Primary, Secondary, and Tertiary Prevention of Substance Use Disorders through Socioecological Strategies

By Amanda D. Latimore, Elizabeth Salisbury- Afshar, Noah Duff, Emma Freiling, Brett Kellett, Rebecca D. Sullenger, Aisha Salman, and the Prevention, Treatment, and Recovery Services Working Group of the National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic

September 6, 2023 | Discussion Paper

ABSTRACT | Rapidly rising drug overdose rates in the United States during the past three decades underscore the critical need to prevent overdose deaths and reduce the development of opioid and related substance use disorders (SUDs). Traditional public health models of prevention emphasize the biological and physical risks of SUDs, often neglecting to consider the broader environmental and social factors that influence health and well-being. Taking a socioecological approach, the authors aim to illustrate the complex interplay among individual, interpersonal, societal, and structural factors that contribute to the development of SUD and overdose risk. The authors propose evidence-informed strategies and interventions across primary, secondary, and tertiary levels of prevention. By doing so, the authors hope to encourage policymakers, funders, service providers, and community leaders to broaden their approaches to SUD prevention and consider how they can create and advocate for a health-promoting environment by addressing the social and structural factors that drive rising SUD and overdose trends.

Introduction

Clinical medicine and public health have long held dueling perspectives of illness. Leading public health thinkers have consistently connected socioeconomic factors to illness, while some traditional clinical medicine professionals have held views restricted to the somatic parameters and “the organic elements . . . of human malfunction” (Jones-Eversley and Dean, 2018; Engel, 1977). The biomedical model described in the latter half of the previous sentence forms the basis of classical Western medical training, in which illness can be reduced to a biological or physiological physical element. Rudolf Virchow (1848), considered the father of modern pathology, stated that “medicine is a social science” and understood that disease operates at the cellular level. He also recognized the social conditions that facilitated the spread of disease, yet this acknowledgment had minimal influence in the evolution of the biomedical model.

In many ways, the American health care system still struggles with the same dilemma today: reimbursem*nt structures incentivize delivery of high acuity care and surgical procedures and rarely pay for care coordination, case management, or other services known to impact long-term health outcomes. But there is an increasingly urgent need, made more salient during the co-occurring COVID-19 and overdose epidemics, to resolve the philosophical debate over clinical medicine’s scope of responsibility for identifying, treating, and preventing substance use disorder (SUD). While the importance of understanding the social and economic conditions of patients is a common component of medical training, the application of this notion to people who use drugs (PWUD) is less common (Yoast et al., 2008). Furthermore, training on the importance of patient socioeconomic conditions may not translate to an understanding of how medical professionals can play an active role in addressing them, through prevention, treatment, or policy advocacy.

Effectively addressing SUDs and their associated social determinants of health requires a collaborative, cross-sector approach involving not only health care systems and professionals, but also schools, social service organizations, and local communities. By working together, partners can have a greater impact and yield more significant outcomes. They can realize collective impact by fostering strategic partnerships to invest in and implement prevention programs and by improving both the capacity to treat SUDs and the awareness of available supportive service (Health and Human Services Office of the Surgeon General, 2016).

The urgency of such collaborative strategies has been underscored in an era marked by the COVID-19 pandemic, which has heightened society’s awareness of nonbiomedical influences on health. The pandemic has exacerbated risk factors for increased substance use and SUD, disrupting employment, housing, health care access, and social connection, and heightening fear, anxiety, financial stress, and grief—particularly among those with preexisting structural vulnerabilities (Collins et al., 2022). Pandemic-related stressors have been tied to escalation of the ongoing overdose epidemic and increases in substance use (Ghose, Forati, and Mantsch, 2022). For example, caregiving responsibilities, stress, depression, and anxiety were associated with increased substance use during the pandemic (Schmidt et al., 2021). After a historic 30 percent year-to-year increase in overdose fatalities from 2019 to 2020, estimates suggest that the United States again experienced a 15 percent increase in overdose fatalities in 2021, with a record-breaking 109,179 deaths—75 percent of which were related to opioids (Centers for Disease Control and Prevention, 2021). Overdose fatalities remained steady in 2022, with provisional data indicating 109,680 deaths (Ahmad et al., 2023).

