








































Prevention of Opioid Addiction


COMMONWEALTH, Volume 20, Issue 1 (2018). © 2018 The Pennsylvania Political Science Association.  
ISSN 2469-7672 (online). http://dx.doi.org/10.15367/com.v20i2-3.187. All rights reserved.

Prevention of Opioid Addiction

RALPH E. TARTER
University of Pittsburgh

GERALD COCHRAN
University of Pittsburgh

MAUREEN REYNOLDS
University of Pittsburgh

Ameliorating the factors that cause and sustain opioid addiction is essential 
for effective prevention. Accordingly, this discussion begins with a brief review 
of the etiological components, developmental pathways, and phases of addic-
tion across the lifespan. Next, assessment of risk for addiction is discussed as to 
the basis of objective determination of prevention tactics. The main prevention 
tactics are succinctly noted. Lastly, the challenges that need to be surmounted to 
increase access to and success of prevention interventions are considered. Rec-
ommendations that may improve effectiveness of prevention of opioid addiction 
conclude this article. In particular, it is argued that successful prevention is 
contingent on shifting resources from the criminal justice system to the health 
care system.

The modern practice of medicine is anchored to the principle that inter-
vention effectiveness, whether prevention or treatment, is contingent 
on ameliorating the factors that cause and sustain the particular dis-

ease. Prevention of diseases that have one causal factor is straightforward, 
involving either strengthening the person’s resistance (e.g., inoculation) or 
eliminating the etiological agent from the environment (e.g., water and air 
purification). Multifactorial diseases, on the other hand, technically termed 
complex, do not have a single causal determinant. Rather, these diseases, 



Prevention of Opioid Addiction 39

including opioid addiction, ensue over a period of time from the continuous 
interplay of three etiologic components: (1) genetic and biobehavioral vulner-
ability of the individual; (2) quality of the physical and social environments; 
and (3) pharmacological properties of the specific substance. A three- pronged 
strategy is therefore required to prevent opioid addiction, defined herein as 
consumption behavior that is beyond voluntary control (Dirckx 2001). Com-
pulsive drug seeking, usually embedded in physical dependence, captures the 
original Latin meaning of the term addiction, namely, the once master becom-
ing the slave, in this case to the drug.

Etiology of Addiction

Opioid addiction, as shown in Figure 1, has manifold etiological influences 
spanning characteristics of the individual, environmental circumstances, and 
particular type of opioid. Accordingly, the population of opioid addicts is very 
heterogeneous. Diverse etiological pathways leading to clinical disorder (opi-
oid addiction), termed equifinality, illustrates the importance of deploying 
individualized intervention.

A person- centered approach to prevention (informed by etiology) requires 
capitalizing on risk- attenuating (i.e., resilience) characteristics while amelio-
rating risk-e nhancing characteristics. All factors pertinent to the three etio-
logical domains, depicted in Figure 2, determine the person’s overall risk (R), 
ranging from 0–1, of developing opioid addiction. Because the repertoire of 
risk- enhancing and risk-a ttenuating characteristics is uniquely configured in 
each individual, the prevention framework must be adaptive; that is, it must 
selectively use methods tailored to the particular needs of the individual. 
Adaptive prevention thus corresponds conceptually with person-c entered 
medicine.

Etiology of opioid addiction is discussed briefly below, followed in the 
next section with a description of assessment methods and prevention tactics.

Individual Vulnerability

The psychological characteristics of the individual that predispose him or her 
to addiction aggregate into two main clusters: (1) suboptimal psychological 
self- regulation, and (2) deficient reward processing.

Psychological Self-Regulation 
The capacity to exercise cognitive control over behavior and emotions is 
essential for social adaptation. Constituting the executive cognitive functions, 



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Prevention of Opioid Addiction 41

Figure 2. Opioid Addiction Risk (R) Results from the Interplay of Individual, Environmental, and 
Drug Characteristics. (Created by authors.)

this capacity is integral to planning distant goals (telescopic thinking), self- 
monitoring ongoing behavior, and changing motivational course in response 
to shifting circumstances. Internal language (thought) mediates these pro-
cesses. For example, impulsivity, one of the cardinal features of addiction risk, 
is essentially acting without thinking. Preventing addiction should begin, 
therefore, with techniques that consolidate language competencies (reading, 
oral communication, problem solving, contingent “if- then” thinking, etc.) in 
early childhood.

Neuromaturation, beginning during fetal development and extending to 
27–28 years of age, underlies the acquisition of psychological self-r egulation. 
Approximately 1% of babies in the United States are born in opioid with-
drawal. This disturbance, termed neonatal abstinence syndrome (NAS), is the 
result of exposure during gestation to medicinal and/or illegal (Schedule I) 
opioids. The main feature of NAS is severe physiological dysregulation, which, 
although usually subsiding within a month, challenges caregiver investment 
in the baby and parenting competencies. Moreover, frequently present char-
acteristics of addicted women (psychiatric disturbance, medical disability, 
lack of social support, chronic stress) impede emotional bonding and parent-
ing. One outcome of dysfunctional baby- caregiver bonding is development of 
behavioral disturbances in the young child, thereby biasing ontogeny toward 
nonnormative socialization, which almost invariably manifests as early age–
onset substance use and other risky behaviors. In 2016, over 300 babies were 
born with NAS at the Magee Women’s Hospital in Pittsburgh.



