STEP 1: Assessment

Step 1

Assessment is a critical first step in prevention planning; without it, communities risk selecting strategies that do not address the true problem or its contributing factors.

In Step 1: Assessment, you will systematically gather and analyze local data related to the priority problem—NMUPD among high school-age youth—which will help you do the following:

  •  Identify the nature and extent of the NMUPD problem and related behaviors among different groups, including those defined by age, gender, race/ethnicity, or other demographic characteristics
  •  Identify health disparities (preventable differences in the burden of disease that are experienced by socially disadvantaged populations) related to NMUPD
  •  Determine whether your community or organization is ready to address the priority problem(s) and what additional resources may be needed
  •  Identify intervening variables (risk factors and protective factors linked to NMUPD within the community)

These data will also serve as a baseline for program monitoring and evaluation.

STEP 1: Assessment comprises the following primary tasks:

TASK 1: Assess Problems and Related Behaviors

The first step is to create a descriptive profile of the problem—NMUPD among high school-age youth—and the related behaviors (i.e., consumption patterns and consequences) as they manifest within your community.

Quantitative data show how often an event or behavior occurs or to what degree it exists.32 These data are usually reported numerically, often as counts or percentages.

Examples:

  • Percentage of high school students reporting current (past 30 day) NMUPD
  • Percentage of high school-age youth of varying demographics (age, gender, race/ethnicity, socio-economic status, educational attainment, etc.) reporting lifetime NMUPD
  • Average age of first misuse or abuse of stimulants (or other category of prescription drug)
  • Number of prescription drug-related emergency room visits among 14–18 year olds
  • Number of prescription drug-related arrests involving 14–18 year olds
  • Number of prescription drug-related school disciplinary incidents

In addition to self-reported survey data, quantitative data can be mined from archival data sources, such as police reports, school incident and discipline reports, court records, hospital discharge data, and ED data (see Archival and Survey Data Sources—A Community Data Checklist).

To define the needs of your community specific to substance misuse and abuse, problems and related behaviors are typically thought of in terms of consumption and consequence patterns. Both types of information may be collected from various quantitative data sources.

Data on consumption (use) patterns describe NMUPD in terms of the frequency or amount used.

Examples:

  • Percentage of high school students reporting current (past 30 days) non-medical use of prescription opioids
  • Percentage of high school students reporting past-year non-medical use of prescription stimulants
  • Percentage of high school students reporting non-medical use of prescription sedatives within their lifetime

While these types of data are often collected by national or state surveys, local data specific to your community may not be as readily available. When collecting community data, try to use the same questions and wording as the national and state surveys. Many items in these instruments have been rigorously tested across multiple settings and may serve as good sources of comparative data in certain instances.

Data on consequences can help you better understand the extent of the problem of NMUPD among high school-age youth in your community. NMUPD is associated with many social, economic, and health problems, including increased risk of overdose, injury, and death; delinquency and/or violent behavior; and poor academic performance.33

Examples:

  • Number of prescription drug-related arrests
  • School incident and discipline reports
  • Emergency department admittances and hospital discharge data

This information may have to be compiled locally from different sources (such as schools, the police department, and hospitals).

Qualitative data may help you gain a deeper understanding of the substance misuse and abuse problem within your community by offering insight into the beliefs, attitudes, and values of various stakeholders, and may help explain why people behave or feel the way they do.33 Common methods for obtaining qualitative data include key stakeholder interviews and focus groups.

When collecting qualitative data, it is important to use methods that are culturally competent and appropriate. For example:

  • When developing your interview or focus group guide, carefully review all questions to make sure that they will not be perceived as too personal or inappropriate.
  • Consider any translation needs, and make sure that the interviewers or group facilitators reflect the composition of the group being interviewed.
  • Select an accessible meeting space, and consider providing childcare where appropriate.

It is important to assess any differences among sub-groups, defined by characteristics such as gender, grade, race, ethnicity, culture, and sexual orientation, that may be differentially related to NMUPD consumption patterns.

