“Just Say No” didn’t work , but experts are employing new holistic programs to help steer kids away—or at least keep them from dying—from illicit substances.
By Zara Abrams Date created: March 1, 2024 14 min readVol. 55 No. 2
Print version: page 48
Abrams, Z. (2024, March 1). More teens than ever are overdosing. Psychologists are leading new approaches to combat youth substance misuse. Monitor on Psychology, 55(2). https://www.apa.org/monitor/2024/03/new-approaches-youth-substance-misuse
For years, students in middle and high schools across the country were urged to “just say no” to drugs and alcohol. But it’s no secret that the Drug Abuse Resistance Education (D.A.R.E.) program, which was typically delivered by police officers who urged total abstinence, didn’t work. A meta-analysis found the program largely ineffective and one study even showed that kids who completed D.A.R.E. were more likely than their peers to take drugs (Ennett, S. T., et al., American Journal of Public Health, Vol. 84, No. 9, 1994; Rosenbaum, D. P., & Hanson, G. S., Journal of Research in Crime and Delinquency, Vol. 35, No. 4, 1998).
“We know that the ‘Just Say No’ campaign doesn’t work. It’s based in pure risks, and that doesn’t resonate with teens,” said developmental psychologist Bonnie Halpern-Felsher, PhD, a professor of pediatrics and founder and executive director of several substance use prevention and intervention curriculums at Stanford University. “There are real and perceived benefits to using drugs, as well as risks, such as coping with stress or liking the ‘high.’ If we only talk about the negatives, we lose our credibility.”
Partially because of the lessons learned from D.A.R.E., many communities are taking a different approach to addressing youth substance use. They’re also responding to very real changes in the drug landscape. Aside from vaping, adolescent use of illicit substances has dropped substantially over the past few decades, but more teens are overdosing than ever—largely because of contamination of the drug supply with fentanyl, as well as the availability of stronger substances (Most reported substance use among adolescents held steady in 2022, National Institute on Drug Abuse).
“The goal is to impress upon youth that far and away the healthiest choice is not to put these substances in your body, while at the same time acknowledging that some kids are still going to try them,” said Aaron Weiner, PhD, ABPP, a licensed clinical psychologist based in Lake Forest, Illinois, and immediate past-president of APA’s Division 50 (Society of Addiction Psychology). “If that’s the case, we want to help them avoid the worst consequences.”
While that approach, which incorporates principles of harm reduction, is not universally accepted, evidence is growing for its ability to protect youth from accidental overdoses and other consequences of substance use, including addiction, justice involvement, and problems at school. Psychologists have been a key part of the effort to create, test, and administer developmentally appropriate, evidence-based programs that approach prevention in a holistic, nonstigmatizing way.
“Drugs cannot be this taboo thing that young people can’t ask about anymore,” said Nina Christie, PhD, a postdoctoral research fellow in the Center on Alcohol, Substance Use, and Addictions at the University of New Mexico. “That’s just a recipe for young people dying, and we can’t continue to allow that.”
In 2022, about 1 in 3 high school seniors, 1 in 5 sophomores, and 1 in 10 eighth graders reported using an illicit substance in the past year, according to the National Institute on Drug Abuse’s (NIDA) annual survey (Monitoring the Future: National Survey Results on Drug Use, 1975–2022: Secondary School Students, NIDA, 2023 [PDF, 7.78MB]). Those numbers were down significantly from prepandemic levels and essentially at their lowest point in decades.
Substance use during adolescence is particularly dangerous because psychoactive substances, including nicotine, cannabis, and alcohol, can interfere with healthy brain development (Winters, K. C., & Arria, A., Prevention Research, Vol. 18, No. 2, 2011). Young people who use substances early and frequently also face a higher risk of developing a substance use disorder in adulthood (McCabe, S. E., et al., JAMA Network Open, Vol. 5, No. 4, 2022). Kids who avoid regular substance use are more likely to succeed in school and to avoid problems with the juvenile justice system (Public policy statement on prevention, American Society of Addiction Medicine, 2023).
“The longer we can get kids to go without using substances regularly, the better their chances of having an optimal life trajectory,” Weiner said.
The drugs young people are using—and the way they’re using them—have also changed, and psychologists say this needs to inform educational efforts around substance use. Alcohol and cocaine are less popular than they were in the 1990s; use of cannabis and hallucinogens, which are now more salient and easier to obtain, were higher than ever among young adults in 2021 (Marijuana and hallucinogen use among young adults reached all-time high in 2021, NIDA).
“Gen Z is drinking less alcohol than previous generations, but they seem to be increasingly interested in psychedelics and cannabis,” Christie said. “Those substances have kind of replaced alcohol as the cool thing to be doing.”
Young people are also seeing and sharing content about substance use on social media, with a rise in posts and influencers promoting vaping on TikTok and other platforms (Vassey, J., et al., Nicotine & Tobacco Research, 2023). Research suggests that adolescents and young adults who see tobacco or nicotine content on social media are more likely to later start using it (Donaldson, S. I., et al., JAMA Pediatrics, Vol. 176, No. 9, 2022).