Among those in the United States who died of overdose, the racial inequity that existed before the pandemic was amplified by the heavier economic, social, and health burdens carried by non-Hispanic Black individuals during the pandemic. This group had the greatest annual increase in drug-related overdose deaths in 2020 (Mistler et al., 2021; SAMHSA, 2020a). While rates of drug overdose death have consistently been higher among the White versus Black population, Black people have seen a 3.6-fold increase in overdose deaths since 2015, compared to the 1.7-fold increase among White individuals. In 2021, the age-adjusted drug death rates of Black (44 per 100,000) and American Indian/Alaskan Native (56 per 100,000) people were significantly higher than the rate for White people (36.8 per 100,000; National Center for Health Statistics, n.d.). To mitigate the worsening overdose crisis, the broader health and human services system must consider the structural and social determinants behind these growing disparities.

To make this case, this paper first explores the historical events that have informed the current US biomedical paradigm for SUD prevention, using the example of opioid use disorder (OUD), and the problems that have, in part, resulted from this approach. The authors then discuss how a socioecological framework—which considers the complex interplay among individual, interpersonal, societal, and structural factors—can offer a more comprehensive and effective means of understanding SUD prevention. The paper concludes with an exercise in which the authors apply a socioecological lens to the traditional public health model of OUD prevention, elucidating evidence-informed strategies and interventions across primary, secondary, and tertiary levels of prevention that aim not only to prevent disease but also to promote overall health and well-being.

The authors recognize the pivotal role the socioecological approach has played in shaping responses to various health conditions, including mental health conditions (Akers et al., 2023; National Institute on Minority Health and Health Disparities, 2017). However, despite its proven merits, the socioecological approach remains underused and its integration into the field of SUD prevention has been limited. Therefore, the primary purpose of this paper is to articulate the application of this approach and underscore its significance within the overarching context of SUD prevention. Further, this paper seeks to catalyze the expansion and uptake of this approach, empowering stakeholders to identify strategies that align with their circ*mstances and available resources.

From Moralization to Medicalization

The United States has a long history of politicizing, moralizing, and racializing drug use, a history that existed for nearly a century before President Richard Nixon formally declared the “war on drugs” in the 1970s (Rosino and Hughey, 2018). Political rhetoric preceding legislation that restricted or criminalized the possession of opium, cocaine, and cannabis featured statements that stoked fears of lost virtues and moral hygiene, and often cited unsubstantiated claims of the victimization of White women at the hands of people of certain races and ethnicities. For example, prior to the enactment of the 1914 Harrison Narcotics Act, proponents of racial prejudice warned Congress, claiming that “[m]ost of the attacks upon [W]hite women of the South are the direct result of a cocaine-crazed Negro brain” (Nunn, 2002). Congress passed the act, which regulated and taxed the production, importation, and distribution of opiates, and spurred federal agencies to prohibit physicians from prescribing opioids to persons with addiction, effectively initiating the criminalization of SUD in the United States at the federal level (Courtwright, 2015; Kleber, 2008).

Contrary to popular belief, the process of “scheduling”—which categorizes drugs based on their potential for abuse— as controlled substances was not informed by a systematic examination of relative drug risk, but rather by geopolitical and commercial interests and xenophobic ideologies that marginalized certain racial and ethnic populations (Daniels et al., 2021). For instance, the Controlled Substance Act of 1970, which laid the foundation for the current US drug scheduling system, emerged amid a broader cultural and political shift during the Nixon administration. Strategically aiming to neutralize the 1960s counterculture, the Nixon administration “knew [they] couldn’t make it illegal to be either against the war or [B]lack, but by getting the public to associate hippies with marijuana and [B]lacks with heroin, and then with criminalizing both heavily, [they] could disrupt those communities” (Baum, 2016).

In the ensuing years, US drug policy has consistently prioritized addressing the perceived moral outrage against drug use through tough-on-crime policies and a seemingly unrestricted cascade of federal dollars invested in drug interdiction (Shepard and Blackley, 2004). However, rather than serving as an effective public health strategy, this punitive approach has only served to perpetuate stigmatizing attitudes by erroneously associating drug use with social deviance and criminality (Dineen and Pendo, 2021). Prevention strategies have often relied on harsh criminal legal actions and fear-based educational campaigns, ostensibly to send a warning to individuals who might sell or use drugs. Nevertheless, research suggests that compulsory detention, other harsh criminal penalties, and youth-focused scare tactics have had little impact on reducing drug supply or curbing demand (Substance Abuse and Mental Health Services Administration, 2015; Global Commission on Drug Policy, 2011; Degenhardt et al., 2010).