42 Ralph E. TaRTER, GERald CoChRan, and MauREEn REynolds

Transient disturbances during infancy, often mundane and considered 
innocuous, may also hamper development of psychological self- regulation 
and subsequent normative socialization. Colic, for example, is evinced as 
fussiness, intense crying, flushed face, clenched hands, and physical discom-
fort indicated by knees pulled up to the chest. Without reliable comforting 
from the caregiver (soothing, holding, stroking, mild exercise, etc.), emotional 
development of the baby may be jeopardized. Distress in the infant that is not 
alleviated by a caregiver hinders affectional bonding, which commonly mani-
fests in later childhood and adolescence as a strong propensity for disruptive 
and antisocial behavior, including substance use.

During toddlerhood, suboptimal self- regulation, usually referred to as 
difficult temperament, consists of high emotionality, behavioral overactiv-
ity, low sociability, low persistence to goals, and distractibility. These emo-
tion and behavior deviations in two- year- old children increase the risk for 
addiction two decades later (Horner et al. 2015). Low self- regulation in middle 
childhood is evinced as symptoms of attention deficit hyperactivity disorder 
(ADHD), often in conjunction with conduct disorder (CD). Both disorders 
amplify conflict with peers and adults, resulting in marginalization that is 
often accompanied by internalization of resentment, aggressivity, alienation, 
and affiliation with peers who are similarly undercontrolled and prone to 
deviant behavior. In effect, a friendship cluster forms consisting of youths 
who mutually encourage norm-v iolating behavior, including substance use. 
Notably, severely deficient psychological self- regulation in late childhood seg-
ues to addiction, consequent to the most negatively sanctioned drugs, such as 
cocaine and opioids (Krueger et al. 2002). By mid- adolescence, low psycho-
logical self- regulation often manifests as antisocial personality disorder (more 
often in males) and borderline personality disorder (more often in females), 
which are the most frequent presaging and co- occurring personality distur-
bances associated with hazardous substance use and addiction. Hence, the 
core individual characteristic comprising the liability to addiction is subopti-
mal psychological self-r egulation, predisposing to nonnormative socialization 
and associated nonadherence with mores and laws.

Internal and external stressors may diminish previously acquired psycho-
logical self- regulation. Examples of internal stressors include psychiatric ill-
ness, sleep disorder, and pain. Examples of stressors having an external source 
include divorce, maltreatment, and unsafe neighborhood. Alcohol and other 
addictive drugs alleviate stress in the short term; however, habitual consump-
tion results in neuroadaptation (chronic tolerance) and other symptoms of 
addiction. Stress associated with (1) preoccupation of ensuring a reliable opi-
oid supply, (2) craving, and (3) staving off withdrawal symptoms catalyzes 



Prevention of Opioid Addiction 43

strongly motivated drug seeking, which in severe cases manifests as compul-
sivity that may lower inhibition for criminal behavior.

Deficient Reward Processing
A body of empirical evidence, albeit not pertaining to opioids, documents 
deficient reward processing in individuals who subsequently develop addic-
tion. Quality of reward experience, however, most likely predisposes to opioid 
addiction, considering that all addictive drugs impact the same dopaminergic 
mesolimbic circuitry comprising the reward system in the brain (Vanyukov 
et al. 2009).

The pharmacological actions of addictive drugs produce three types of 
subjective effects: (1) positive reinforcement (euphoria, pleasure), (2) nega-
tive reinforcement (relief from emotional and/or physical discomfort), and 
(3) punishment (e.g., panic, nausea). Experiencing punishment lowers the 
probability of repeated use, whereas positive and negative reinforcement 
increase the probability of repeated use, although not inevitably leading to 
addiction. However, because the potency of some opioids is very strong, risk 
for addiction is augmented in individuals who have low vulnerability to addic-
tion. For example, fentanyl, a synthetic opioid, is several thousand times more 
potent than heroin. Notably, regular vigorous physical activity (i.e., exercise 
and recreation) is rewarding via enhancement of feelings of well- being and 
diminution of negative feelings (anxiety, depression, etc.). Hence, mediated by 
activation of the endogenous opioid system, physical activity may lower the 
desire to consume opioids (and other drugs).

Environment

Multiple environments (family, school, military, Moose Lodge, church, etc.) 
regulate individual behavior via (1) informal folkways (e.g., shaking hands in 
a greeting), (2) formal secular and cultural rules (e.g., not jumping position 
in a checkout line, desisting alcohol intoxication), and (3) laws (e.g., smoking 
in restaurants, giving alcohol to a minor). Social adjustment thus requires 
conformity with many expectations, spanning a large variety of different con-
texts. Where there is a mismatch, the person must accommodate or adapt to 
the discrepancy and associated stress. For example, gay marriage is proscribed 
by almost all religions, yet accepted in secular Western societies. A person 
with strong religious convictions must, therefore, reconcile discordant cul-
tural and secular values. In the absence of resolution, alcohol or drug use may 
be adopted as a stress- coping tactic, which, over time and facilitating circum-
stances, segues to addiction. The point is that alcohol or drug use may ensue 



44 Ralph E. TaRTER, GERald CoChRan, and MauREEn REynolds

from stress caused by adapting to multiple environments that place variable 
and often conflictual demands on the person.

Family
The family is a system of genetic and social relationships. It is the first and 
most important environment interacting with the fetus and the child. Parents, 
siblings, and extended family members inculcate in children the values, hab-
its, and attitudes that guide behavior throughout life.

