Publication: American Journal of Psychiatry – 15 January 2024

Despite having made some strides with respect to reducing adolescent drinking rates, substance use disorder (SUD) rates are significantly above national targets for health promotion and disease prevention in Canada and the United States (1–5). These data suggest that there is a pressing need for more targeted intervention strategies designed to help those most at risk of transitioning to SUD. Recent national surveys suggest an alarmingly high prevalence of SUD in the general population (16.5%), with the highest rates reported among young adults, and approximately 9% of the adolescent population screened positive for past-year SUD (1–3). There is also an ongoing crisis of nonmedical prescription drug use in North America, as indicated by the dramatic increase in the prevalence of past-year prescription drug misuse and overdose deaths from 2003 to 2022 (1, 2) and the disproportionate growth of hospitalizations due to opioids among individuals 15–24 years of age (1–4). Furthermore, only ∼5% of respondents who report symptoms of SUD report having received any treatment for their SUD (1). As highlighted in numerous reports (5–9), including the U.S. Surgeon General’s 2016 report on addiction (2), evidence-based upstream solutions that prevent transition to SUD are desperately needed, considering the scale and severity of these public health concerns.

Most school-based prevention programs are universal and use some combination of alcohol and drug awareness, testimonials, flyers, brochures, peer education, and alcohol/drug-free activities. These have been shown to have weak positive or even negative effects (10, 11), but programs that promote general coping and drug-refusal skills are more promising (2, 10, 12, 13). One possible contributing factor to poor outcomes of many prevention programs is that they target generic factors implicated in normal drinking and drug experimentation and fail to target factors linked to risk for the development of more severe substance use problems (2, 10, 14–18), despite well-supported evidence for robust predictors of substance use and misuse across several sociodemographic contexts (2). New approaches to prevention are needed that translate research on addiction vulnerability to personalized prevention and early intervention (2).

Longitudinal and machine learning prediction strategies have highlighted the role of both externalizing and internalizing traits in future risk for substance misuse (19–23). A recent review suggests that distinct personality traits are related to risk for substance misuse through different motivational and cognitive risk profiles (23). Impulsivity and its cognitive correlate, poor response inhibition, appear to be specifically associated with conduct problems and misuse of stimulants (including prescription stimulant medications); sensation seeking and its neurocognitive correlate, reward sensitivity, are more associated with alcohol and cannabis misuse (2, 20–23). Anxiety sensitivity and hopelessness have been shown to be associated with risk for internalizing problems and preferential use/misuse of depressant drugs, such as alcohol, sedatives, and opioids (19, 20, 24–26).

The PreVenture Program is a brief (two group sessions) school-based cognitive-behavioral program focusing on building personality-specific skills and self-efficacy to reduce need on the part of a young person to use substances as a way to cope with interpersonal or intrapersonal challenges associated with each personality trait (27, 28). Given research indicating that different neurocognitive profiles mediate the relationship between specific personality factors and concurrent mental health conditions (22–26), the program focuses on promoting personality-specific cognitive-behavioral skills (e.g., skills relevant to the management of poor response inhibition for teens who report high levels of impulsivity vs. skills relevant to the management of global negative attributional styles for teens who report high levels of hopelessness). Numerous randomized trials have shown that the program is effective in reducing alcohol and drug use and mental health symptoms by a notable 30%–80% among secondary students (13–17, 21, 27, 28). However, this approach has yet to be shown to prevent transition to SUDs, which is critical when informing comprehensive drug prevention and health promotion strategies.

As a primary outcome, this longitudinal cluster-randomized controlled trial examined the impact of personality-targeted preventive interventions in reducing risk for SUD in adolescents over a 5-year period (18). It is becoming increasingly recognized that treatment outcome research should focus on pragmatic outcomes to facilitate the translation of research findings to policy and practice, and this was an important aim of the present study. Therefore, in consultation with local stakeholders, we selected a validated measure of SUD that is used to screen for SUD and to guide the delivery of SUD interventions in schools throughout the region in which the study was conducted. The primary research hypothesis was that relative to a control condition, the intervention would be associated with a reduced risk of transitioning to SUD by the end of high school among youths who report personality risk factors. Secondary outcomes examined the intervention effects on mental health outcomes in the 4 years after the intervention.