Concern for youth well-being is what drove the well-intentioned, but ultimately ineffective, “mad rush for abstinence,” as Robert Schwebel, PhD, calls it. Though that approach has been unsuccessful in many settings, a large number of communities still employ it, said Schwebel, a clinical psychologist who created the Seven Challenges Program for treating substance use in youth.
But increasingly, those working to prevent and treat youth substance use are taking a different approach—one that aligns with principles Schwebel helped popularize through Seven Challenges.
A key tenet of modern prevention and treatment programs is empowering youth to make their own decisions around substance use in a developmentally appropriate way. Adolescents are exploring their identities (including how they personally relate to drugs), learning how to weigh the consequences of their actions, and preparing for adulthood, which involves making choices about their future. The Seven Challenges Program, for example, uses supportive journaling exercises, combined with counseling, to help young people practice informed decision-making around substance use with those processes in mind.
“You can insist until you’re blue in the face, but that’s not going to make people abstinent. They ultimately have to make their own decisions,” Schwebel said.
Today’s prevention efforts also tend to be more holistic than their predecessors, accounting for the ways drug use relates to other addictive behaviors, such as gaming and gambling, or risky choices, such as fighting, drag racing, and having unprotected sex. Risk factors for substance use—which include trauma, adverse childhood experiences, parental history of substance misuse, and personality factors such as impulsivity and sensation seeking—overlap with many of those behaviors, so it often makes sense to address them collectively.
“We’ve become more sophisticated in understanding the biopsychosocial determinants of alcohol and drug use and moving beyond this idea that it’s a disease and the only solution is medication,” said James Murphy, PhD, a professor of psychology at the University of Memphis who studies addictive behaviors and how to intervene.
Modern prevention programs also acknowledge that young people use substances to serve a purpose—typically either social or emotional in nature—and if adults expect them not to use, they should help teens learn to fulfill those needs in a different way, Weiner said.
“Youth are generally using substances to gain friends, avoid losing them, or to cope with emotional problems that they’re having,” he said. “Effective prevention efforts need to offer healthy alternatives for achieving those goals.”
At times, the tenets of harm reduction and substance use prevention seem inherently misaligned. Harm reduction, born out of a response to the AIDS crisis, prioritizes bodily autonomy and meeting people where they are without judgment. For some harm reductionists, actively encouraging teens against using drugs could violate the principle of respecting autonomy, Weiner said.
On the other hand, traditional prevention advocates may feel that teaching adolescents how to use fentanyl test strips or encouraging them not to use drugs alone undermines the idea that they can choose not to use substances. But Weiner says both approaches can be part of the solution.
“It doesn’t have to be either prevention or harm reduction, and we lose really important tools when we say it has to be one or the other,” he said.
In adults, harm reduction approaches save lives, prevent disease transmission, and help people connect with substance use treatment (Harm Reduction, NIDA, 2022). Early evidence shows similar interventions can help adolescents improve their knowledge and decision-making around drug use (Fischer, N. R., Substance Abuse Treatment, Prevention, and Policy, Vol. 17, 2022). Teens are enthusiastic about these programs, which experts often call “Just Say Know” to contrast them with the traditional “Just Say No” approach. In one pilot study, 94% of students said a “Just Say Know” program provided helpful information and 92% said it might influence their approach to substance use (Meredith, L. R., et al., The American Journal of Drug and Alcohol Abuse, Vol. 47, No. 1, 2021).
“Obviously, it’s the healthiest thing if we remove substance use from kids’ lives while their brains are developing. At the same time, my preference is that we do something that will have a positive impact on these kids’ health and behaviors,” said Nora Charles, PhD, an associate professor and head of the Youth Substance Use and Risky Behavior Lab at the University of Southern Mississippi. “If the way to do that is to encourage more sensible and careful engagement with illicit substances, that is still better than not addressing the problem.”
One thing not to do is to overly normalize drug use or to imply that it is widespread, Weiner said. Data show that it’s not accurate to say that most teens have used drugs in the past year or that drugs are “just a part of high school life.” In fact, students tend to overestimate how many of their peers use substances (Dumas, T. M., et al., Addictive Behaviors, Vol. 90, 2019; Helms, S. W., et al., Developmental Psychology, Vol. 50, No. 12, 2014).
A way to incorporate both harm reduction and traditional prevention is to customize solutions to the needs of various communities. For example, in 2022, five Alabama high school students overdosed on a substance laced with fentanyl, suggesting that harm reduction strategies could save lives in that community. Other schools with less reported substance use might benefit more from a primary prevention-style program.
At Stanford, Halpern-Felsher’s Research and Education to Empower Adolescents and Young Adults to Choose Health (REACH) Lab has developed a series of free, evidence-based programs through community-based participatory research that can help populations with different needs. The REACH Lab offers activity-based prevention, intervention, and cessation programs for elementary, middle, and high school students, including curricula on alcohol, vaping, cannabis, fentanyl, and other drugs (Current Problems in Pediatric and Adolescent Health Care, Vol. 52, No. 6, 2022). They’re also working on custom curricula for high-risk groups, including sexual and gender minorities.