Beginning your assessment with an examination of the nature and extent of NMUPD will help you focus your assessment of intervening variables and capacity to those items that are most relevant to the local manifestation of NMUPD and, more importantly, to the identified group(s) or sub-groups.

TASK 2: Prioritize Problems and Develop a Problem Statement

Use the data you collected in task 1 to decide which problem(s) is most important for your group to address. Consider the following criteria:

  • Magnitude: Which problem seems to affect the largest number of people?
  • Time trend: Is the problem getting worse or better over time? Is one problem getting worse more quickly than others?
  • Severity: How severe is each problem? Is it resulting in mortality? Is one more costly than others?
  • Comparison: How does the local rate of each problem compare to state or national rates?

Once you have analyzed the data, you can determine which problem or problems are the most pronounced and need to be addressed. (See Tips for Examining Data for more information and guidance on examining and prioritizing your data.)

If more than one problem related to NMUPD among high school-age youth exists, determine whether your group has the capacity to address only one problem or more than one. Since each problem will require multiple strategies, considering your community’s available resources and readiness to address each problem is critical.

Each problem you identify should be formulated into its own problem statement.

Note: Remember that the PFS 2015 grant is a primary prevention program aimed at the prevention and reduction of NMUPD among high school-age youth. Therefore, addressing consumption patterns, rather than consequences, among this particular population is a priority. In other words, to affect the consequences that often result from NMUPD, the patterns of use must be addressed.

However, grantees are encouraged to examine the consumption rates of different prescription drug categories (e.g., opioids, stimulants) among the target population, as well as group(s) or sub-group(s) disproportionately affected by the issue.

A problem statement will help you focus on where to build capacity and how to measure outcomes and plan for sustainability. Interventions without a clearly articulated problem statement may lose steam over time—and it’s also difficult to know whether any progress has been made toward the identified issue. Communities should use their data about consumption, consequences, readiness, and resources to frame their problem statement in specific terms.

A good problem statement will meet each of the following criteria:

  • Identify one issue or problem at a time, driven by the collected data
  • Identify why it is a problem or issue
  • Identify a target population
  • Identify the drug to be targeted
  • Reflect community concerns as heard during the assessment process
  • Avoid blame
  • Avoid naming specific solutions or strategies

When you develop your problem statement(s), be sure to describe the consumption patterns that are problematic and not the intervening variables or lack of community resources needed to address the problem.

For example:

  • “The local school system lacks effective substance abuse prevention curricula”

This is more a statement of a resource deficiency than of the larger problem you are attempting to solve. It also assumes that addressing this lack of curricula alone will solve the problem. In reality, many factors may also contribute to the problem. The lack of curricula is not “the problem” and does not belong in a problem statement.

Defining a problem simply as a lack of something will narrow your planning focus and direct energy and resources to strategies that are not likely to be sufficient on their own, while missing other important factors.

A better statement might be:

  • “20% of high school students report that they have used a prescription pain reliever not prescribed to them”

Keeping the focus on the priority consumption patterns at this stage in the planning process will help you select accurate contributing risk and protective factors and, hence, a comprehensive array of strategies that are more likely to be effective in addressing the problems you have identified.

TASK 3: Assess Intervening Variables Linked to the Problem Statement

Intervening variables are factors that have been identified through research as having an influence on substance misuse and abuse. They include, but are not limited to, risk and protective factors.

(Read more on why risk and protective factors for NMUPD should not be the sole basis for your assessment here.)

Risk factors are characteristics of school, community, and family environments―as well as characteristics of youth and young adults and their peer groups―that are known to be related to an increased likelihood of substance misuse and abuse.

