Alternatives to Drug Abuse: Some Are and Some Are Not

2015

The purpose of this paper is to discuss the current state of the art of alternatives to substance abuse as one of several approaches to prevention. This paper defines four different approaches to prevention that have been proposed and reviews the literature related to each approach. Two recent studies of alternative programs and activities will be presented and the paper will conclude with recommendations for further research.

The concept of alternatives to substance abuse was one of the first responses to the problem (). The early advocates of this strategy recommended substituting positive experiences for the experiences reported to be associated with substance abuse. Some early workers in the field were aware that not all alternatives would automatically provide an acceptable substitute for some of the pleasures sought and perceived by drug-using and-abusing individuals. For example, Swisher and Horman () discovered, upon completion of a program for college student leaders, that one individual had been very impressed by the emphasis on alternatives; and even though he was only an experimenter with some drugs, he decided to pursue a viable alternative–skydiving, which may have been a greater health risk.

Four models of alternative programming

It is important to begin by outlining the basic approaches that have been attempted and in some instances evaluated as part of a larger cluster of programming known as alternatives to substance abuse. First of all, programs that are variations of forms of treatment and/or incarceration are not considered to be prevention programs and have not been included in this paper. This type of treatment is often confused with the concept of alternatives as it is applied to prevention. It is important in any discussion on this topic to make a distinction between treatment (after the fact) and prevention (before the fact). Therefore, alternative programming includes planned-for activities that will prevent individuals from becoming abusers or substance-dependent users prior to any significant involvement with substances.

The four models of alternative programming relevant to prevention include the following:

  1. Providing specific activities for young people (e.g., operating a radio station)
  2. Matching specific types of needs with specific types of activities (e.g., sensory needs met through sensory awareness training)
  3. Reinforcing participation in existing alternative activities (e.g., encouraging individuals to develop, expand and involve others in their present interests)
  4. Facilitating youth-directed groups in the process of initiating self-selected activities (e.g., Channel One)

Specific Activities

The original model for alternatives to substance abuse has no single identifiable source, but the idea of providing alternative activities for young people was seen as a consensus among prevention professionals in the early 1970’s (). This approach often took the form of opening a youth center that provided a unique activity or a specified set of activities for the young people in a community. The assumption behind this approach was that young people could be provided with real life experiences that would be as appealing as the use of substances and would in turn preclude their involvement with substances. Horan () described this assumption as competing reinforcement hierarchies which are very complex and must be considered in the context of specific situations along with interpersonal dynamics.

One of the emphases within this first general model of alternatives was to change the affective-cognitive state of an individual. Weil () was the most notable advocate of this emphasis which he labeled “altered states of consciousness.” Weil argued that drug use was in part a natural outgrowth of a child’s interest in different states, (e.g., being dizzy). However, one could argue with equal data that children also thrive on maintaining balance (e.g., walking the curb).

As an example of providing a specific activity in the context of prevention, Ventura and Dundon () evaluated an Outward Bound type of program. Their results did not reveal any statistically significant differences, between groups or as a result of the pre- and post-test occasions, but the authors concluded that the participants’ self-reports, and behavioral observations of the participants revealed positive changes.

Religious participation as an alternative activity has always fared well in the literature. For example, Bowker (), Turner and Willis (179), and Yohe () all found that greater participation in religious activities was associated with lower levels of use of substances. Similarly, Jessor and Jessor () and Kandel () have also concluded that involvement with religion is associated with less use of various substances.

Matching Need With Alternatives

The second major approach to alternative programming recommended matching alternatives with unfulfilled needs of individuals. While several authorities have advocated this approach, Cohen’s model () is the most well-developed conceptualization in this arena. Table Examples of Cohen’s approach to alternatives below illustrates four of Cohen’s levels of potential unmet needs and alternative activities that would accommodate those needs. A distinguishing feature of this approach to alternative programming is the individualization of activities rather than the provision of a predetermined activity or group of activities. Cohen’s model also emphasized addressing underlying causes in a manner that would allow the individuals legitimate expressions of their needs.