The REACH Lab programs, including the comprehensive Safety First curriculum, incorporate honest discussion about the risks and benefits of using substances. For example: Drugs are one way to cope with stress, but exercise, sleep, and eating well can also help. Because many young people care about the environment, one lesson explores how cannabis and tobacco production causes environmental harm.
The programs also dispel myths about how many adolescents are using substances and help them practice skills, such as how to decline an offer to use drugs in a way that resonates with them. They learn about the developing brain in a positive way—whereas teens were long told they can’t make good decisions, Safety First empowers them to choose to protect their brains and bodies by making healthy choices across the board.
“Teens can make good decisions,” Halpern-Felsher said. “The equation is just different because they care more about certain things—peers, relationships—compared to adults.”
Because substance use and mental health are so intertwined, some programs can do prevention successfully with very little drug-focused content. In one of the PreVenture Program’s workshops for teens, only half a page in a 35-page workbook explicitly mentions substances.
“That’s what’s fascinating about the evidence base for PreVenture,” said clinical psychologist Patricia Conrod, PhD, a professor of psychiatry at the University of Montreal who developed the program. “You can have quite a dramatic effect on young people’s substance use without even talking about it.”
PreVenture offers a series of 90-minute workshops that apply cognitive behavioral insights upstream (addressing the root causes of a potential issue rather than waiting for symptoms to emerge) to help young people explore their personality traits and develop healthy coping strategies to achieve their long-term goals.
Adolescents high in impulsivity, hopelessness, thrill-seeking, or anxiety sensitivity face higher risks of mental health difficulties and substance use, so the personalized material helps them practice healthy coping based on their personality type. For example, the PreVenture workshop that targets anxiety sensitivity helps young people learn to challenge cognitive distortions that can cause stress, then ties that skill back to their own goals.
The intervention can be customized to the needs of a given community (in one trial, drag racing outstripped substance use as the most problematic thrill-seeking behavior). In several randomized controlled trials of PreVenture, adolescents who completed the program started using substances later than peers who did not receive the intervention and faced fewer alcohol-related harms (Newton, N. C., et al., JAMA Network Open, Vol. 5, No. 11, 2022). The program has also been shown to reduce the likelihood that adolescents will experiment with illicit substances, which relates to the current overdose crisis in North America, Conrod said (Archives of General Psychiatry, Vol. 67, No. 1, 2010).
“People shouldn’t shy away from a targeted approach like this,” Conrod said. “Young people report that having the words and skills to manage their traits is actually helpful, and the research shows that at behavioral level, it really does protect them.”
As young people leave secondary school and enter college or adult life, about 30% will binge drink, 8% will engage in heavy alcohol use, and 20% will use illicit drugs (Alcohol and Young Adults Ages 18 to 24, National Institute on Alcohol Abuse and Alcoholism, 2023; SAMHSA announces national survey on drug use and health (NSDUH) results detailing mental illness and substance use levels in 2021). But young people are very unlikely to seek help, even if those activities cause them distress, Murphy said. For that reason, brief interventions that leverage motivational interviewing and can be delivered in a school, work, or medical setting can make a big difference.
In an intervention Murphy and his colleagues are testing, young adults complete a questionnaire about how often they drink or use drugs, how much money they spend on substances, and negative things that have happened as a result of those choices (getting into an argument or having a hangover, for example).
In an hour-long counseling session, they then have a nonjudgmental conversation about their substance use, where the counselor gently amplifies any statements the young person makes about negative outcomes or a desire to change their behavior. Participants also see charts that quantify how much money and time they spend on substances, including recovering from being intoxicated, and how that stacks up against other things they value, such as exercise, family time, and hobbies.
“For many young people, when they look at what they allocate to drinking and drug use, relative to these other things that they view as much more important, it’s often very motivating,” Murphy said.
A meta-analysis of brief alcohol interventions shows that they can reduce the average amount participants drink for at least 6 months (Mun, E.Y., et al., Prevention Science, Vol. 24, No. 8, 2023). Even a small reduction in alcohol use can be life-altering, Murphy said. The fourth or fifth drink on a night out, for example, could be the one that leads to negative consequences—so reducing intake to just three drinks may make a big difference for young people.
Conrod and her colleagues have also adapted the PreVenture Program for university students; they are currently testing its efficacy in a randomized trial across multiple institutions.
Christie is also focused on the young adult population. As a policy intern with Students for Sensible Drug Policy, she created a handbook of evidence-based policies that college campuses can use to reduce harm among students but still remain compliant with federal law. For example, the Drug Free Schools and Communities Act mandates that higher education institutions formally state that illegal drug use is not allowed on campus but does not bar universities from taking an educational or harm reduction-based approach if students violate that policy.
“One low-hanging fruit is for universities to implement a Good Samaritan policy, where students can call for help during a medical emergency and won’t get in trouble, even if illegal substance use is underway,” she said.
Ultimately, taking a step back to keep the larger goals in focus—as well as staying dedicated to prevention and intervention approaches backed by science—is what will help keep young people healthy and safe, Weiner said.
“What everyone can agree on is that we want kids to have the best life they can,” he said. “If we can start there, what tools do we have available to help?”
