The Prevention Path Forward: What We Have Learned and What Is Next

Part 1 — How Treatment Shaped the Prevention Landscape^[1]

^[1] Part 2- The Rise of Prevention Science; Part 3-Rethinking Risk: The Evolution of Harm Reduction; Part 4-What Is Next in Prevention: Research, Practice and Action.

For decades, prevention of substance use has been the ‘step-sister’ of substance use treatment.  Not only in terms of research dollars spent on questions regarding understanding the mechanisms that underlie the initiation of substance use but also very much related to developing and, most challenging, to document the effectiveness of prevention interventions.  Very much related to the research has been the difficulty of supporting and implementing these evidence-based prevention strategies within communities across the world.

Before we discuss the Future of Prevention, it is important to review the history and role of substance use prevention, treatment, and, most recently, harm reduction.  This history is shaped by the attitudes and beliefs about substance use disorders.  Medical sociologists have been debating the factors that play a role in stigmatizing a health issue (See Goffman, 1963).  For today, let’s propose a relatively simple perspective:

• Is the affected person responsible for his/her condition?

• Do the symptoms experienced by the affected person impact others?

• Is the condition addressed and understood by the medical professional?

• Are effective treatments available? AND are these treatments accessible?

Although 70 years of research have addressed ALL of these questions, stigma remains a key issue among policy makers and the general population and underscored by the press (e.g., Carlon et al., 2025; McGinty et al., 2019). 

Substance Use “Treatment” 1900 to Today

The history of prevention, harm reduction, and treatment approaches are very much intertwined with U.S. laws/regulations regarding the use of opium, heroin, other narcotics, cocaine, amphetamines hallucinogens, depressants.  I show only 11 of the many federal laws related to substance use. These laws such as the Harrison Act and the Anti-Heroin Act impose taxes on the importation, manufacture, sale of narcotics and later other substances and laws such as the Boggs Act and the Narcotics Control Act outline the penalties for the manufacture, sale and possession of narcotics or other scheduled substances.

U.S. laws/regulations

On the other hand, we see here Federal actions to support the treatment of substance use, primarily narcotics.  This action began with the Morphine Maintenance Clinics and the Narcotic Farms through to 2010 when treatment for substance use was covered under the Affordable Care Act.  The acknowledgement that drug addiction is a medical condition by the American Medical Association and the approval of methadone and buprenorphine to treat substance use helped to make this happen.  Also note key actions of the Federal government to support services and research for substance use through the establishment of the Special Action Office for Drug Abuse Prevention that later became the Office for National Drug Control Policy, the National Institute on Drug Abuse, and the Substance Abuse and Mental Health Services Administration.

Federal actions to support the treatment of substance use

SAMHSA Illustration 1800

This illustration from SAMHSA  emphasizes that by the late 1800s, it was believed that most of those with opiate issues were upper and middleclass white women who were prescribed these drugs for menstrual issues.  But also soldiers who served in the Civil War and were injured were also among the numbers of opiate users. And, we can see from this add from January 1900 from the St. James Society in New York City early efforts to treat addiction.  It reads…”We will send anyone addicted to OPIUM, MORPHINE, LAUDANUM, or other drug habit, a Trial Treatment, Free of Charge, of the most remarkable remedy ever discovered.  Contains Great Vital Principle heretofore unknown…Confidential correspondence invited from all, especially Physicians.”

New York City efforts to treat addiction

Morphine Maintenance Clinics established in the 1920s were supported by the Federal government and operated locally often by medical groups.  They were closed as the belief was that they were not effective.  Researchers in the 1970s and 1980s reviewed the available records of these clinics and found that they were effective for some of their clients (Musto?). Other programs that were supported by the Federal government included the Public Health Service Hospitals which was one of the first hospitals that treated those convicted of the violation of Federal narcotic laws and who voluntarily signed up for treatment.  These facilities not only provided treatment but also became research operations that eventually formed the basis for the intramural research program of the National Institute on Drug Abuse.  The Treatment of Alternative to Crime (TASC) program grew out of the experiences of the civil commitment programs and was created by President Nixon's Special Action Office for Drug Abuse Prevention.  Both the Civil Commitment programs and TASC not only provided in-patient treatment but also referred

drug-involved offenders into appropriate community-based treatment programs.  TASC is viewed as the pre-runner to Drug Courts. The expansion of community treatment began in the 1950s through the mid-1970s.  The 1990s was a time of expanded research efforts supporting randomized controlled trials and outcome studies of existing treatment programs.  The findings of this research was summarized by the National Institute on Drug Abuse in the Principles of Drug Abuse Treatment (updated in 2018) including 13 Treatment Principles:

