normal, healthy
functioning across
the human lifespan
but are
fundamentally
preventable

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