Substance-Abuse

=Substance Abuse =

**FACILITATORS: Lauren Gruber, Maura Anzia**




 * **Contents**
 * Learner Objectives
 * Required Readings and Websites
 * Healthy People 2020 Objective
 * Related Epidemiological Data
 * Screening Guidelines and Assessment Parameters
 * Behavioral Intervention Recommendations
 * Discussion of Intervention Efficacy ||


 * ====Analyze how substance abuse impacts Healthy People 2020 Objectives====
 * ====Compare and contrast approaches to screening, counseling, and immunization across the lifespan for individuals impacted by substance abuse====
 * ====Use USPSTF screening and immunization recommendations for people at risk due to substance abuse====
 * ====Identify behavior interventions best suited to individuals and communities====
 * ====Analyze efficacy of interventions====
 * ====Engage in moderated discussion to display mastery of objectives and content knowledge====

 Required readings and Websites »

 * [|CDC: Persons Who Use Drugs]
 * [|National Institute on Alcohol Abuse and Alcoholism]
 * [|Substance Abuse and Mental Health Services Administration]
 * [|USPSTF website to identify appropriate prevention interventions].
 * McDaniel, Campbell, Hepworth, Lorenz (2005). Chapter 21: When drinking or drugs is part of the problem: A family approach to the detection and management of substance use and abuse.
 * Sussman, S. (2011). Preventing and treating substance abuse among adolescents. //Prevention Researcher, 18(2), 3-7.//
 * [[file:NCIPC_FactSheets_PPO_v7.pdf]] Preventing Prescription Painkiller Overdoses
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Recommended Materials

 * [|National Institute on Drug Abuse (2011): Drug Abuse and the Link to HIV/AIDS and Other Infectious Diseases]
 * [|College Drinking Prevention]
 * [|Rethinking Drinking]
 * media type="youtube" key="vy_BhFiBP-w" width="425" height="350"

Healthy People 2020 Objectives »
There are multiple relevant Healthy People 2020 Objectives relating to substance abuse. Three of these objectives are:
 * Increase the proportion of adolescents never using substances
 * Reduce the proportion of persons engaging in binge drinking of alcoholic beverages
 * Reduce the past-year nonmedical use of prescription drugs

Other objectives can be found at [|Healthy People 2020]

**What's a Standard Drink?**

(shown in a 12-oz glass) || ** = ** || 5 fl oz of (such as sherry or port; 3.5 oz shown) || ** = ** || 2-3 oz of (2.5 oz shown) || ** = ** || 1.5 oz of (a single jigger or shot) || ** = ** || 1.5 fl oz shot of ("") ||
 * 12 fl oz of
 * regular beer** || ** = ** || 8-9 fl oz of
 * malt liquor**
 * table wine** || ** = ** || 3-4 oz of
 * fortified wine**
 * cordial, liqueur, or aperitif**
 * brandy**
 * 80-proof spirits**
 * [[image:http://rethinkingdrinking.niaaa.nih.gov/images/graphic_beer.jpg width="45" height="84" caption="12 fl oz of regular beer - about 5% alcohol"]] ||  || [[image:http://rethinkingdrinking.niaaa.nih.gov/images/graphic_maltliquor.jpg width="56" height="101" caption="8 - 9 fl oz of malt liquor in a 12 oz glass - about 7% alcohol"]] ||   || [[image:http://rethinkingdrinking.niaaa.nih.gov/images/graphic_tablewine.jpg width="45" height="120" caption="5 fl oz of table wine - about 12% alcohol"]] ||   || [[image:http://rethinkingdrinking.niaaa.nih.gov/images/graphic_fortifiedwine.jpg width="42" height="115" caption="3-4 oz of fortified wine - about 17% alcohol"]] ||   || [[image:http://rethinkingdrinking.niaaa.nih.gov/images/graphic_cordial.jpg width="39" height="86" caption="2-3 oz of cordial, liquer, or aperitif - about 24% alcohol"]] ||   || [[image:http://rethinkingdrinking.niaaa.nih.gov/images/graphic_brandy.jpg width="46" height="64" caption="1.5 oz of brandy (a single jigger) - about 40% alcohol"]] ||   || [[image:http://rethinkingdrinking.niaaa.nih.gov/images/graphic_spirits.jpg width="78" height="61" caption="1.5 fl oz shot of 80-proof spirits ('hard liquor' - whiskey, gin, rum,, vodka, tequila, etc.) - about 40% alcohol"]] ||
 * about 5% alcohol ||  || about 7% alcohol ||   || about 12% alcohol ||   || about 17% alcohol ||   || about 24% alcohol ||   || about 40% alcohol ||   || about 40% alcohol ||

Related Epidemiological Data »
In the United States, alcohol, marijuana, non-medical use of prescription drugs, and illicit drug use are evident concerns. In 2009, 8.7% of people 12 years and older reported using an illicit drug in the past month, 6.6% of people 12 years and older reported using marijuana, and 2.8% reported non-medical use of any psychotherapeutic drug (Center for Disease Control and Prevention (CDC), 2010).