To counter the prevailing erroneous theories of addiction as a moral failing, the medical community put forth the brain disease model, which expressed addiction in scientific terms, namely explaining that SUD resulted from a brain system that had been dysregulated by drug use (Heilig et al., 2021; Leshner, 1997). However, the mechanistic view of drugs “hijacking” the brain was not in conflict with the interdiction paradigm that similarly targeted drugs as the source of growing social ills. The mechanistic causal narrative continued to focus on regulating drugs and the drug supply instead of interrogating the social factors that drove the demand for drugs (El-Sabawi, 2019; Office of the Surgeon General, 2016; Institute of Medicine et al., 1994; Hawkins, Catalano, and Miller, 1992). In more recent years, and in response to greater attention to racial disparities in the criminal legal system, advocates within the medical community have called for reform of the criminal legal response to SUD and targeted broader social change, including increased access to housing, education, and health care (AMA, 2022; AMA, 2021; ASAM, 2021a; ASAM, 2021b; AMA, 2020).

From Medicalization to a Socioecological Approach

Prescriptive biomedical views of SUD prevention have led to simplistic problem statements and unidimensional solutions. For example, the United States experienced an excessive focus on increased opioid prescribing as a response to the opioid overdose crisis, often at the expense of supportive strategies (Dasgupta, Beletsky, and Ciccarone, 2018). The increase in prescribing stemmed from a complex interplay between predatory marketing of opioids and the need to address the undertreatment of chronic pain in the 1990s and early 2000s (DeWeerdt, 2019). However, the disproportionate emphasis on pharmaceuticals in the public narrative obscured other important drivers of the crisis, while fostering a defensive dynamic between patients and prescribers.

Key factors—such as the high prevalence of illicitly manufactured opioids, the counterproductive role of prohibition policies in creating an increasingly toxic drug supply, and evolving trends in substance use—have been largely overlooked. This reductionist view diverted attention from the myriad of contextual factors related to the onset and progression of SUD (Herzberg et al., 2016; Wailoo, 2014). A case in point is the rigid misapplication of prescribing limits outlined in the 2016 “CDC [Centers for Disease Control and Prevention] Guideline for Prescribing Opioids for Chronic Pain,” which contributed to many patients with pain who benefited from opioid therapy being nonconsensually tapered or denied further treatment (Kroenke et al., 2019; Dowell, Haegerich, and Chou, 2016). Consequently, some individuals resorted to seeking illicit alternatives for pain relief, paradoxically exacerbating the very issue that the guideline sought to address (Coffin et al., 2020).

The focus on reducing opioid prescriptions may have the veneer of a less punitive and more medical approach to preventing SUD but is still a supply-side narrative (El-Sabawi, 2019). Moreover, a purely biomedical focus for preventing SUD offers limited insight into the structural and systemic factors driving racial and ethnic disparities in overdose deaths.

A Socioecological Theoretical Framework for SUD Prevention

A socioecological framework for SUD prevention recognizes the complex interactions between people and their environments at the individual, interpersonal, and macro levels (Agency for Toxic Substances and Disease Registry, 2015; Bronfenbrenner, 1979). Social epidemiologists have established causal mechanisms to support the application of a socioecological framework to health broadly and to clarify how structural and social determinants of health create socially patterned distributions of disease (Berkman, Kawachi, and Glymour, 2015; Krieger, Dorling, and McCartney, 2012; Glass and McAtee, 2006; Link and Phelan, 1995). Social epidemiologic research supports the assertion that the context in which individuals make health-related choices serves as a barrier to or facilitates health (Galea, Nandi, and Vlahov, 2004; DuBois, 2003). Race, often treated in biomedical perspectives as biologically defined (Ioannidis, Powe, and Yancy, 2021), is recognized as a socially constructed factor that is not biologically determined but does create differences in biological outcomes (Krieger, Dorling, and McCartney, 2012; Roberts, 2012).

Figure 1 illustrates the nested levels of factors considered in a socioecological framework, which have been highly simplified for the purpose of organizing the current argument. Macro-level factors, such as policies and practices, can have direct impacts on individuals’ health by subjecting them to stigma, trauma, and discrimination stemming from these broader influences. These experiences then physically manifest via stress response mechanisms (Hatzenbuehler et al., 2015; Geller et al., 2014). Additionally, macro-level factors shape the interpersonal structures in communities, influencing individuals’ access to resources and opportunities, and their health-related behaviors and beliefs. Importantly, the interplay among levels is interdependent and multidirectional, with influences at one level often facilitated or inhibited by elements at another level.

Understanding this interplay, social epidemiology recognizes that people make places and places make people (Macintyre and Ellaway, 2003). Due to the complex feedback loops and interactions between people and their environments (e.g., people may not buy healthy foods because stores do not carry healthy foods, and stores may not carry healthy foods because of a perception that people will not buy them), reductionist views of health can be antithetical to the socioecological perspective. While not the focus of this current work, the authors recognize that this complex person-environment interaction can occur across the life course and is intergenerational (Latimore et al., in press).