Table Examples of Cohen’s approach to alternatives

Level of Experience Corresponding Motives (Examples) Possible Alternatives (Examples)
Physical Desire for physical satisfaction, physical relaxation, relief from sickness, desire for more energy, maintenance of physical dependency. Athletics, dance, exercise, hiking, diet, health, training, carpentry or outdoor work.
Sensory Desire to stimulate sight, sound, touch, taste, need for sensual-sexual stimulation. Sensory awareness training, sky diving, experiencing sensory beauty of nature.
Emotional Relief from psychological pain, attempt to solve personal perplexities, relief from bad mood, escape from anxiety, desire for emotional insight, liberation of feeling, emotional relaxation. Competent individual counseling, well-run group therapy, instruction in psychology of personal development.
Interpersonal To gain peer acceptance, to break through interpersonal barriers, to “communicate,” especially non-verbally, defiance of authority figures, cement two-person relationships, relaxation of interpersonal inhibition, solve interpersonal hangups. Expertly managed sensitivity and encounter groups, well-run group therapy, instruction in social custom, confidence training, social-interpersonal counseling, emphasis on assisting others in distress via education, marriage.

Barnes and Olson () investigated the remedies junior and senior high school students used to relieve negative states or achieve positive states. They gave a questionnaire that listed fourteen remedies (six drug and eight nondrug remedies) and positive and negative states or moods. The negative states were anxiety, depression, and hostility and the positive states were adventure, cameraderie, and pleasure. Their goal was to identify which alternatives were used to achieve and/or relieve emotional states. The nondrug alternatives were physical activity, personal contemplation, discussions with friends or parents, counseling, social activities, and risk-taking behaviors.

One of their major findings was that alternatives used to reduce the negative states were seldom used to achieve positive states and vice versa (). Distracting activities, discussions with friends, and personal contemplation were used most frequently to relieve negative states. Social activities, risk-taking behaviors, and physical activities were used significantly more to achieve positive states. The authors also found that illicit drugs and alcohol were used significantly more to achieve positive states than to relieve negative states. They recommended that alternatives should be paired with the state (need) that they have the highest likelihood of facilitating.

Chanin (), Dohner (), Goodwin (), and Floyd and Lots of () also emphasized alternatives as a means for meeting more fundamental needs. They emphasized providing meaningful experiences with a somewhat avant garde flavor such as: transcendental meditation, sensitivity groups, yoga, creative and esthetic experiences.

While Cohen’s () model has been frequently cited as part of a rationale for alternative programming, there have been no evaluation projects based on the model. Several methodological problems are inherent in evaluating an approach that emphasizes individualization of services. Nonetheless, the need for research on this model remains unfulfilled.

Enhancing Existing Alternatives

The third model of alternative programming involved the application of reinforcement techniques to encourage and expand existing alternative activities in small groups (). The process involved discussions with students regarding current nondrug activities which were positively responded to by the group leader. Individuals who were involved in positive alternatives served as role models for the group members who were less involved. The assumption was that it would be possible to increase the overall level of participation in alternatives which, in turn, would reduce involvement with various substances.

This approach was evaluated at the junior high level by Warner et al. (), at the senior high level by Swisher et al. (), and at the college level by Swisher et al. (). All of these studies were true experimental designs with random assignment of students to experimental and control conditions, random assignment of group leaders to experimental and control conditions and pre- and post-testing with reliable and valid instruments. However, this first series of studies concluded the following:

  1. Regardless of approach, the knowledge level of participants significantly increased
  2. Regardless of approach, the use levels did not change
  3. Regardless of approach, the attitudes of students did not change

The most positive finding was among the college students who reported lower levels of use as a function of being in humanistically oriented group processes.

