Last Thursday, Pocahontas County preventionists, social workers, mental health coaches, school officials and community members attended the much anticipated seminar with Alfgeir Kristjansson, PhD, MSc, who spoke about the model implemented in Iceland to eradicate substance abuse among teens.
Kristjansson is an associate professor with the West Virginia University School of Public Health and a senior researcher for ICSRA at Reykjavik University in Iceland.
In the 1990s, the substance abuse among teens in Iceland was overwhelming and, at its wits’ end, the country chose to be proactive by finding ways to prevent teens from using substances, thereby helping to eradicate the problem. The Iceland Model was created more than 20 years ago and, today, teen substance abuse has decreased immensely.
Drawing from Iceland’s success, Kristjansson has started to spread awareness about the model in West Virginia in hopes it will help teens here, as well.
The first step is to define the types of prevention and the best uses of each type, Kristjansson said. The three types of prevention are primary, secondary and tertiary.
“When we do prevention – that’s in the sense of primary prevention – it’s usually long term,” he said. “Oftentimes, it’s community-based or works within organizations like schools, worksites, so on. With that primary prevention, we’re trying to prevent anything from starting, which means we have to understand what the risk and the factors for the initiation are or otherwise, we don’t have anything to work with.
“Secondary prevention is typically what we call behavior change models,” he continued. “The most typical secondary prevention is, for example, smoke cessation programs. People are already using, but they may not necessarily be sick from their use, yet. We’re trying to mitigate and transfer them and change their ways throughout their use.
“Tertiary prevention is when we have mitigating life-threatening situations and we’re trying to save people,” he added. “That is essentially how our healthcare system works – which is much better labeled a sick care system. We’re trying to prolong life when people already have serious problems.”
For too long, the focus has been on tertiary prevention and not implementation of all three at the same time.
“You think about prevention as a stream – like a river stream,” Kristjansson said. “We sit at the end of the stream, and we wait for people to come down. At the end of the stream, they come down with all the problems that they have caused and have been subjected to. You know for each addict, there’s a broken family. There are all kinds of things that have been lost along the way. There are all kinds of things that have happened that are really detrimental to society.
“We spend more than ninety percent of our resources in the care section on tertiary care – when we use prevention and operate in a tradition that way, we are really doing what is least effective, population-wise, and we are really creating a much bigger problem than it necessarily has to be.”
With the Iceland Model or what Kristjansson calls it for West Virginia – The Integrated Community Engagement (ICE) Collaborative – the focus will be on primary prevention for the entire population of children for an extended period of time.
“We did not want to wait at the end of the stream,” he said. “We had been using the traditional ways of prevention with kids and they simply weren’t working.”
The prevention begins with understanding why children begin using substances in the first place.
Kristjansson said there are three potential scenarios with only one that is most likely to happen. The first is that a child makes a conscious decision one day to just begin using substances; the second is that a child is forced to take substances; and the third and most likely, is that a child turns to substances because they are a part of that child’s social life.
“The most likely scenario is that the individual makes an unconscious decision in the context of peers and social circumstances that favor drug use,” Kristjansson said. “That is almost always what happens. Kids that initiate drug use do it inside the peer group, if the norms around them are okay with them starting early. I’m not talking about opioids necessarily. I’m just talking about tobacco and alcohol, because when kids start early using tobacco and alcohol, they are most likely to pick up these other things.”
One of the reasons substance abuse among teens was so high in Iceland, Kristjansson explained, is that it was a social norm for 13-year-olds to celebrate their birthdays with their parents by drinking alcohol. From there, it would increase to where students were getting drunk or “smashed” before going to school events, and no one would intervene.
In a study of European countries in the late 1990s, Iceland was ranked fifth in drunkenness – 10 times or more often in the last 12 months among boys and girls – and fifth in the number of children who had been drunk for the first time before the age of 13.
While the Iceland Model was a success story, there were many lessons learned throughout its implementation.
“First of all, substance abuse risk is not randomly distributed among the population,” Kristjansson said. “It’s not just random. Everyone is just as equal to starting. We know that very well. Secondly, behavior change is notoriously difficult. There are no quick fixes and simple solutions for substance abuse prevention. Short term programs are not very likely to lead to population change. We need a longer and much more consistent type of change.”
The key to the Model is collaboration between the researchers, the practitioners who work with the students and the policymakers who provide funding for the programs implemented through the Model.
It begins and ends in the community, because, as Kristjansson said, the students spend more than 90 percent of their time in the local community, the county or the state.
“The Icelandic Model that we call the ICE Collaborative in West Virginia, is a primary prevention,” he said. “The main focus is on changing adolescent social environment. Our belief is that kids are largely products of their social environment. We’re not trying to change individuals, we’re trying to change the environment because the environment produces the individuals.”
It took nearly two decades to make a drastic change in Iceland, and Kristjansson shared the results from the study done on students in eighth, ninth and tenth grades.
“In 1998, the proportion of tenth grade students in Iceland that had been drunk in the past month [prior to the evaluation] was forty-two percent,” he said. “Almost every other child. That ratio is six percent today. Twenty-three percent were daily tobacco smokers. That’s one percent today. Seventeen percent had used marijuana or cannabis substances. That’s six percent today.”
Between 2011 and 2019, the numbers plateaued, but Kristjansson said it wasn’t because the program was failing, it was because the children in the later years had grown up during the time of the study and the environment and peer system was completely different for them than for those at the beginning of the study.
While West Virginia will be different from Iceland in terms of programs implemented to prevent substance use, Kristjansson said the results can be the same as long as the community, practitioners and parents get involved and help children see that substance abuse is not the right stream for them.