The importance of the family in addiction etiology cannot be overstated. 
Addiction in a parent increases addiction risk in the child up to sevenfold, 
consequent to conjoint influences of genetic liability and family environment. 
For example, adults with addiction not infrequently spiral into socioeconomic 
decline, thus forcing the family to relocate to a disadvantaged neighborhood 
in which illegal drugs are more readily available and their consumption is 
tolerated. Hence, the child is at heightened risk for addiction, concomitant 
to genetic predisposition along with adverse family and neighborhood envi-
ronments. To cite another important example, it is well known that genetic 
risk for addiction is shared in large part with several psychiatric disorders 
and criminal behavior. These disorders in parents, especially when severe, 
may lower the threshold for maltreatment of their child. In effect, the child’s 
risk for addiction and frequently co- occurring outcomes (e.g., crime) is deter-
mined conjointly by genotype and adverse home environment. Maximizing 
a positive environment by investing in addiction recovery and mental health 
services for parents is, therefore, integral to deterring addiction in children.

Many family characteristics bias the child toward addiction. Salient 
features during early childhood include weak affectional bonding with the 
primary caregiver, due either to disinterest or child-r earing incompetence. 
Additional risk- promoting factors include low family cohesion, poor com-
munication among family members, insufficient supervision of the child, 
mutual dissatisfaction between parent and child, family disengagement from 
cultural/religious identity, and economic disadvantage. Single parenting, 
especially in the absence of extended family or other social support, is also 
potentially problematic. In summary, internalized societal norms and pro-
social values are ordinarily transmitted from family members to children. 
Failure to inculcate traditional values and prosocial behavior portends devi-
ant socialization and substance use onset at a young age.

Peers
Play during toddlerhood is essential for acquiring social competence. Coop-
eration inculcates trust, empathy, and skills required for optimal social 



Prevention of Opioid Addiction 45

interactions. Where play is marked by aggression or dominance asserting 
behavior, risk for early age-onset substance use is heightened. Bullying behav-
ior, for example, consolidates a spectrum of problematic behaviors that pre-
dispose to substance use. Victimization from a bully, on the other hand, may 
cause long-te rm emotional disturbance, including low self- esteem, leading to 
substance use as a stress- coping response.

Two aspects of the peer environment during adolescence exert a par-
ticularly strong influence on risk for addiction. The first factor, parental 
supervision, usually declines during adolescence in tandem with increas-
ing opportunities for the youngster to affiliate with socially deviant peers, 
and thus initiate alcohol and drug consumption. In the absence of parental 
oversight, desisting a drug or alcohol offer is less likely among youth with 
suboptimal self- regulation. The second factor is timing and rate of physical 
growth and sexual maturation. Precocious onset of puberty manifests overtly 
as appearing older (e.g., facial hair in boys, breast development in girls) rela-
tive to actual chronological age. Consequently, the early- maturing youngster 
is at heightened risk for being drawn into a friendship cluster consisting of 
older peers who introduce them to risky behaviors, including substance use.

School
The school is a socially and cognitively demanding environment. Beginning 
with pre- K education, youths are prepared for citizenship by acquiring cogni-
tive and behavioral competencies required for gainful employment and adult 
roles. Maladjustment in school and/or underachievement increase likelihood 
of truancy and dropout, which heightens risk for affiliation with socially non-
normative peers and substance use.

The school building, vacant about half the year, is a potentially valuable 
resource to provide health and social services, which, among other benefits, 
could lower risk for opioid addiction. Drug abuse education, family counsel-
ing, routine health services (e.g., vaccinations, orodental hygiene services), 
out- of- school physical recreation, and adult- supervised social recreation are 
examples of activities that lower risk for addiction, which can be easily imple-
mented in the school building serving as a neighborhood hub.

Community
Economically disadvantaged communities have a higher density of retail 
outlets displaying and selling alcohol and tobacco products. This visibility 
normalizes consumption of addictive substances. Hence, drug peddling and 
consumption are more prevalent and tolerated in disadvantaged communi-
ties, especially when there is lax law enforcement and weak social cohesion. 



46 Ralph E. TaRTER, GERald CoChRan, and MauREEn REynolds

Opportunity for seclusion in vacant buildings also facilitates illegal drug use. 
In sum, a socioeconomically disadvantaged neighborhood is more likely to 
tolerate, and in varying degrees acquiesce to, drug use.

Reducing opioid peddling and consumption (as well as other illegal 
behaviors) would, at first glance, appear to simply require rehabilitating the 
community. Often the cornerstone of urban renewal policy, this strategy is 
not likely to have a robust effect because it merely shifts illegal activity to 
another proximal disadvantaged neighborhood.

Disadvantaged neighborhoods are, however, not inevitably locked into a 
high rate of illegal behaviors, including drug distribution and consumption. 
Many neighborhoods inhabited by the low- income segment of the population 
do not have elevated rates of nonadherence to mores and laws. Accordingly, 
they provide good models for drug prevention programming. An important 
mitigating factor is the neighborhood’s social capital; namely, leadership hav-
ing expertise in and commitment to promoting the welfare of the residents 
in conjunction with preservation of the physical and social infrastructure of 
the neighborhood. Enforcing social norms, supporting legitimate economic 
activity, protecting societal institutions (health, social welfare, education, reli-
gious, legal), sustaining partnerships with philanthropic and business entities, 
and ensuring access to safe social and physical recreational activities (e.g., 
sports league, Scouts, etc.) are also essential for protecting the community 
from decline, thereby preventing an opening wedge for drug peddling and the 
opportunity for initiating drug use.

Drug Properties

Repetitive consumption of a drug that has reinforcement properties is the 
third etiological determinant of addiction. Importantly, opioid addiction risk 
is potentiated by consumption of other addictive substances. This is not sur-
prising, however, considered in light of the fact that almost 100% of genetic 
risk is common to all addictions (Tsuang et al. 1998; Kendler et al. 2003). 
Hence, effective primary prevention of opioid addiction is contingent on 
averting the onset of consumption of other addictive substances.