The numbers for alcohol, however, are much higher. In 2009, past month use of alcohol was reported by 51.9% of the population, binge alcohol use was reported by 23.7% of the population, and heavy alcohol use was reported by 6.8% of the population (CDC, 2010). The National Institute of Drug Abuse (NIDA) (2011) identified that approximately 30.2 million people (12 percent) over the age of 12 reported driving under the influence of alcohol at least once in 2009. The age distribution of alcohol users was fairly even after the age of 18, but reported binge drinking was more common between 18 and 34. Among high school students, however, both alcohol use and binge drinking have decline, though the numbers are still high (NIDA, 2011).

The reported illicit drug, marijuana, and non-medical prescription drug use were consistently higher between the ages of 16 and 25. Across the board, more males reported using substances than females (CDC, 2010). Non-medical prescription and over-the-counter medications accounted for a large portion of drugs used by 12th graders in 2009 (NIDA, 2011).

Marijuana use increased among high school students in 2009 to reach the highest point (6.1%) since the early 1980s. The perception of risk relating to marijuana decreased among high school students, indicating a potential future trend of increasing rates of marijuana use (NIDA, 2011).

Non-medical prescription and over-the-counter medications accounted for a large portion of drugs used by 12th graders in 2009. Non-medical Vicodin use is at 8% among 12th graders, while Adderall is at 6.5% and over-the-counter cough medicines are at 6.6% (NIDA, 2011).

<span style="font-family: Verdana,Geneva,sans-serif;"> <span style="font-family: Verdana,Geneva,sans-serif;"> <span style="font-family: Verdana,Geneva,sans-serif;">
 * 2004 Reported Alcohol Use By State in Ages 12 and Up (Substance Abuse and Mental Health Services Administration (SAMHSA), 2005)
 * 2004 Reported Binge Alcohol Use By State in Ages 12 and Up (SAMHSA, 2005)
 * <span style="font-family: Verdana,Geneva,sans-serif;">2004 Reported Marijuana Use By State in Ages 12 and Up (SAMHSA, 2005)
 * <span style="font-family: Verdana,Geneva,sans-serif;">2004 Reported Illicit Drug Use By State in Ages 12 and Up (SAMHSA, 2005)
 * <span style="font-family: Verdana,Geneva,sans-serif;">2004 Reported Non-medical Pain Reliever Use By State in Ages 12 and Up (SAMHSA, 2005)


 * Substance Abuse and Transmission of HIV/AIDS, Hepatitis B and C, and Tuberculosis**

Drugs that are taken through injection, such as heroin, provide a strong risk for the contraction of human immunodeficiency virus (HIV). It is common knowledge that sharing needles or using dirty needles can lead to transmission of diseases that are transmitted through blood or body fluids, such as HIV and hepatitis C. However, an even larger concern for drug abusers is that drug use impairs judgment and can lead to risky sexual behavior that puts them at risk for contraction of sexually transmitted diseases. Furthermore, substance abuse facilitates the progress of HIV by compromising the immune system (NIDA, 2011). HIV was found to cause greater cognitive impairment in drug users when compared with non-drug users due to the impact of drug use on HIV progression (NIDA, 2011). Data from 2005 to 2009 found that 64% of individuals with HIV had used an illicit drug, but not intravenously, and only 19% of people with HIV reported never using an illicit drug. In 2009, 25% of individuals with HIV reported using alcohol or drugs at a level that required treatment (NIDA, 2011).

Other infectious diseases, such as Hepatitis B (HBV) or C (HCV) and Tuberculosis (TB) also can result from intravenous drug use. It was found that up to 90% of intravenous drug users with HIV may also be infected with HCV (NIDA, 2011). TB, on the other hand, has been declining in the United States for many years. However, more recently, the decline of TB has slowed by half and is clearly linked with HIV and drug abuse (NIDA, 2011).