The application of a socioecological framework to SUD is not new (American Institutes for Research, 2022; Park et al., 2020; Jalali et al., 2020; Galea, Nandi, and Vlahov, 2004), but the addiction field has been slow to adopt the framework in practice. Macro-level risk factors such as restrictive drug policies and stigma isolate people with SUD from social and economic resources, such as services associated with SUD prevention, treatment, recovery, and harm reduction. These resources influence health at the individual level through physiological, psychosocial, and health behavior pathways. Similarly, racial disparities in SUD result from the experience of race in society and the distribution of economic and social resources that affect health. For the remainder of the paper, the authors focus on OUD, because of its relative contribution to the current overdose epidemic and the availability of resources targeted to OUD. However, the authors recognize the evolving nature of drug trends, the need for attention to other SUDs, and the applicability of this theoretical approach and related strategies to related SUDs.

Applying a Socioecological Framework for a More Nuanced View of OUD and Public Health Prevention

In the biomedical model of health and health care, prevention interventions have traditionally been classified according to three distinct levels: primary, secondary, and tertiary (Leavell and Clark, 1965). Primary prevention strategies aim to mitigate risk factors and prevent health conditions from ever developing. Secondary prevention interventions seek to identify a health condition as early as possible to halt or slow its progression. Tertiary prevention approaches strive to minimize acute negative consequences, like death, among those who have the disease.

In the context of OUD, a primary prevention approach under the traditional biomedical model aims to avoid the onset of OUD by, for example, educating clinicians and patients on alternative modalities and non-opioid medications for effective pain management to reduce exposure to prescribed opioids. Similarly, screening and referring patients to be prescribed medications for OUD constitute one approach to achieving the secondary prevention goal of identifying, diagnosing, and treating OUD as early as possible. Lastly, providing naloxone to those using opioids is an example of tertiary prevention, as naloxone can reduce the risk of opioid overdose and death among individuals with OUD.

While the primary, secondary, and tertiary classification can be useful for partitioning types of responses, its typical application to a biomedical model focuses on a clinical response and does not include efforts to address structural determinants of health and the complex interactions among the human body, the environment, and an individual’s life circ*mstances included in the socioecological perspective.

For example, negative stereotypes persist about people with OUD that do not exist for people with other chronic conditions; the latter are met with relatively clear pathways to additional testing, treatment, and support. Comparatively, upon discovery of their nonprescribed opioid use, too often individuals face judgement or blame and are left without connections to appropriate, evidence-based care (Tsai et al., 2019). Such counterproductive interactions with health care professionals and the health care system deter individuals from seeking help at critical moments before and after the development of OUD and associated negative health and social consequences. Widespread recognition that OUD is a treatable condition, and that stigmatizing language has negative impacts on people with OUD, is critical for reducing the continuous rise in overdoses.

The primary, secondary, and tertiary prevention classification is somewhat ill-fitting for the nonlinear nature of addiction and other chronic health conditions, particularly if the treatment approach does not consider the social and environment factors impacting disease and health. OUD is a medical diagnosis defined by a pattern of opioid use that leads to problems or distress (e.g., physical, mental, interpersonal, and financial; American Psychiatric Association, 2013). Most people who are exposed to opioids do not develop OUD. Of the estimated 10.1 million individuals 12 years or older who reported problematic use of opioids in 2019, 1.6 million met The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, criteria for OUD (SAMHSA, 2020b). Among individuals prescribed opioids long term for chronic pain, between 8 percent and 12 percent will develop an addiction to opioids, although nuance exists in the reported estimates (Dowell, Haegerich, and Chou, 2016; Volkow and McLellan, 2016; Vowles et al., 2015). Individuals can move in and out of the “diagnosed” and “high-risk” categories as they reduce their drug use and no longer meet the criteria for OUD. Among those with an OUD diagnosis, the extent to which they participate in drug use behaviors that place them at high risk for overdose can fluctuate.

The definitions of recovery and remission are hotly debated topics that involve differing schools of thought (Office of the Surgeon General, 2016). While there is general agreement that recovery involves achieving a state of improved well-being, varying perspectives exist on the nature of addiction, the goals of treatment, the necessity of treatment, and the possibility of complete remission. At one end of the spectrum, proponents argue that long-term abstinence is the primary criterion for recovery. Conversely, alternative schools of thought adopt a more inclusive approach to recovery, recognizing that complete abstinence may not be immediately feasible or desirable for everyone. Instead, they emphasize harm reduction approaches and focus on positive behavior changes and improved well-being as indicators of recovery.