Consumption usually advances from easily obtainable, inexpensive, and 
legal substances (e.g., alcohol, nicotine) to illegal or negatively sanctioned 
substances. This pattern has been widely thought to reflect a developmen-
tal progression in which cannabis is the pivotal (gateway) drug promoting 
transition from legal substances to “hard” drugs, including opioids. Usu-
ally referred to as the gateway hypothesis (Kandel and Yamaguchi 1999), this 
notion has been discredited on both logical and empirical grounds (Tarter et 



Prevention of Opioid Addiction 47

al. 2006). It has long been known that (1) opioid use does not invariably ensue 
after cannabis use, and (2) most cannabis users do not transition to opioid 
use. Nevertheless, the gateway hypothesis has been the rationale underpin-
ning the punishment of individuals caught smoking marijuana, even though 
there is no empirical evidence that consumption is the stepping stone to 
opioid use.

The rise in opioid use during the past two decades cannot be attributed 
to marijuana use. Other factors appear to have a more prominent influence. 
Opioids in contemporary society have, however, several special features. 
Whereas opium was once the only opioid product, there are currently dozens 
of formulations consisting of FDA- approved “medicines” and Schedule I (ille-
gal) drugs. Consumption of medicines with physician prescription is socially 
responsible, indeed expected, in conformance with Aesculapian authority of 
the doctor for treatment of ailments; however, consumption without physician 
prescription is not severely negatively sanctioned, if at all. Moreover, there 
are currently readily available, albeit illicitly, potent medicinal opioids (e.g., 
fentanyl, carfentanyl) that accelerate progression to addiction and confer great 
fatality risk from overdose. Strong potency, low cost, and easy availability, in 
conjunction with quick sharp euphoria obtained via opioid administration 
using disposable syringes, converge to heighten the risk for consumption, and 
subsequently addiction. Because many individuals are not capable or moti-
vated to initiate recovery from addiction, harm- reduction techniques (second-
ary prevention), such as providing clean needles and providing heroin legally 
in a controlled setting, lower the risk for disease and injury.

Opioid use, as can be seen in Figure 3, does not inevitably advance to 
hazardous use and addiction. Comprehensive reviews of the literature sug-
gest that addiction ensues in only a subset of the population of patients using 

Figure 3. Phases of Addiction Development Synchronized with Prevention Type. (Created by authors.)



48 Ralph E. TaRTER, GERald CoChRan, and MauREEn REynolds

opioids for analgesia under physician oversight (Fields 2011). Determining 
whether the individual using an opioid is at high risk for transitioning to 
addiction is therefore a high priority for cost- efficient secondary prevention.

A change in the magnitude of risk for addiction can occur very quickly. 
Drug peddling entering the community, a parent receiving physician- 
prescribed opioid medication who unintentionally lets his children access the 
supply, and opioid consumption after surgery in vulnerable individuals can, 
for example, rapidly accelerate use culminating in addiction. Establishing an 
intimate relationship with a drug- abstinent partner or joining an organiza-
tion that enforces mores prohibiting consumption lowers the risk for addic-
tion. Temporally monitoring individuals who may be prone to addiction is, 
therefore, the key to timely intervention.

One location in which to conduct long- term monitoring is the community 
pharmacy. The pharmacist has specialized expertise in medication manage-
ment, including promoting safe drug use and adherence with the prescribed 
regimen. Pharmacists are among the most accessible health care professionals. 
Indeed, 93% of the population resides within five miles of a retail pharmacy. 
Furthermore, the expansion of pharmacist- delivered services (e.g., influenza 
immunization clinics, blood pressure monitoring) requires allocating space in 
the pharmacy for private interactions with patients. Currently, 40% of phar-
macies in the United States have a consulting room. In sum, the community 
pharmacy is an ideal setting in which patients receiving physician- prescribed 
opioids can be monitored for addiction risk, thereby enabling timely on- site 
prevention intervention. Notably, a recent study has found that approximately 
15% of patients screened in four community pharmacies located in western 
Pennsylvania misuse their opioid medication (Cochran et al. 2015).

Lifespan Perspective of Opioid Addiction Etiology

The three phases of addiction etiology and development shown in Figure 3 
correspond to primary, secondary, and tertiary prevention. Because individu-
als vary with respect to their duration in each phase, it is difficult, if even 
possible, to conduct effective prevention intervention in a fixed “one size fits 
all” program. For example, one person may consume a substance for many 
years before risk ramps up, leading to addiction, whereas another person may 
rapidly progress to addiction soon after initiating consumption. A schema of 
addiction etiology accounting for both chronological age and variability of 
duration in each addiction phase is depicted in Figure 4.

Initial magnitude of risk is established at the moment of conception. 
Thereafter, risk- enhancing and risk- attenuating factors constitute vectors (v1, 
v2, v3, etc.), namely, quantities that have both force and direction (analogous 



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50 Ralph E. TaRTER, GERald CoChRan, and MauREEn REynolds

to an airplane in flight). In aggregate, the vectors constitute the overall risk 
vector (VR) biasing the person toward addiction with a particular momen-
tum. Figure 4 illustrates also that the etiological trajectory is nonlinear. This 
is due to the fact that the person’s biological and psychological risk charac-
teristics change throughout life, concurrent with changing environmental 
contexts and exposure to an ever-e xpanding panoply of addictive substances. 
Risk magnitude, therefore, is not constant but variable. This important point 
has two noteworthy ramifications: (1) Because magnitude of addiction risk is 
changeable, it can be reduced, thereby providing the rationale for prevention; 
and (2) it is not practical or even possible to conduct long- term forecasting. 
Hence, once the need for prevention is determined, intervention needs to focus 
on lowering the risk of near future outcomes, so as to bias the trajectory away 
from addiction. This task requires comprehensive quantitative assessment.