Risk factors that have been specifically linked to NMUPD among 12–17 year olds include the following:

  • Perceived acceptability and safety of prescription drug misuse
  • Peer prescription drug misuse34
  • Experiencing multiple negative life events, and peer substance abuse or use35

Protective factors exert a positive influence or buffer against the negative influence of risks; they are related to reducing the likelihood that youth and young adults will engage in problem behaviors such as NMUPD. Protective factors include a high commitment to doing well in school, community norms against use,34 and a strong parental bond.35

See the CAPT Decision Support Tool: Prescription Drug Misuse: Understanding Who Is at Increased Risk for more on risk and protective factors identified through the research.36, 37

Intervening variables fall into two categories: (1) those that cannot be modified, and (2) those that can.

Factors that cannot be modified are useful for identifying the focus of prevention interventions (i.e., individuals or groups that may be at disproportionate risk). For example:

Factors that can be modified are generally the focus of prevention interventions. They include:

Gender

Evidence is mixed regarding gender differences and NMUPD. Some studies have found that adolescent females are more likely to report NMUPD.29, 38, 39 In particular, females may be more likely to report non-medical use of opioids or sedatives/anxiolytics16, 40 and are more likely to report non-medical use for the purpose of “self-treating,” compared to males who tend to report more “sensation-seeking” reasons (e.g., to get high).41

However, one study found that males reported more non-medical use of opioid analgesics than did females.30 Another study examining 2006 NSDUH data of all U.S. individuals age 12 or older found that males were more likely to report lifetime and past-year non-medical use of prescription opioids, but there were no gender differences for rates of abuse or dependence on prescription opioids.63

Additionally, males and females may gain access to prescription drugs for non-medical purposes differently. Adolescent females are more likely to obtain opioid prescription drugs for free or to steal them from a friend or relative, while adolescent males are more likely to purchase opioid prescription drugs or to acquire them from a physician.24, 34

Ethnicity/Race

Research has consistently found higher rates of NMUPD, including use of opioids, among individuals who identify as white, after accounting for other risk factors (availability, peer use, etc.).30, 38, 39, 40, 42 A larger percentage of white respondents reported sensation-seeking motives for NMUPD compared to non-white respondents.41

Access and Availability

Multiple studies have examined the relationship between access/availability and NMUPD.43 While causality has not been established, many studies suggest that increased availability is a contributing factor for NMUPD. Collins and colleagues, for example, found that a perception that prescription drugs were readily available was associated with increased levels of prescription drug misuse among a sample of middle and high school students in Tennessee.34

According to pooled estimates from NSDUH in 2013 and 2014, the most common source of pain relievers among 12–25 year olds during their most recent use within the past year was from a friend or relative, which they received for free (43.1% for 12–17 year olds, 50% for 18–25 year olds). The second and third most common sources were from a single doctor (22.9% for 12–17 year olds, 16.8% for 18–25 year olds) and by buying it from a friend or relative (9.4% for 12–17 year olds, 13.6% for 18–25 year olds). None of the other potential sources accounted for more than 8% for either age group.11

Perception of Risk or Harm

Ford and Rigg found a protective effect of having greater perception of risk of substance abuse on prescription opioid misuse outcomes based on an analysis of NSDUH data.44 Arria and colleagues found a similar relationship among college students.45

Parents and Family

Collins and colleagues found that greater parental disapproval toward prescription drug misuse had a protective effect on prescription drug misuse outcomes.34 Similarly, Schroeder and Ford found that stronger bonds with parents were associated with lower levels of prescription drug misuse.35 Ford and Rigg found that favorable parental attitudes toward substance use were associated with higher levels of prescription opioid misuse.44

Peers

Greater misuse of prescription drugs by peers, and peer attitudes favorable toward substance use have both been associated with prescription drug misuse.34, 44

Substance Use or Misuse

Current cigarette smoking, past-year alcohol misuse, past-30-day drunkenness, past-year marijuana misuse, past-year other illicit substance use, past-30-day other substance use, younger age of first prescription, and younger age of substance use initiation have each been associated with NMUPD.44, 46, 47