Another study in this series with junior high students () produced a significant and positive change in the students’ expressed willingness to try drugs. This particular project involved regular weekly supervision of the group leaders in order for them to function according to the prescribed procedures. The college results mentioned above were also produced as a result of extensive supervision of group leaders. Subsequent attempts to implement this approach without the weekly supervision of group leaders were not successful. The theoretical basis of this reinforcement model was also contrary to the then dominant affective education philosophy in the field of prevention.

Self-Directed Youth Alternatives

The most recent model of self-directed youth alternative prevention to emerge (known as Channel One) follows a seven-step procedure which culminates in youth-directed special projects. The original Channel One formed when artist Al Duca, of Gloucester, Massachusetts, hired a small group of youth to help him with a large statue that he had been commissioned to produce. This same group of young people subsequently elected to restore a historic grave yard, with some financial support from the Gloucester Community Development Corporation. While these projects were being initiated Al Duca began discussions with Prudential Insurance Company regarding the involvement of regional sales managers as consultants to local community groups who would create additional Channel One groups.

The National Institute on Drug Abuse became interested in further stimulating the adoption of Channel One groups across the country, and to accomplish this objective, each Single State Authority was given a special grant ().

The Channel One process involves a local prevention professional and a regional sales manager from Prudential (or a representative from another business) who meet to identify community needs. Subsequently community leaders are identified and they form a “steering committee” of adult consultants. The steering committee recruits young people to form “task forces” (Channel One groups) that have responsibility for initiating alternative activities of their own choosing. This self-directed process assumes that young people will elect responsible courses of action and by generating meaningful alternatives they will ultimately become less involved with substance abuse.

Resnick and Adams () reported that, as of May, 1981, there were 3,748 youth involved in 132 Channel One task forces in almost every State in the country. As self-directed groups, 79 have elected vocational skill projects, 44 alternative projects, 19 social service projects, 14 educational projects, 11 historic preservation projects and 5 environmental projects. The Resnick and Adams () survey also revealed that two-thirds of the groups were assisted by businesses other than the Prudential Insurance Company. The involvement of the business community has been viewed as a positive factor in the promulgation of Channel One groups by NIDA.

It is important to point out that 58 of the active 89 Channel One groups reported that they were having serious financial difficulties. This problem highlights one of the missing ingredients in the total replication process. The original Channel One groups were actually hourly employees whereas, the replication groups were assumed to be volunteers. Given the choice of projects listed above, it appears that the participants would prefer income producing alternatives and in the absence of this opportunity the groups will probably disband ().

Evaluation of channel one

Graefe () conducted a comprehensive process evaluation of a Channel One replication and concluded that the community, parents, and students had positive attitudes toward their experiences. Some data suggested reduced truancy among “active” Channel One members. The evaluation did not include control groups and data on drug use behaviors were not collected.

Hu et al. () conducted the most recent outcome evaluation of the Channel One process. The purpose of their evaluation was to determine the effectiveness and the cost-effectiveness of this type of alternatives programming. A community-based drug and alcohol agency, currently conducting Channel One type groups that had received an incentive grant for the effort, was nominated by a northeastern State as an appropriate site for the evaluation. Even though several Channel One groups were presently operating in the community, the local agency decided to initiate new groups for this project. The groups were initiated at six year-round community recreation centers. Three of the six sites were randomly assigned to an active status (experimental) and three were assigned to an inactive status (delayed treatment control). The Channel One program evaluated by Hu et al. () included the essential components of natural group formation, group interaction, involvement in alternative activities, youth-initiated activities, the opportunity for decision-making, and the necessity for taking responsibility for one’s own decisions. Channel One participants identified their own program activities and goals. The evaluation focused on the extent to which Channel One increased participation in alternative activities, improved decision-making and problem-solving skills, improved self-concepts, increased creativity, and reduced substance use.