Assessment of Addiction Risk

Employing the data obtained in a 25- year longitudinal study conducted by 
the Center for Education and Drug Abuse Research (CEDAR) at the Univer-
sity of Pittsburgh, assessment tools have been developed corresponding to the 
three components of addiction etiology (see Figure 2): namely, individual risk 
(Vanyukov et al. 2009), environmental risk (Kirisci et al. 2009), and drug use 
topology (Kirisci and Tarter 2001). Problems as well as assets that inform pre-
vention targets can be expeditiously delineated (15–20 minutes) using the web- 
based revised Drug Use Screening Inventory (DUSI- R) (ecenterresearch.com). 
As shown in Table 1, problem severity (0%–100%) is quantified in multiple 
domains spanning mental and physical health, behavior, social skills, and key 
environments (family, peers, school, work). Importantly, the person’s responses 
are immediately and automatically scored so that the results can be shared with 
the individual at the time of assessment. Denial of problems (a frequent defense 
by addicted individuals) is not possible since problem severity directly mirrors 
the person’s responses on the inventory. Moreover, a Lie Scale detects inten-
tional deception. Lastly, the data from the automated DUSI- R can be easily 
aggregated to evaluate effectiveness of the prevention program and to quantify 
magnitude of the benefit obtained from the intervention for each individual.

Prevention Tactics

The following discussion describes prevention techniques corresponding 
to the main addiction pathways (see Figure 1). It should be noted that the 



Prevention of Opioid Addiction 51

Table 1. scales of the Revised drug use screening Inventory (dusI-R) for 
adolescents and adult Versions

primary scales

Frequency of Substance Use (20+ compounds)
Substance Use Problems
Behavior Patterns
Health Status
Emotional Health
Social Competence Overall Problem 
Family System Density Score
School Performance (0%–100%)
Work Adjustment
Peer Relationships
Leisure and Recreation
Lie Scale (validity check)

subscales

Behavior Undercontrol
Deviance Proneness
Feeling Safe at Home and School
Attention Deficit Hyperactivity Disorder
Conduct Disorder
Anxiety
Depression
Academic Underperformance
Anger
Dependence Syndrome
Interpersonal Aggression
Nonviolent Legal Violation
Paranoia
School Disengagement
Social Withdrawal

Source: Compiled by authors.

interventions below (primary, secondary, and tertiary prevention) target the 
three etiological components (Figure 2) spanning the three phases of addic-
tion development (Figure 3). It is important to emphasize that the tactics 
deployed during each phase of addiction development must also include tac-
tics that ameliorate the etiology influences that are present in the prior phase. 
For example, averting the transition to addiction in drug users must include 
interventions that address the factors that led to prodromal drug use. To reit-
erate, prevention encompasses three phases: targeting etiology pertaining to 
vulnerability disposition prior to onset of substance use, pattern of substance 
use, and addiction manifestations.



52 Ralph E. TaRTER, GERald CoChRan, and MauREEn REynolds

Subpopulation A: Self- Directed Opioid Use

This etiological pathway to addiction originates with behaviors that violate 
social mores and laws.

Primary Prevention (Pre- Drug Use Stage)
As appropriate:

• Ameliorate externalizing behavior (attention deficit hyperactivity 
disorder, conduct disorder, oppositional defiant disorder).

• Devise a personalized curriculum to potentiate academic achieve-
ment.

• Inculcate parenting and communication skills in caregivers.
• Ensure reliable presence of prosocial adult mentors.
• Prevent friendships with undersocialized peers.
• Connect the youngster with adult- led social, cultural, and recre-

ational organizations.
• Cultivate the child’s expertise in a skill (music, craft, sport, etc.).
• Encourage breastfeeding to promote affectional bonding between 

caregiver and baby.
• Enhance socialization in toddlerhood through cooperative play.
• Establish regularity in daily routine (eating, sleeping, homework, 

bathing, etc.).
• Monitor and supervise health promotion behaviors (oral hygiene, 

hand washing, seat belt use, etc.).
• Provide opportunity for and require regular vigorous exercise and 

recreation.
• Expect the child to regularly perform age- appropriate tasks that 

benefit a social group (e.g., household chores for the family, volun-
teer activities in a nursing home).

• Elevate the barriers to drug dealing in the neighborhood (watch 
committees, police presence, surveillance cameras, etc.).

• Provide safe adult- supervised outdoor recreational space for 
unstructured and adult- supervised recreation.

• Reduce ubiquity of legal retail sale of addictive substances, includ-
ing tobacco and alcohol advertising.

• Strengthen cohesion, identity, and pride in the community (fairs, 
festivals, sports leagues, etc.).

• Prevent entry into vacant and abandoned buildings.
• Establish volunteer corps to upgrade attractiveness of the neighbor-

hood.



Prevention of Opioid Addiction 53

• Incentivize long- term residence in the neighborhood.
• Repurpose school buildings as a community hub when not occu-

pied for education.
• Provide neighborhood setting for AA, Al- Anon, and Alateen 

groups.
• Recruit businesses essential to a self- contained neighborhood.
• Provide multiyear drug education in schools.
• Establish home visitation program for high-r isk children (e.g., 

parent in prison, single- parent families, parent receiving opioid 
medication).

