President Donald Trump, in announcing Thursday that the opioid epidemic is a public health emergency, seemed to revise the Reagan-era “Just Say No” approach to drug abuse. In previous talks on drugs, Trump directly showed his support for this concept.
MedPage Today invited addiction experts to comment on the “Just Say No” approach and to discuss the data on its effectiveness historically.
Sharon, Levy, MD, MPH, Children’s Hospital, Boston: “Just Say No” sounds oversimplified and corny, but it’s on the right track. I’d like a slightly more sophisticated message that our kids hear from the adults in their lives that goes something like this “choosing not to use alcohol or drugs is best for your health.” I was a bit frustrated when President Trump stopped a little bit short of that message. He talked about how his brother struggled with alcoholism and so he never tried alcohol, but then he talked about some other drugs that he might have tried or at least he implied that. I think it was supposed to be a joke but I worry that it detracted from the main message. To be effective we have to be very clear with adolescents: “Non-use is best for health.” If we failed to frame messages that are inclusive of all substances we just ping-pong from one problem to the next and we are at risk of watching rates of marijuana use go up while alcohol and cigarettes decrease.
Marvin D. Seppala, MD, Chief Medical Officer, Hazelden Betty Ford Foundation: The genesis of the current crisis lies in the overprescribing of prescription opioids by healthcare professionals. Why would patients “Just Say No” to relief from suffering when nothing else is offered? Those at highest risk of addiction are genetically predisposed, and addiction is not screened for nor attended to in most medical settings. When we begin to recognize the realities of addiction as a brain disease we will alter policy and practice, train our healthcare professionals appropriately, stop fighting a war and treat these people with the same dignity and respect offered anyone with a life threatening illness.
David Craig, PharmD, Moffitt Cancer Center: I’m not aware of evidence that supports this type of “Just Say No” messaging and its relationship to downward trends in drug use. I am not opposed to increased messaging that highlights the harms of drug use, however, I’m not positive this alone will save lives. In my opinion, ways to reduce drug use should focus on destigmatizing those with a drug use disorder using better identification tools and more available treatment options.
Sarah L. Desmarais, PhD, North Carolina State University: There is scientific consensus that “Just Say No” is not an effective strategy to address substance use, including opioids. There have been several meta-analytic reviews of the research that show “Just Say No” programs typically have little to no effect on substance use for several reasons. “Just Say No” programs often don’t include the key elements that contribute to successful substance abuse prevention, such as multiple sessions over long period of times that include opportunities for building and rehearsing skills. They also can have the unintended effect of contributing to increases in the use of milder substances, such as alcohol. Harm reduction approaches have been shown to be much more effective.
Dessa Bergen-Cico, PhD, Syracuse University: Trump’s message for prevention boils down to “Just Say No 2.0,” the same ineffective ill-informed approach from the 1980s under Nancy Reagan.
There is an international evidence based approach to drug policy which encompasses four pillars: 1) prevention, 2) harm reduction, 3) treatment, and 4) enforcement.
Politicians often use drugs and addiction issues as proxies for other agendas like “building walls” and blaming the crisis on other countries and cultures. The more difficult and long-range solutions require ongoing comprehensive prevention at the pre-K-12 level.
Prevention is an upstream process meaning that it needs to begin early and it is more about developing emotional regulation skills than “drug education.”
The more difficult and long-range solutions require ongoing comprehensive prevention at the pre-K-12 level. The most promising and lasting prevention strategies may be social emotional learning and mindfulness-based training which fosters self-regulation, distress tolerance, and resiliency. People turn to alcohol and other drugs in unhealthy ways when they lack the skills and capacity to effectively manage difficult emotions and mental health problems (e.g., depression, anxiety etc.)
Although knowing the risks involved in using various substance is important – it alone does not change behavior or prevent experimentation. To understand this all we need to do is look at American eating behavior. There are many complex psychological and social factors that influence why we may know what is healthy to eat and why we don’t choose healthy foods most of the time.
Stefan Kertesz, MD, MSc, University of Alabama at Birmingham School of Medicine: In terms of scientific data, it has always been the case that young adults tend to think drugs are harmful, and for every drug but marijuana that simply is not changing much. Among 12th graders, the percentage who disapprove of trying heroin once or twice was 95% in 1990 and 94% in 2016. (p. 423)
The percentage who disapprove of using marijuana occasionally has really dropped (50.5% in 2016 compared to 69% in 2006). In that regard, our 12th graders reflect social perceptions more broadly. There may be risk there, since use of marijuana in adolescence may have some association with illicit drug use, so we should attend to that.
But on whole, illicit drug use by adolescents has been on a decade-long downward slide (see p. 219, Table 5). So with most young adults disapproving, and most not using drugs, it’s hard to see why we need to tell them to disapprove of what they’re continuing to not use for the most part. The 10-year trend in report of any drug use is down for narcotics other than heroin, down for alcohol, down for cocaine, and it’s very slightly up for marijuana.
J.C. Garbutt, MD, University of North Carolina at Chapel Hill: Start investing in primary prevention efforts to reduce the number of individuals who become addicted to opioids. This will require input from experts who know how to intervene successfully with youth, simply “Just Say No” is not going to work. But, if we come up with smart plans based on solid evidence we can have an impact. I think two examples provide evidence that major changes in behavior related to drugs can happen.
First, the change in rates of cigarette smoking over the past 20 years in the United States has been a tremendous public health success and has saved many lives. This occurred through many efforts including a change in public attitude towards smoking. Second, the drop in deaths from drinking and driving has been another huge success with about 10,000 fewer deaths a year. Again, this occurred through education, advertising, tax policy, legal changes and overall change in public attitudes. Can we do the same thing with opioids? I think so if we are smart and devote the needed resources to the task.
William Moyers, Vice President of Public Affairs and Community Relations, Hazelden Betty Ford Foundation: The phrase “Just Say No” is an important parenting tool, not a public policy strategy to deal with America’s addiction crisis.”