Socioecological Levels of Prevention for OUD

To address the limitations of the classical prevention categorizations, the authors have recast OUD prevention with a socioecological framework that recognizes the nonlinear interconnectivity between people and their environments. Hood et al. (2016) estimate that individual health behavior accounts for about one-third of health outcomes; the remaining two-thirds of health factors can be broadly defined as social determinants and include social and economic factors (47 percent), the physical environment (3 percent), and access to quality health care (16 percent). These social determinants can be broken into two categories: risk factors and protective factors. Protective factors—such as community safety, supportive relationships, financial stability, and access to care—are associated with positive health outcomes. Conversely, unsafe living conditions, food insecurity, poverty, and social isolation are associated with negative health outcomes.

Risk and protective factors exist within the contexts in which a person interacts and exists. Combining the socioecological framing of risk and protective factors with the classical framing of prevention (Figures 2, 3, and 4) is a start to identifying individual, interpersonal, and macro-level strategies that can promote or deter health for those at different stages of the prevention continuum.

Primary Prevention of OUD Using a Socioecological Model

Primary prevention using a socioecological framework seeks to prevent the onset of disease and acknowledges that an individual’s risk of developing OUD is shaped by a combination of intersecting biopsychosocial and environmental risk and protective factors, as outlined in Figure 2. Evidence-based primary prevention interventions address both biopsychosocial and environmental risk and protective factors at the individual, interpersonal, and macro levels to prevent the onset of OUD (Office of the Surgeon General, 2016).

An example could involve adverse childhood experiences (ACEs) and positive childhood experiences (PCEs), which both play crucial roles in shaping a person’s life trajectory. ACEs—which encompass negative, stressful, and traumatizing events that occur before the age of 18—are strongly associated with increased risk of developing OUD over the life span (Guarino et al., 2021). On the other hand, PCEs, such as supportive relationship and safe environments, can act as protective factors against the harmful effects of ACEs (Bethell et al., 2019). Factors that contribute to ACEs include the lack of a consistent caring adult during childhood and/or growing up with food insecurity, while factors that promote PCEs involve creating and sustaining safe, stable, and nurturing relationships and environments in which children and families can thrive (CDC, 2022; CDC, 2019). Recognizing the prevalence of ACEs and their strong association with opioid use and related behavioral health outcomes, it is crucial to prioritize prevention of ACEs. Further research is needed to describe the cultivation of PCEs and impact on incidence of OUD. (National Academies of Science, Engineering, and Medicine, 2019).

Applying the socioecological lens to primary prevention provides targets at the individual, interpersonal, and macro levels for preventing the onset of OUD (Figure 2). Examples of interventions at each of these levels include the following:

Individual: Mentoring and Out-of-School Programs

Research demonstrates that school completion, stable career employment, and quality relationships are associated with reduced high-risk substance use patterns, including opioid use, leading into young adulthood (Merrin et al., 2020). Mentoring and out-of-school programs—such as Big Brothers Big Sisters of America (n.d.), After School Matters (n.d.), and Powerful Voices (n.d.)—support the growth and development of youth and adolescents by addressing the need for positive adult contact and offering skills development opportunities, resources, and platforms. The enhanced support helps to increase confidence and foster professional values, such as leadership, teamwork, and respect, all of which have been shown to reduce problematic drug use among youth (Erdem and Kaufman, 2020; CDC, 2019).

Interpersonal: Family Support Programs

Data support the assertion that close family relationships can ameliorate the impact that trauma, stress, and adversity have on an individual’s physical health over their life span (Chen, Brody, and Miller, 2017; Brody et al., 2016). Culturally relevant and asset-based family support programs, such as the Strong African American Families Program (University of Georgia, Center for Family Research, n.d.), help to foster positive family environments and improve supportive parenting practices, including positive racial socialization, communication, and consistent discipline, thereby enhancing parents’ and caregivers’ efforts to help youth develop positive goals as well as skills to resist involvement in risk behaviors, like early initiation of opioid or other drug use (Brody et al. 2006).

Macro: Federal and State Policies and/or Investments That Support Resource-Limited Families

The harmful effects of economic hardship and financial instability on child health and development are well documented (Sandstrom and Huerta, 2013). Research shows that when families can meet their basic needs—such as food, housing, and health care—parents and caregivers can better provide the critical emotional and material support that children need to grow into healthy, productive adults (Masten, Lombardi, and Fisher, 2021). Policies and investments in social programs—including livable minimum wage requirements, child care subsidies, and federal tax credits—can be important levers to reduce the strain on low-income families to meet their basic needs, thereby reducing socioeconomic risks for parents and their children, which in turn decreases the risk of developing OUD (Cooper, Mokhiber, and Zipperer, 2021; Milligan and Stabile, n.d.).