Secondary Prevention (After Substance Use Onset)
As appropriate:

• Provide accessible drug/alcohol, mental health, and family/social 
professional services.

• Ensure treatment access for drug/alcohol offenders (e.g., DUI, drug 
possession).

• Create employment and job training opportunities, including 
apprenticeships.

• Implement program for school dropout prevention.
• Implement employment assistance program.
• Inculcate adaptive coping tactics to replace substance use.
• Terminate affiliation with norm- violating friends.
• Provide marital and family counseling services in the neighborhood.
• Conduct contingency management of substance use in conjunction 

with brief intervention tactics at point of health service (physician, 
pharmacy, social agencies).

+ Incorporate primary prevention tactics as appropriate.

Tertiary Prevention (Health and Legal Problems Subsequent  
to Addiction)
As appropriate:

• Ensure that opioid medication type and dose are therapeutically 
effective.

• Introduce long- term recovery resources (e.g., therapeutic commu-
nity, AA/NA).

• Ensure access to psychiatric treatment.



54 Ralph E. TaRTER, GERald CoChRan, and MauREEn REynolds

• Provide social and legal support services.
• Implement behavioral interventions to reduce lifestyle risky 

behaviors.
• Conduct routine infection- risk monitoring (HIV, STD, etc.).
• Intervene with an individualized person- centered approach to for-

mulate life goals, ingrain health promotion values, and instill self- 
motivated character development.

• Guide and oversee participation in prosocial organizations (e.g., 
church, sport league, social club).

+ Incorporate primary and secondary prevention tactics as appropriate.

Subpopulation B: Physician- Prescribed Opioid Use

A subset of patients receiving opioid medication (usually to manage pain) are 
at heightened risk for addiction.

Primary Prevention
N/A

Secondary Prevention
As appropriate:

• Monitor proactively in pharmacy at time of prescription refill.
• Ensure that medication for pain management is effective.
• Refrain, if possible, from taking psychotherapeutic medications that 

have addiction liability.
• Desist recreational use of addictive substances (alcohol, nicotine, 

etc.).
• Reduce environmental and internal stressors.
• Ensure access to psychiatric disorder treatment.
• Monitor healthy diet.
• Teach coping methods to manage pain (and other stressors) to 

replace alcohol or drugs.
• Provide education pertaining to addiction risk.
• Ensure understanding of the risk of adverse outcomes consequent to 

nonadherence with the physician- prescribed medication regimen.
• Prevent accumulation of an opioid supply via accessing multiple 

physicians and pharmacies.



Prevention of Opioid Addiction 55

• Quantitatively monitor change in magnitude of addiction risk at 
the point of service while on a medication regimen (e.g., retail phar-
macy at each prescription refill).

+ Incorporate primary and secondary tactics as appropriate (re: Subpopula-
tion A).

Tertiary Prevention
• Same as Subpopulation A

+ Incorporate primary and secondary tactics as appropriate (re: Subpopula-
tions A and B).

Subpopulation C. Physician-P rescribed Opioid Use Transitions  
to Self- Directed Use of Medicinal and/or Schedule I Opioids

Some patients legitimately receiving opioid medicine transition to self- 
directed use.

Primary Prevention
N/A

Secondary Prevention
As appropriate:

• Ensure effective analgesia.
• Ensure that the dose is sufficient to avoid feelings of incipient 

withdrawal.
• Ensure that the patient can obtain legitimately prescribed opioid 

medication.
• Monitor risk status and intervene at the point of service (retail 

pharmacy).

+ Same as Subpopulations A and B as appropriate.

Tertiary Prevention
+ Incorporate the same interventions as Subpopulations A and B as 
appropriate.



56 Ralph E. TaRTER, GERald CoChRan, and MauREEn REynolds

Subpopulation D: Opioid Use to Manage Addiction  
under Medical Supervision Transitions to Self- Directed Use  
of Medicinal and/or Schedule I Products

Medicinal opioids are a standard treatment of opioid addiction. Some patients 
transition to self- directed use.

Primary Prevention
N/A

Secondary Prevention
N/A

Tertiary Prevention
As appropriate:

• Avert craving using behavioral and physiological tactics.
• Ensure transportation access to methadone clinic or other facility 

that dispenses opioid medications (e.g., physician’s office).
• Provide social services support.
• Facilitate childcare assistance to enable accessing drug and nondrug 

treatment facilities.
• Obtain financial resources subsidy for medications and related 

treatment.
• Provide a community resident navigator.

+ Incorporate primary, secondary, and tertiary prevention tactics (re: Sub-
populations A, B, C) as appropriate.

Prevention in Context of Politics and Policy

The discussion up to this point addressed: (1) etiology of opioid addiction, 
(2) cost-e fficient scalable assessment, and (3) prevention tactics. Because the 
state has multiple interests (tax revenue, health promotion, protecting public 
safety, etc.), policies to prevent opioid addiction and its aftermath are unavoid-
ably and intricately connected to politics.

From the standpoint of health promotion, the current constellation of 
federal and state laws and regulations lack consistency. In Pennsylvania, the 
state is the monopoly retailer of spirits, yet these beverages can be purchased 
in sufficient quantity to cause death from intoxication. Marijuana, which 



Prevention of Opioid Addiction 57

Pennsylvania currently outlaws for recreational use, does not cause death 
from intoxication. Pennsylvania does not regulate distribution of powder caf-
feine, even though one tablespoon can be fatal. (This substance is often added 
to alcohol drinks to offset sedation.) With respect to toxic injury, cigarette 
smoking, legal at 18 years of age, is responsible for over 400,000 deaths each 
year in the United States, whereas alcohol, which accounts for about a fifth of 
this number of deaths, is legal at 21 years of age. Hookah, a coarse tobacco, is 
almost completely unregulated. Protection of safety effected through laws and 
regulations thus has consistency gaps and arguably lacks coherence.