The outcomes varied across the three sites, with Site 1 becoming significantly more democratic in its group problem-solving. Furthermore, Site 2 became significantly more involved in positive alternatives. There were no significant changes in self-esteem for any site. There were, however, negative findings for Sites 2 and 3. In these sites, use of inhalants and hallucinogens, and the frequency of being drunk increased ().

The costs of Channel One were calculated by including:

  1. Costs to the program, such as personnel, transportation, materials and supplies
  2. Costs to other organizations, such as space, equipment, and supervision
  3. Costs to the participants, such as transportation and equivalent hourly wages

Including the potential wages, the cost per participant ranged from $180 to $214. Excluding potential wages, the cost per participant ranged from $78 to $82. The slight positive findings for improvement in democratic problem-solving and participation in alternatives are offset by the clearly significant increases in the use of selected substances. Therefore, the program was not effective with regard to substance abuse outcomes although there were some other benefits for the participants. Also the social costs for all participants must be considered when judging the program’s effectiveness.

The findings of this evaluation indicate that this particular alternative program partially achieved the intended effects on the affective goals of the groups. On the negative side of the ledger, it appears that the process has a negative effect on the substance use levels of the participants.

There were many difficulties encountered in starting the groups, collecting the data (e.g., on one test occasion false data were submitted by two groups members hired to collect the data), and in terms of the adequacy of experimental and control groups. Furthermore, this single study, while making a contribution to the literature on costs and effectiveness of alternative types of prevention programming, cannot be construed to be representative of the 132 Channel One groups that were active at the time.

A recent survey of alternatives to drug use

During the 1981-1982 academic year, the Pennsylvania Department of Education, funded by the Office of Drug Abuse Policy (Pennsylvania Department of Health), initiated a school improvement process. All schools in Pennsylvania were mailed a request for a proposal to participate in a demonstration project. A review panel was established to select the demonstration sites and ten geographically dispersed schools were included. Four regional staff members of the Addictions Prevention Network were given training in administration of the questionnaire and they in turn provided inservice workshops to all of the teachers in the junior and senior high schools participating in the school improvement process. The total sample was approximately 14,000 students in grades seven through twelve.

Instruments

The Primary Prevention Attitude and Usage Scale (PPAUS) consists of nine subscales as follows:

  1. Demographic characteristics (four items on age, grade level, sex, and grade average)
  2. School climate (four items on feelings about teachers, subjects, classmates, and school in general)
  3. Intentions to use scale (twelve items on situations in which an individual would be willing to use different substances)
  4. Self-reported use (twelve items on the extent of use of different substances)
  5. Extracurricular activities (eight items on the extent of participation in school and community activities)
  6. Social behavior (twenty items on positive and negative social behaviors)
  7. Prevention variables (eight items on variables that influence use of substances)
  8. Intervention preferences (ten items on individuals that one would turn to for help with substance abuse problems)
  9. Location of use (one item describing the typical setting for use of substances)

The total scale is seventy-seven items in length and requires approximately thirty minutes to complete. Emphasis is given during the administration of the scale to each individual’s right not to answer any offensive questions. Students are also assured of the anonymous nature of the procedure and they are allowed to shuffle their answer sheets.

Reliability for subscales was established by calculating alpha coefficients from existing data for various subscales. These data are listed in Table “Reliability for survey subscales” below. Validity has been established by correlating the rank order of substances reported by students in the norm group with the rank order of substances reported by a national survey of high school seniors. In essence, the rank order of substances in both surveys is in nearly perfect agreement, suggesting high validity for the survey results.

A separate analysis was conducted on those students reporting any use of serotonin. This is a means of detecting individuals who exaggerate their use of substances or merely are careless in filling out the questionnaire. The range of inappropriate answers from the various schools in this group was approximately 3% to 7%.