1. No single treatment is appropriate for all

2. Treatment needs to be readily available

3. Effective treatment attends to the multiple needs of the individual

4. Treatment plans must be assessed and modified continually to meet changing needs

5. Remaining in treatment for an adequate period of time is critical for treatment

   effectiveness

6. Counseling and other behavioral therapies are critical components of effective treatment

7. Medications are an important element of treatment for many patients

8. Co-existing disorders should be treated in an integrated way

9. Medical detoxification is only the first stage of treatment

10. Treatment does not need to be voluntary to be effective

11. Possible drug use during treatment must be monitored continuously

12. Treatment programs should assess for HIV/AIDS, Hepatitis B & C, Tuberculosis and other infectious diseases and help clients modify at-risk behaviors

13. Recovery can be a long-term process and frequently requires multiple episodes of treatment.

The Guide also listed “scientifically-based” approaches to treatment:

Scientifically based approaches to treatment

Evaluations of substance use treatment programs found positive outcomes associated with:

Staying longer in/ being more compliant with treatment—especially through behavioral contracting for positive reinforcement;

• Having an individual counselor or therapist;

• Having specialized services provided for associated medical, psychiatric, and/or family problems;

• Receiving proper medications—both for psychiatric conditions and anti-craving medications; and,

• Participating in AA or NA following treatment.

However, it was also found that:

• Treatment programs had not adopted useful research findings into clinical practice (e.g., minimal use of methadone and naltrexone, contingency management);  

• Morale of staff in treatment programs is too low;

• Social, emotional and behavioral services have been reduced over time;

• Too few substance users were attracted to treatment;

• Rates of illicit substance use by clients in treatment are high;

• Clients are not clinically matched with treatment programs, e.g., psychiatric severity;

• Treatment retention rates are too low; and,

• Relapse rates after treatment are unacceptably high.

When the concept of ‘evidence-based’ was applied to substance use treatment, Mark and colleagues (2020) summarized what constituted ‘evidence-based treatment’…’a combination of therapies and other services to meet the needs of the individual patient’. 

And other studies of existing treatment programs conducted by this group have shown that:

•       <50% offered medications for opioid use disorder; testing for hepatitis C, HIV and STD; offered self-help groups; employment assistance; or transportation assistance

•       51% were accredited in 2017

•       52% provided assessments for mental health comorbidities

•       68% provided mental health services.

Without supportive services those having completed treatment are not able to reintegrate into their communities and resort to substance use (e.g., Karriker-Jaffee et al., 2018). 

There are many lessons from prevention science that can inform the structuring of treatment and support services to increase positive outcomes from treatment and the reintegration of substance users into their roles as parents, family and productive community members.

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References           

Carlon, H.A., Hebden, H.M., Christie, N.C., Tuchman, F.R., Moniz-Lewis, D.I.K., Boness, C.L., Witkiewitz, K. & Hurlocker, M.C. (2025). "Either way, they will use. And so, probably, would you:" A critical discourse analysis of harm reduction portrayal in United States opinion news media. International Journal on Drug Policy, 140:104801. doi: 10.1016/j.drugpo.2025.104801.

Goffman, E. (1963). Stigma; Notes on the Management of Spoiled Identity. Englewood Cliffs, NJ: Prentice-Hall.

Karriker-Jaffe, K.J., Witbrodt, J., Subbaraman, M.S. & Kaskutas, L.A. (2018). What Happens After Treatment? Long-Term Effects of Continued Substance Use, Psychiatric Problems and Help-Seeking on Social Status of Alcohol-Dependent Individuals. Alcohol and Alcoholism, 1, 53(4),394-402. doi: 10.1093/alcalc/agy025. PMID: 29617709; PMCID: PMC6016698.

Mark, I.L., Dowd, W.N. & Council, C.I. (2020). Tracking the Quality of Addiction Treatment Over Time and States: Using the Federal Government’s “Signs” of Higher Quality. RTI Press Publication No. RR-0040-2007. Research Triangle Park, NC:RTI Press.

McGinty, E.E., Stone, E.M., Kennedy-Hendricks, A. & Barry, C.L. (2019). Stigmatizing language in news media coverage of the opioid epidemic: Implications for public health. Preventive Medicine, 124,110-114. doi: 10.1016/j.ypmed.2019.03.018. PMID: 31122614.

National Institute on Drug Abuse. (2018). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition).

Paino, M., Aletraris, L. & Roman, P. (2016). The relationship between client characteristics and wraparound services in substance use disorder treatment centers. Journal of Studies on Alcohol and Drugs, 77(1), 160-169. doi: 10.15288/jsad.2016.77.160. PMID: 26751366; PMCID: PMC4711315.

Pringle, J.L., Emptage, N.P. & Hubbard, R.L. (2006). Unmet needs for comprehensive services in outpatient addiction treatment. Journal of Substance Abuse Treatment, 30(3), 183-189. doi: 10.1016/j.jsat.2005.11.006. PMID: 16616161.