The effectiveness of prevention of opioid addiction via laws and regula-
tions is thus doubtful, especially considered in light of U.S. legislative history. 
The first attempt in the United States to regulate opioid consumption was the 
1875 Opium Den Ordinance Act in San Francisco. This ordinance, like many 
statutes since, had racist and nativist sentiments insofar as it was aimed at 
reducing a perceived threat from Chinese immigrants. Violators were fined 
and occasionally jailed. Opium use was, however, not curbed. A subsequent 
law passed in California in 1907 ramped up enforcement, including covert 
police infiltration of distributors. Whereas consumption did not noticeably 
decline, opium distribution and consumption were driven underground, 
thereby establishing a new criminal population defined by using this drug. 
Once opium use by statute was designated as nonnormative or deviant, indi-
viduals with antisocial propensities as well as those with a socially noncon-
forming lifestyle (hipsters, artists, writers, jazz musicians, etc.) were inclined 
toward consumption.

During the past three decades, the population of opioid users has 
expanded by drawing in individuals from the normative segment of the gen-
eral population. This has occurred for two main reasons: (1) normalization 
of a wide range of traditionally negatively sanctioned behaviors (e.g., gam-
bling, tattoos, homosexual relationships); and (2) easy availability of opioid 
medicines that do not carry the stigma of heroin. An expanding spectrum 
of normative behaviors combined with access to medicinal opioids have thus 
largely catalyzed an upsurge in consumption. (Other factors that are beyond 
the scope of this discussion have also been influential.) Medicines do not 
carry the negativity associated with heroin, hence they most often comprise 
the first type of opioid consumed by the majority of individuals who subse-
quently become addicted. Among all illegal drugs, opioid use by youths ranks 
second only to cannabis.

The first national legislation aimed at curtailing opioids and cocaine use 
was the Harrison Act in 1914. This statute initially mandated obtaining a 
license to sell these drugs, but subsequently morphed into a prohibition law. 



58 Ralph E. TaRTER, GERald CoChRan, and MauREEn REynolds

The Volstead Act, which prohibited the manufacture, distribution, and con-
sumption of alcohol, was passed five years later. Attempts to deter the con-
sumption of alcohol and other addictive substances for the past century have 
been primarily effected through laws enforced by specialized departments 
in the federal government such as the Food and Drug Administration, the 
Bureau of Alcohol, Tobacco, Firearms, and Explosives, and the Drug Enforce-
ment Agency.

Within the guise of protecting public safety, prevention of addiction and 
prodromal consumption has emphasized control of drug supply. However, 
because addiction is essentially defined as compulsive drug seeking, it is clear 
that emphasis must also be given to reducing demand. Policies aimed at pre-
venting consumption solely by eliminating or controlling supply will meet 
certain failure because individuals with intense demand (compulsive urge to 
consume the drug) constitute a reliable profitable consumer market for nefari-
ous manufacturers and distributors.

The American Psychiatric Association officially designated addiction as a 
mental disorder upon publication of the second edition of the Diagnostic and 
Statistical Manual in 1968. The Supreme Court first ruled in 1963 (Robinson 
v. California) that addiction was a disease, asserting that the Eighth Amend-
ment of the Constitution (“cruel and unusual punishment”) protects narcotic 
addicts from incarceration. Nevertheless, to this day a substantial portion of 
the U.S. prison population is serving long sentences connected to alcohol and/
or drug addiction. The point to be made is that shifting focus from reducing 
supply to lowering demand also requires a shift from a legal/regulatory frame-
work of prevention to a health framework.

Accordingly, reducing demand for drugs can best be cost- efficiently con-
ducted within a comprehensive health delivery system. The infrastructure 
and expertise required to provide age- appropriate interventions, spanning 
gestation to old age, are established. Considering that up to 20% of the U.S. 
population will develop addiction at some time in life, often with severe mani-
fold co- occurring diseases, shifting emphasis to prevention is consistent with 
the mission of health providers. However, this shift in intervention resources 
to prevention must accommodate financial concerns, specifically the loss of 
future revenue accrued from treatment services.

A proposed solution is to fund all addiction services from a dedicated 
fund accrued from a small levy on all substances that have empirically docu-
mented addictive properties. In addition to prescription analgesics, stimu-
lants, anxiolytics, and hypnotics, this tax would extend to nonprescription 
“nutrition” supplements, proprietary medicines, alcohol, and nicotine prod-
ucts. One immediate benefit of a dedicated tax is that it focuses attention on 



Prevention of Opioid Addiction 59

addiction, which, with respect to opioids, constitutes a recently designated 
national emergency. From the practical perspective, tax on the addictive agent 
is insurance for the consumer; namely, it ensures that intervention for addic-
tion and concomitant medical conditions will be available. In 2016, almost 
45% of the U.S. population over 12 years of age used a prescribed psycho-
therapeutic drug having addictive properties. Hence, a one- penny tax on each 
dose, costing up to three dollars/month, would fund most, if not all, addiction 
prevention and treatment services.

Lastly, it should be noted that treatment of opioid addiction is largely, and 
not infrequently entirely, confined to long- term (i.e., lifetime) consumption 
of an opioid. The benefits of “medication-a ssisted treatment” have been well 
documented; however, lifetime opioid use for the purpose of forestalling crav-
ing and withdrawal is not recovery. Because secondary and tertiary prevention 
may require intensive and potentially long- term intervention, vacated facili-
ties, including former state psychiatric hospitals, can be repurposed.