For additional examples of socioecological primary prevention interventions for OUD, please refer to Table A-1.

Secondary Prevention of OUD Using a Socioecological Model

Secondary prevention interventions using a socioecological framework focus on biopsychosocial and environmental strategies that target early identification of OUD and support for those with OUD. As illustrated in Figure 3, several risk factors impede and/or challenge the success of screening and treatment referral, including stigma, discrimination, and insufficient provider competency and/or knowledge, all of which can influence an individual’s engagement in their health and human services.

Applying the socioecological lens to secondary prevention provides targets at the individual, interpersonal, and macro levels for supporting those in the early or mild stages of OUD. Examples of interventions at each of these levels include the following:

Individual: Access to Trauma-Informed Care

Based on a large population-based survey, an estimated 50 percent to 60 percent of adults in the United States have experienced some type of traumatic event at least once in their lives (Husarewycz et al., 2014). Given the strong link between exposure to trauma and OUD, receiving trauma-informed care—which includes considering a person’s traumatic experiences when providing care and adopting policies, procedures, and practices that avoid retraumatization and support healing and recovery—can help to improve patient engagement, OUD treatment adherence, and health outcomes (SAMHSA, 2014a).

Interpersonal: Training in Structural and Cultural Competency

Culturally and linguistically diverse populations face greater challenges to accessing OUD treatment (Gainsbury, 2016). Consequently, it is vital that health and treatment providers create a more inclusive care environment by developing a greater awareness and understanding of the cultural, structural, and linguistic factors that may help their patients feel more comfortable in accessing care. Training and education programs for health professionals that focus on developing cultural and structural competencies—such as the National Culturally and Linguistically Appropriate Services Standards (Office of Minority Health, n.d.) can help to improve patient engagement in services, therapeutic relationships between patients and providers, and treatment retention and outcomes to advance health equity (Jones and Branco, 2021; SAMHSA, 2014b).

Macro: Comprehensive, Interprofessional Addiction Curricula and Training Programs

OUD touches nearly every aspect of the health care system. Individuals who experience a nonfatal opioid overdose are likely to interact with at least one health professional in the six months preceding their overdose (Wagner et al., 2015). Given this context, it is critical that all health professionals have the requisite knowledge, skills, abilities, and attitudes to effectively identify and support those with problematic substance use. Adoption of interprofessional curricula and training programs, such as those outlined in the National Academy of Medicine’s 3Cs Framework for Pain and Unhealthy Substance Use (Holmboe et al., 2022), provide the opportunity to better prepare health professionals across the care continuum to identify and meet the complex and varied needs of patients with unhealthy substance use behaviors. (See Table A-2 for additional examples of secondary prevention interventions using the socioecological framework.)

Tertiary Prevention of OUD Using a Socioecological Model

Tertiary prevention strategies seek to mitigate the negative consequences and worsening of symptoms among those with OUD through a wide range of services and supports. These could include treatment and recovery services, self-help, and mutual aid groups, as well as harm reductions services to support individuals who are active in their substance use. Tertiary prevention strategies do not stop new cases of OUD from emerging, yet they do significantly reduce opioid-related morbidity and mortality and improve overall well-being. Many of the interventions at this stage are typically categorized as harm reduction; however, it is worth noting that harm reduction includes a spectrum of interventions, including strategies across the primary and secondary levels of prevention.

The socioecological model acknowledges that more can be done to address and prevent collateral consequences and comorbidities associated with OUD, including incarceration and spread of infectious diseases (see Figure 4).

Applying the socioecological lens to tertiary prevention provides targets at the individual, interpersonal, and macro levels for preventing severe consequences among those with OUD, such as overdose death and infectious diseases like HIV and hepatitis C (HCV) related to injection drug use. Examples of interventions at each of these levels include the following:

Individual: Low-Barrier Access to Harm Reduction Services and Supplies

Harm reduction services, which include interventions such as the distribution of sterile syringes and naloxone, have been proven to be effective at preventing morbidity and mortality associated with injection drug use. However, a significant number of PWUD do not have access to these services, a gap that frequently stems from geographical limitations (e.g., for those residing in rural areas) and the enduring stigma associated with the receipt of such services (Harm Reduction International, 2020). Innovative, remote harm-reduction platforms like NEXT Distro have emerged to address these obstacles, leveraging the reach and convenience of digital technologies (e.g., internet, text messaging, and e-mail) to mail essential harm reduction supplies directly to those in need (NEXT Distro, n.d.). These platforms not only dismantle geographical and stigma-related access barriers but also provide comprehensive harm reduction resources and support (Barnett et al., 2021; Yang, Favaro, and Meacham, 2021). With an emphasis on anonymity and privacy, these services expand accessibility, offering a practical, transformative solution for PWUD.