Table Alternative activities and factors influencing use of substances in 1981-82 school year presents the result of a multiple regression analysis for data collected from the 1981-1982 participating schools. A regression was calculated for the extent to which the use of that substance is associated with the types of items found in the questionnaire. For example, all of the factors listed down the left-hand column are analyzed in terms of their association with the use of cigarettes. The factors that are significantly (p less than .05) related to use of cigarettes are given a descriptive label, such as “less.” This would be interpreted to mean that the less time students spend participating in sports, the more they smoke cigarettes. In order to understand the chart, it is necessary to verbalize each statement. In the example above, the statement has a logical quality and is not difficult to understand. However, some of the statements may require a review of the questionnaire in order to fully understand the interpretation.

TABLE Alternative activities and factors influencing use of substances in 1981-82 school year

Factors Substances
CIG BEER MARJ INH DEP HALL STIM
Gender Girl BOY
Grade High High High
Average Low Low
Entertain More More More More More More
Academic Less Less Less
Sports Less More Less Less Less Less
Social More More More More More More More
Religion Less Less Less Less
Hobbies Less
Extra More More More More More More
Vocation More More More More More More More

In all cases, if a word (such as more, less, higher, lower) is present in the table, it indicates “more use” of the substance under which it is listed. If there is no word listed, this indicates that the factor was not significant. However, no individual factor should be considered as extremely important. The weight of each factor is minimal, but if a pattern shows up (e.g., females consistently listed across the top), this would indicate a need for focusing on educational materials with a female point of view.

The following conclusions regarding alternatives can be drawn from the regression model presented in Table Alternative activities and factors influencing use of substances in 1981-82 school year.

  1. Entertainment activities are significantly associated with use of cigarettes, beer, marijuana, inhalants, depressants, and stimulants.
  2. Academic activities are associated with less use of beer, marijuana, and stimulants.
  3. Participation in sports is associated with less use of cigarettes, marijuana, depressants, hallucinogens, and stimulants; however, sports were significantly associated with more use of beer.
  4. Participation in social activities was associated with more use of everything.
  5. Involvement in religious activities was associated with less use of cigarettes, beer, marijuana, and stimulants.
  6. Active hobbies were associated with less use of beer and stimulants.
  7. Participation in extracurricular activities was associated with more use of cigarettes, beer, marijuana, inhalants, depressants, and stimulants.
  8. Participation in vocational activities was associated with more use of all substances in the questionnaire.

Conclusions and recommendations

One apparent conclusion from this review of research on alternative programming is that there is a sparse evaluation literature and uneven correlational literature upon which to base any conclusion. During the last decade ten thousand studies have appeared in the professional literature involving the MMPI (). One is hard pressed to find one percent of that record for the entire field of prevention.

Schaps et al. (), in a comprehensive review of 127 outcome studies of all types of prevention programs, found only twelve studies of alternative programming. Seven of the 12 studies reported no program impact on participants. The other 5 studies had positive outcomes which resulted in alternative programming being second in positive effects among ten other approaches to prevention. These successful programs suggest some merit for the alternative approach, but more importantly they do not represent an adequate data base for planning.

Programs such as Channel One should be more thoroughly evaluated prior to mass dissemination efforts. Apparently, neither the initiation nor termination of Channel One benefited from an adequate data base.

There is a need for additional research in this domain. Instead of discarding what has been learned, research should further explore what types of alternatives in what kinds of agencies and institutions have a constructive effect on what types of individuals. The research cited in this paper supports the fact that some alternatives detract from drug abuse (e.g., academic, sports, and religious) whereas, other alternatives contribute to the use of various substances (e.g., social, entertainment, and vocational). More basic longitudinal research on underlying psychosocial dynamics needs to be explored regarding these behavioral manifestations.

 

Selections from the book: “Preventing Adolescent Drug Abuse: Intervention Strategies”. Thomas J. Glynn, Ph.D.; Carl G. Leukefeld, D.S.W.; and Jacqueline P. Ludford, M.S., eds. A RAUS Review Report on a variety of approaches to prevention of adolescent drug abuse, how they can be applied, their chances for success, and needed future research. National Institute on Drug Abuse Research Monograph 47, 1983.