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">Screening Guidelines and Assessment Parameters »
The **American Medical Association** (AMA) recommends that clinicians screen all adolescents for:
 * Eating Disorders
 * Sexual Activity
 * **Alcohol and Other Drug Use**
 * **Tobacco Use**
 * School Performance
 * Depression
 * Risk for Suicide

The **United States Preventive Services Task Force** (USPSTF) recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings.

The following are USPSTF recommendations related to substance abuse:
 * Grade A Recommendation: provide these services
 * HIV Screening: Adults and Adolescents at increased risk
 * Chlamydia: Screening-women ages 24 and younger or 25 and older at increased risk
 * Syphilis: Screening- Men and women at increased risk
 * Grade B Recommendation: provide these services
 * Alcohol Misuse: Screening and Behavioral counseling for men, women, and pregnant women
 * Depression Screening: Adults 18 and older, when staff-assisted depression care supports are in place
 * Sexually Transmitted Infections Behavioral Counseling: Sexually active adolescents and adults at increased risk
 * Gonorrhea: Screening- pregnant women and women at increased risk
 * Grade C Recommendation: Uncertain
 * Hepatitis C Screening: Men and women at increased risk
 * Grade D Recommendation: Do not provide
 * Genital Herpes: Screening- adolescents and adults; asymptomatic
 * Hepatitis B: Screening- asymptomatic men and women
 * Hepatitis C: Screening- asymptomatic men and women
 * Syphilis:Screening- asymptomatic men and women


 * National Guideline Clearinghouse**: Screening, Diagnosis, and Referral for Substance Abuse Disorders (2011)
 * Objective:
 * To achieve significant, measurable improvements in the screening and managing of substance use disorders through the development and implementation of common evidence-based clinical practice guideline
 * Valid Screening Tools:
 * =====<span style="background-color: #ffffff; color: #333333; font-family: Verdana,Helvetica,Arial,sans-serif; font-size: 11px;">Alcohol Use Disorders Identification Test [AUDIT} =====
 * =====<span style="background-color: #ffffff; color: #333333; font-family: Verdana,Helvetica,Arial,sans-serif; font-size: 11px;">Michigan Alcohol Screening Test [MAST] or MAST-Geriatric [MAST-G] =====
 * =====<span style="background-color: #ffffff; color: #333333; font-family: Verdana,Helvetica,Arial,sans-serif; font-size: 11px;">CAGE Survey =====
 * =====<span class="FT_highlight" style="background-color: #ffffff; color: #333333; font-family: Verdana,Helvetica,Arial,sans-serif; font-size: 11px;">Substance Abuse <span style="background-color: #ffffff; color: #333333; font-family: Verdana,Helvetica,Arial,sans-serif; font-size: 11px;"> Subtle Screening Inventory [SASSI] =====
 * =====<span style="background-color: #ffffff; color: #333333; font-family: Verdana,Helvetica,Arial,sans-serif; font-size: 11px;">Tolerance, Worried, Eye-opener, Amnesia, and Cut down [TWEAC; for pregnant women] =====
 * =====<span style="background-color: #ffffff; color: #333333; font-family: Verdana,Helvetica,Arial,sans-serif; font-size: 11px;">Drug <span class="FT_highlight" style="background-color: #ffffff; color: #333333; font-family: Verdana,Helvetica,Arial,sans-serif; font-size: 11px;">Abuse <span style="background-color: #ffffff; color: #333333; font-family: Verdana,Helvetica,Arial,sans-serif; font-size: 11px;"> Screening Test [DAST] =====
 * Diagnosis:
 * Assessment of symptoms and behaviors
 * Management:
 * =====<span style="background-color: #ffffff; color: #333333; font-family: Verdana,Helvetica,Arial,sans-serif; font-size: 11px;">Patient education =====
 * =====<span style="background-color: #ffffff; color: #333333; font-family: Verdana,Helvetica,Arial,sans-serif; font-size: 11px;">Counseling =====
 * =====<span style="background-color: #ffffff; color: #333333; font-family: Verdana,Helvetica,Arial,sans-serif; font-size: 11px;">Referral, if appropriate =====
 * =====<span style="background-color: #ffffff; color: #333333; font-family: Verdana,Helvetica,Arial,sans-serif; font-size: 11px;">Pharmacological management =====
 * =====<span style="background-color: #ffffff; color: #333333; font-family: Verdana,Helvetica,Arial,sans-serif; font-size: 11px;">Follow-up =====