In conclusion, progress in addiction prevention is contingent on: (1) a 
shift in emphasis away from law enforcement to health promotion; (2) lead-
ership by elected officials to provide stable funding for services throughout 
life in a health delivery system; and (3) expansion of educational resources, 
especially advanced degrees and training in prevention science and practice. 
It is increasingly obvious that it is not possible to incarcerate all offenders 
or provide treatment at pace with the growing addiction prevalence. Shift-
ing resources to prevention is the only policy and practical option. From two 
centuries of public health experience, there is reason to be optimistic that it is 
feasible to prevent opioid and other addictions.

REFERENCES

Cochran, G., J. Rubenstein, J. Bucci, T. Ylioja, and R. Tarter. 2015. “Screening Community 
Pharmacy Patients for Opioid Misuse.” Journal of Addiction Medicine 9 (September/
October): 411–416.

Dirckx, J. 2001. Stedman’s Concise Medical Dictionary for the Health Professions. 4th ed. 
Baltimore: Lippincott, Williams and Wilkins.

Fields, H. L. 2011. “The Doctor’s Dilemma: Opiate Analgesics and Chronic Pain.” Neuron 
69 (February): 591–594.

Horner, M., B. Braxter, L. Kirisci, and R. Tarter. 2015. “Temperament Disturbances in 
Infancy Progress to Substance Use Disorder 20 Years Later.” Personality and Indi-
vidual Differences 82 (August): 96–101.

Kandel, D., and K. Yamaguchi. 1999. “Developmental Stages of Involvement in Substance 
Use.” In Sourcebook on Substance Abuse: Etiology, Epidemiology, Assessment, and 
Treatment, eds. P. Ott, R. Tarter, and R. Ammerman. Boston: Allyn & Bacon, 50–74.

Kendler K. S., K. C. Jacobson, C. A. Prescott, and M. C. Neale. 2003. “Specificity of 
Genetic and Environmental Risk Factors for Use and Abuse/Dependence of Can-



60 Ralph E. TaRTER, GERald CoChRan, and MauREEn REynolds

nabis, Cocaine, Hallucinogens, Sedatives, Stimulants, and Opiates in Male Twins.” 
American Journal of Psychiatry 160 (April): 687–695.

Kirisci, L., and R. Tarter. 2001. “Psychometric Validation of a Multidimensional Schema 
of Substance Use Topology: Discrimination of High and Low Risk Youth and Predic-
tion of Substance Use Disorder.” Journal of Child and Adolescent Substance Abuse 10 
(June): 23–33.

Kirisci L., R. Tarter, A. Mezzich, T. Ridenour, M. Reynolds, and M. Vanyukov. 2009. “Pre-
diction of Cannabis Use Between Childhood and Young Adulthood: Clarifying the 
Phenotype and Environtype.” American Journal on Addictions 18 (February): 36–47.

Krueger, R., B. Hicks, C. Patrick, S. Carlson, W. Iancono, and M. McGue. 2002. “Etiologi-
cal Connections Among Substance Dependence, Antisocial Behavior, and Personal-
ity: Modeling the Externalizing Spectrum.” Journal of Abnormal Child Psychiatry 111 
(August): 411–424.

Tarter, R., M. Vanyukov, L. Kirisci, M. Reynolds, and D. Clark. 2006. “Predictors of Mari-
juana Use in Adolescents Before and After Licit Drug Use: Examination of the Gate-
way Hypothesis.” American Journal of Psychiatry 163 (December): 2134–2140.

Tsuang, M. T., M. J. Lyons, J. M. Meyer, T. Doyle, S. A. Eisen, J. Goldberg, W. True, N. Lin, 
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55 (November): 967–972.

Vanyukov, M., L. Kirisci, H. Moss, R. Tarter, M. Reynolds, B. Maher, G. Kirillova, T. Rid-
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Ralph E. Tarter is professor of pharmaceutical sciences at the University of Pittsburgh, 
where he also has secondary appointments in the Department of Psychology and the 
Clinical Translational Sciences Institute. From 1989–2017, he directed the Center for 
Education and Drug Abuse Research (CEDAR) funded by the National Institute on Drug 
Abuse. His research has focused on the genetic, biological, and psychological vulnerability 
to addiction, including development of evaluation tools to detect high- risk children and 
adolescents.

Gerald Cochran is associate professor and associate dean for research in the School of 
Social Work at the University of Pittsburgh. He earned his Ph.D. from The University 
of Texas at Austin School of Social Work and completed postdoctoral training with the 
Johns Hopkins School of Medicine, Department of Psychiatry and Behavioral Sciences. 
His area of expertise involves identifying and studying appropriate care for underserved 
populations in health care settings, with particular emphasis on individuals who misuse 
drugs and alcohol. Current interests and publications pertain to evaluating the utility of 
the pharmacy setting for detection of hazardous prescription opioid use.

Maureen Reynolds is associate professor of pharmaceutical sciences at the University 
of Pittsburgh. From 2000–2017, she was administrator of the Center for Education and 
Drug Abuse Research (CEDAR). Her scholarly publications have focused on diverse top-
ics related to addiction etiology within a developmental perspective. Her current work, 
funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), 
is directed at training health professionals to use SBIRT (Screening, Brief Intervention 
and Referral to Treatment) for evaluating harmful substance use among their patients.


	Structure Bookmarks
	Etiology of Addiction
	Lifespan Perspective of Opioid Addiction Etiology
	Prevention in Context of Politics and Policy
	REFERENCES