Interpersonal: Education on Safer Injection Practices

Higher risk of HIV and HCV infections, abscesses, cellulitis, and other skin infections is associated with certain drug injection practices (CDC, n.d.). Promoting safer injection practices among PWUD through education and training—like that of the National Harm Reduction Coalition’s Getting Off Right: A Safety Manual for Injection Drug Users (National Harm Reduction Coalition, 2020)—empowers individuals to minimize potential harms associated with injection drug use (Roux et al., 2021).

Macro: Syringe Service Programs

Nearly 30 years of research strongly support the conclusion that syringe service programs (SSPs) play an important role in promoting community safety and reducing the transmission of HIV, HCV, and other blood-borne infections commonly associated with injection drug use (Javed et al., 2020). Policies that remove barriers to the development of SSPs are critical to increasing access to this evidence-based prevention practice. (An example is Florida’s Infectious Disease Elimination Act [IDEA] of 2016, which permitted county commissions to authorize SSPs through grants and donations from private resources and funds, enabling the University of Miami to open the state’s first and only SSP: IDEA Exchange [IDEA Exchange, n.d.]). These programs are instrumental in ensuring that high-risk individuals have access to the full range of services made available by SSPs, including access to and disposal of sterile syringes and injection equipment, vaccination, testing, and links to infectious disease care and OUD treatment. (Table A-3 includes additional examples of
tertiary prevention interventions.)

Interconnected and Multidirectional Levels of Influences

The above examples highlight the complex interplay among the three levels of prevention and the socioecological levels of influence, wherein multidirectional interactions among levels means that factors at one level are often facilitated or restricted by factors at another. For example, individual-level factors—such as individual behaviors, psychological state, and physiological mechanisms—are both supported and limited by interpersonal factors like social support, sense of community cohesion, and access to person-centered care. However, these interpersonal factors do not exist in isolation; they are influenced and shaped by macro-level factors, such as drug control policies, fragmented and unaccountable treatment delivery systems, concentrated poverty, and stigmatizing cultural narratives about people with OUD. Thus, each level is not only dependent on but also instrumental in shaping the dynamics of the others, thereby creating a complex web of interconnected influences.

Additional examples of socioecological primary, secondary, and tertiary interventions that further illustrate this dynamic are provided in Tables A-1, A-2, and A-3. The interventions included in the tables have been limited to those with promising evidence to reduce the risks associated with precursors of OUD, OUD incidence, OUD morbidity, and OUD-related mortality; however, their inclusion does not suggest, and should not be taken as, an endorsem*nt by the National Academy of Medicine or any of the authors’ organizations.

The goal of this exercise is neither to provide an exhaustive list of all possible interventions, nor to grade the available evidence for various interventions. Instead, the focus is specifically to provide a socioecological public health prevention framework to support a holistic vision for OUD policy, research, and service delivery solutions. Additionally, the socioecological foundation of this framework will foster adaptable and effective solutions that are responsive to the underlying needs of those who are most affected by OUD.

The outlined interventions and strategies can serve as a starting point and inspiration for stakeholders interested in addressing OUD and other related SUDs. By offering examples that make a socioecological approach to OUD prevention practical, the authors hope to provide tangible strategies that can be applied to other SUDs more broadly and that will encourage and empower practitioners, policymakers, funders, service providers, and community leaders to take action through relational dynamics, institutional practices, policy, and advocacy. The tables do not prioritize specific interventions, since each advocate operates within a unique context. Therefore, when determining which strategies and interventions to adopt, advocates should consider their target population and sphere of influence, and the resources they have at their disposal.

Conclusion

Given the severity of the impact of overdose deaths on the nation and the dramatically increasing rates of OUD and other related SUDs in the United States over the past 20 years, it is critical that a public health framework is applied when considering policy, research, and service delivery solutions. This approach is particularly important in light of the structural and systemic factors driving the growing racial and ethnic disparities in SUD treatment and care (Center for Behavioral Health Statistics and Quality, 2021). This discussion paper applies principles of social epidemiology to a traditional public health prevention framework and elucidates contextual and structural points of intervention.

