. 2023 Sep 6;2023:10.31478/202309b. doi: 10.31478/202309b

Table A-1. Evidence-Based Interventions at the Primary Level of Prevention.

I. Targeted Level of Action	II. Risk(s) at the Targeted Level of Action	III. Protective Factor(s) Addressed	IV. Intervention	V. Intervention Description	VI. Examples of Programs/Models
Individual	Adult unemployment	Social support, connectedness, and opportunity for socialization	Out-of-school programs	School completion, obtaining stable career employment, and quality relationships are associated with reducing high-risk substance use patterns leading into young adulthood. [¹]	1. Powerful Voices: https://www.powerfulvoices.org/about 2. Big Brothers Big Sisters of America: https://www.bbbs.org/ 3. After School Matters: https://www.sesp.northwestern.edu/docs/publications/1070224029553e7f678c09f.pdf
Individual	Adult unemployment	In-school and out-of-school programs that support youth achievement of age-appropriate milestones		Mentoring and out-of-school programs (such as Big Brothers Big Sisters of America, After School Matters, and Powerful Voices) support the growth and development of youth and adolescents by offering skills development opportunities, resources, and platforms that help to increase confidence and foster professional values, such as leadership, teamwork, and respect. These qualities have been shown to reduce the use of drugs and drug-related activity. [²]
Interpersonal	Adverse childhood experiences	Promotion of parental and intergenerational health	Family skills training programs	Family skills training programs (such as the Nurse-Family Partnership and Strengthening Families Program) empower and support vulnerable and high-risk families by equipping them with tools and resources that help to reduce risk factors (e.g., substance misuse) and improve protective factors, leading to improved health and life outcomes. [³,⁴]	1. Nurse-Family Partnership: https://www.nursefamilypartnership.org/about/ 2. Strengthening Families Program: https://strengtheningfami-liesprogram.org/
Interpersonal	In utero exposure to maternal stress	Promotion of parental and intergenerational health	Family skills training programs
Interpersonal	Adverse childhood experiences	Stress buffering (e.g., factors that mitigate stress)	Support programs focused on strengthening the family environment	Family support programs, such as the Strong African American Families Program, help to foster positive family environments and thus reduce the impact that childhood stressors can have on biological processes and health behaviors over one’s lifetime, including the development of risky behaviors like substance misuse. [⁵,⁶]	1. Strong African American Families Program: https://cfr.uga.edu/saaf-programs/saaf/
Interpersonal	Adverse childhood experiences	Promotion of parental and intergenerational health
Interpersonal	Racial discrimination		Prejudice habit-breaking strategies	Intervention strategies can reduce the implicit bias of service providers (e.g., stereotype replacement, perspective taking, individuation). Such interventions include Multi-Faceted Prejudice Habit-Breaking Intervention and also increase bias awareness and concern about discrimination. Thus, they help to decrease social stressors that can impact the biological processes and health behaviors that can lead to substance use and development of a SUD. [⁷,⁸]	1. Long-Term Reduction in Implicit Bias: A Prejudice Habit-Breaking Intervention: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603687/
Interpersonal	Adverse childhood experiences	Investment in evidence-based prevention (in- and out-of-school time)	Social-emotional learning programs	Social-emotional learning programs—such as LifeSkills Training, the Good Behavior Game, and Promoting Alternative THinking Strategies (PATHS)—promote positive behavior and help youth and adolescents to develop emotional and social competencies, leading to a range of positive outcomes, including reduced youth alcohol, tobacco, and drug use; depression; anxiety; and suicidal thoughts. [⁹,¹⁰,¹¹,¹²]	1. LifeSkills Training: https://www.lifeskillstraining.com/lst-overview/ 2. Good Behavior Game: https://goodbehavior-game.air.org/about_gbg.html 3. PATHS: https://nationalgangcenter.ojp.gov/spt/Programs/104
Interpersonal	Adverse childhood events In utero exposure to maternal stress	Promotion of parental and intergenerational health	Social determinants of health and adverse childhood events screening in primary care settings, with followup and linkage services	The integration of screening for social determinants of health and adverse childhood events in primary care settings helps primary health care professionals address common psychosocial problems, such as parental depression and substance use. This integration also provides early intervention and counsel, which may lead to reduced child maltreatment. [¹³,¹⁴]	1. Safe Environment for Every Kid: https://seekwellbeing.org/about-seek-2/
Interpersonal (teacher/student) Macro (state and local school systems)	Trauma and stress Co-occurring psychiatric conditions	Investment in evidence-based prevention (in- and out-of-school time)	Wellness and resilience programs	Wellness and resilience programs, such as Project Advancing Wellness and Resiliency in Education (AWARE), focus on building partnerships between state and local school systems to increase awareness of mental illness among school-aged children. The programs also provide school personnel with the skills and training necessary to identify mental health problems and connect students in need of care. Such programs can improve student support at school, which has been shown to help decrease the prevalence of nonmedical use of prescription drugs among school-aged children. [¹⁵,¹⁶,¹⁷]	1. Project AWARE: https://www.samhsa.gov/grants/grant-announcements/sm-20-016
Macro	Insufficient insurance coverage for mental health and medical services	Accessible and affordable health care services	Medicaid expansion	The Affordable Care Act provided state funds to expand Medicaid to adults with incomes below 138 percent of the federal poverty level. The expansion gave millions of previously uninsured adults coverage and expanded access to services that can reduce the risk of an SUD, such as mental, behavioral, and physical health care for chronic conditions. [¹⁸,¹⁹]	1. Status of State Medicaid Expansion Decisions: https://www.kff.org/medicaid/issue-brief/status-of-statemedicaid-expansion-decisions-interactive-map/
Macro	Community disinvestment and poverty	Support for resource-limited families and individuals	Federal and state policies and/or investments that support resource-limited families	Macro-level policies reduce low-income families’ strain to meet basic needs and decrease socioeconomic risks for parents and their children. They also decrease risk for SUD. [²⁰,²¹,²²] Examples include the following: Minimum wage increases Child care subsidies Federal tax credits (e.g., Earned Income Tax Credit, and child and dependent care tax credit)	1. Child Cash Benefits: https://www.nber.org/papers/w21101
Macro	Insufficient capacity of pain management alternatives (and subsequent pursuit of less expensive and more toxic illegal options)	Accessible and affordable health care services	Policies that expand access to pain management	Policies that expand coverage of non-opioid pain management alternatives improve access to high-quality, evidence-based pain care and decrease opioid overuse and exposure. [²³]	1. Medicaid Strategies for Non-Opioid Pharmacologic and Non-Pharmacologic Chronic Pain Management: https://www.medicaid.gov/federal-policy-guidance/downloads/cib022219.pdf
Macro	Community disinvestment and poverty	Support for resource-limited families and individuals	Homelessness diversion programs	While social selection and social adaptation explain the relationship between homelessness and substance misuse, research suggests a greater proportion of individuals develop an SUD after experiencing homelessness. [²⁴,²⁵] Programs such as Bridges to Housing Stability aim to prevent homelessness by helping individuals identify immediate alternate housing arrangements and connecting them with services and financial assistance to help them return to permanent housing, if necessary. [²⁶,²⁷]	1. Michigan’s Shelter Diversion Pilot Program: https://www.michigan.gov/mshda/homeless/homeless-and-special-housing-needs-programs/shelter-diversion-pilot 2. Bridges to Housing Stability: https://bridges2hs.org/bridges-housing-stability-programs/

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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 endorsement 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.