Questions & Answers

Adolescent substance abuse: Limiting the damage

(This article was first printed in the May 2004 issue of the Harvard Mental Health Letter. For more information or to order, please go to http://health.harvard.edu/mental.)

Q I’ve heard about the drug education program known as DARE. What are “harm reduction” programs, and what impact do they have on adolescent alcohol and drug use?

A “Just Say No” was a simple and appealing slogan during the 1980s, and the well-known program, “Drug Abuse Resistance Education” or DARE, is based on that idea. Since the early 1980s, DARE programs have been run collaboratively by schools and police departments throughout the United States and more recently in other countries as well. Their aim is to prevent substance abuse by teaching children and adolescents about the dangers of drugs and alcohol and the desirability of abstaining.

No one can dispute that adolescent substance abuse is a problem and that, thanks to DARE, adolescents know about it. But despite wide dissemination and broad acclaim, there is little scientific evidence to show that DARE is effective. By eighth grade more than half of children, and by the end of high school more than 80%, have consumed alcohol. And of course it doesn’t stop with graduation: 18- to 29-year-olds drink 45% of the alcohol in the U.S., and 63% of the heaviest drinkers (more than 6 drinks per day) are under 30.

Some argue that although alcohol use is illegal for teenagers, it’s unrealistic to expect abstinence. Instead they propose to minimize the harmful effects by teaching “drinking safety,” through programs that focus on limiting the damage from alcohol. That includes not only direct toxic effects but also poor judgment caused by intoxication, which leads to violent and destructive behavior and dangerous risk-taking, including unsafe sex and driving.

The theory behind harm reduction is that the best should not become the enemy of the good. No matter how many warnings they hear, most people under 30 will drink and many will take illicit drugs, so it may be more realistic to emphasize preventing harm rather than abstinence. Examples of such programs are the Life Skills Training Program and the Alcohol Misuse Prevention Study in the United States and Australia’s School of Health and Alcohol Harm Reduction Project (SHAHRP).

These programs generally use cognitive-behavioral methods. Their goals are to reduce anticipation of positive drug effects, explain the negative effects, promote self-esteem and social skills, and teach young people how to resist peer pressure. Another thematic shift is an emphasis on the advantages, even the pleasures, that come from choosing healthy alternatives to drugs and alcohol. Several controlled studies have shown that this shift of emphasis lowers the rate of alcohol-related problems.

Australian researchers have had some success with the SHAHRP approach in 13- and 14-year-olds. Their report was published in the March 2004 issue of Addiction. More than 2,000 students were assigned to the study. Trained research assistants administered a survey that measured knowledge and attitudes about alcohol, consumption of alcohol, and resulting harmful experiences.

In several group sessions over two years, the students in the SHAHRP program group rehearsed skills, put their heads together about decision making, and discussed scenarios of their own devising. These students reported less use of alcohol than a control group receiving standard alcohol education. That difference almost disappeared once the course was completed, but harm reduction persisted. Almost a year and a half after the program concluded, the children in the program still experienced about 23% less harm than the comparison group.

None of these programs accomplish all we might wish for. They are not designed to address mental disorders or family conflict and other environmental stress that might contribute to alcohol and drug use. But promising controlled studies suggest that subtle differences in emphasis are quite important. As we refine our knowledge, we can hope for improved efficacy and positive changes in the adolescent culture of alcohol use.

— Michael Craig Miller, M.D.
Editor in Chief, Harvard Mental Health Letter