The authors hope to expand the purview of action and responsibility beyond the individual, encourage an expanded lens for those who ascribe only to the biomedical approach to health and well-being, and promote an evergreen focus on SUD prevention that elevates the conversation beyond any particular drug. Leveraging a socioecological approach empowers leaders to champion prevention strategies that address health equity and amend the nation’s historically unjust practices, some of which persist today. With health equity in mind, the authors encourage US leaders to sharpen their attention toward macro-level solutions for prevention; these hold the greatest potential for sustainably improving health for all citizens across a broad set of health outcomes.

While there are a variety of evidence-based and promising practices related to SUD and overdose prevention, there remain significant gaps in researchers’ and practitioners’ understanding. Public funds addressing overdose trends should ensure individual-, interpersonal-, and macro-level investments across the primary, secondary, and tertiary prevention spectrum and support continued research on intended and unintended health outcomes of all funded interventions.

The nation can no longer solely target individuals for one of the greatest social ills of modern times (Reinarman and Levine, 1997). Rather, it must embrace a more comprehensive, multitiered approach that also considers the interpersonal, societal, and structural factors in which individuals interact. This view will ensure that the health care system not only treats the symptoms of disease but also concentrates on the underlying drivers that have fueled the unrelenting rise in incidence of SUD and overdose. In turn, this broader focus on prevention and treatment can also contribute significantly to promoting overall health and well being. Addressing these underlying determinants of health has the potential to enhance not only addiction outcomes but also broader societal health outcomes, fostering healthier, more resilient communities.

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NOTES: Some interventions address both risks and protective factors; other interventions may address only one.

The interventions included in the table have been limited to those with promising evidence to reduce the risks associated with precursors of SUD, SUD incidence, SUD morbidity, or SUD-related mortality; however, their inclusion does not suggest, and should not be taken as, an endorsem*nt by the National Academy of Medicine or any of the authors’ organizations. Additionally, it should be noted that this table does not encompass an exhaustive list of all primary level interventions.

The selection process involved a thorough review of existing scientific literature, including published studies, meta-analyses, systematic reviews, and program evaluations. In determining the inclusion of interventions, the authors considered various factors, such as the strength of evidence supporting the program’s effectiveness, the quality of research studies conducted on the intervention, the consistency of positive outcomes across multiple studies, and the intervention’s relevance to the prevention of OUD and its associated risks.

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NOTES: Some interventions address both risks and protective factors; other interventions may address only one.

The interventions included in the table have been limited to those with promising evidence to reduce the risks associated with precursors of SUD, SUD incidence, SUD morbidity, or SUD-related mortality. In some cases the interventions are specific to harms related to opioid use/opioid use disorder, and this is clearly described in the table. However, their inclusion does not suggest, and should not be taken as, an endorsem*nt by the National Academy of Medicine or any of the authors’ organizations. Additionally, it should be noted that this table does not encompass an exhaustive list of all secondary level interventions.

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NOTES: Some interventions address both risks and protective factors; other interventions may address only one.

The interventions included in the table have been limited to those with promising evidence to reduce the risks associated with precursors of SUD, SUD incidence, SUD morbidity, or SUD-related mortality. In some cases the interventions are specific to harms related to opioid use/opioid use disorder, and this is clearly described in the table. However, their inclusion does not suggest, and should not be taken as, an endorsem*nt by the National Academy of Medicine or any of the authors’ organizations. Additionally, it should be noted that this table does not encompass an exhaustive list of all tertiary level interventions.

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Primary, Secondary, and Tertiary Prevention of Substance Use Disorders through Socioecological Strategies - National Academy of Medicine (2024)

Introduction

From Moralization to Medicalization

From Medicalization to a Socioecological Approach

A Socioecological Theoretical Framework for SUD Prevention

Applying a Socioecological Framework for a More Nuanced View of OUD and Public Health Prevention

Socioecological Levels of Prevention for OUD

Primary Prevention of OUD Using a Socioecological Model

Individual: Mentoring and Out-of-School Programs

Interpersonal: Family Support Programs

Macro: Federal and State Policies and/or Investments That Support Resource-Limited Families

Secondary Prevention of OUD Using a Socioecological Model

Individual: Access to Trauma-Informed Care

Interpersonal: Training in Structural and Cultural Competency

Macro: Comprehensive, Interprofessional Addiction Curricula and Training Programs

Tertiary Prevention of OUD Using a Socioecological Model

Individual: Low-Barrier Access to Harm Reduction Services and Supplies

Interpersonal: Education on Safer Injection Practices

Macro: Syringe Service Programs

Interconnected and Multidirectional Levels of Influences

Conclusion

Sources

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Sources

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References

References