Assessment for Alcohol Abuse:
 * In the past year, has a patient’s drinking caused
 * Risk of Bodily Harm
 * Relationship Trouble
 * Role Failure
 * One or more indicates alcohol abuse
 * In the past year, has a patient
 * Not been able to cut down or stop
 * Not been able to stick to drinking limits
 * Shown tolerance
 * Shown signs of withdrawal
 * Kept drinking despite problems
 * Spent a lot of time drinking
 * Spent less time on other matters
 * Three or more indicate alcohol dependence


 * (National Institute on Alcohol Abuse and Alcoholism, 2005)

Assessment for Drug Abuse:
 * In the past year, how often has the patient
 * used prescription drugs for non-medical reasons
 * used illegal drugs
 * The risk increases with the frequency of use


 * (National Institute on Drug Abuse and Addiction, 2010)

Immunization Guidelines for Adults (CDC, 2012):

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">Behavioral Intervention Recommendations »
<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Persons Who Use Drugs** <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">CDC (2011) recommends the following interventions for Persons Who Use Drugs (PWUD):


 * 1) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Behavioral interventions: aimed at reducing sexual and injection transmission of HIV/AIDS
 * 2) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Outreach: community outreach and street level outreach provides PWUD with prevention and risk reduction, testing, and referral services
 * 3) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Safe Syringe Practices
 * 4) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Syringe disinfection by PWUD works against HIV, Hepatitis B, and Hepatitis C, decreasing the chance of transmission. Disinfection does not, however, sterilize syringes.
 * 5) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Sterile syringes decrease disease transmission and can be acquired through pharmacy purchase, physician prescription, and syringe exchange programs. Congress has banned federal funding to any program distributing of sterile syringes to PWUD since 1988. The possession of syringes is prohibited by many cities and states making the acquisition of sterile syringes difficult.
 * 6) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Safe syringe disposal
 * 7) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Testing and Vaccines
 * 8) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Persons at high risk for HIV infection, including PWUD, should be screened at least annually
 * 9) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">HPV Vaccination (age 13-26 for catch up vaccination)
 * 10) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Hepatitis A Vaccine for users of injection and non-injection illicit drugs
 * 11) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Routine testing for chronic hepatitis B virus
 * 12) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Hepatitis B Vaccination in adulthood if reporting risk factors for infection including PWUD
 * 13) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Hepatitis C screening regularly and treatment
 * 14) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Testing for latent tuberculosis infection: injection drug use is associated with latent TB infection progressing to TB disease
 * 15) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Drug Overdose Prevention
 * 16) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Integrated guidelines: provide the most comprehensive services to the broadest population

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**A CDC (2011) Recommended Change in language regarding addition from Unrealistic to Realistic** ** e ** eliminate drug use recovered cured forever on my own one-shot treatment relapse is unacceptable ||= **TO** reduce or stop drug use in recovery treated and controlled one day at a time with help ongoing process relapse happens ||
 * = **FROM**

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Principles of Effective Drug Addiction Treatment** <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The National Institutes of Health National Institute on Drug Abuse (NIDA) (2009) has developed a research-based guide delineating the principles of effective drug addiction treatment. The following are the identified treatment principles:
 * 1) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Addiction is a complex but treatable disease that affects brain function and behavior
 * 2) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">No single treatment is appropriate for everyone
 * 3) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Match setting, intervention, and services to the individual
 * 4) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Treatment needs to be readily available
 * 5) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Effective treatment attends to multiple needs of the individual, not just his or her drug use
 * 6) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Address drug abuse
 * 7) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Address medical, psychological, social, vocational, and legal issues
 * 8) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Adapt to age, gender, ethnicity, and culture
 * 9) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Remaining in treatment for an adequate period of time is critical
 * 10) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">Depends on type or degree of his or her problems or needs
 * 11) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">A minimum of 3 months is typically required to significantly reduce or stop drug use
 * 12) <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;"><span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The best outcomes occur with longer treatment duratio n
 * 13) ====Counseling- group and/or individual- and other behavioral therapies are the most commonly used forms of drug abuse treatment====
 * 14) ====Outpatient behavior treatments====
 * 15) ====Cognitive-behavioral therapy: patients recognize, avoid, and cope with situations in which they are likely to abuse drugs====
 * 16) ====Multidimensional family therapy: for adolescents with drug problems and their families====
 * 17) ====Motivational interviews: looks at readiness for change====
 * 18) ====Motivational incentives: positive reinforcement====
 * 19) ====Residential treatment====
 * 20) ====Typically 6-12 months====
 * 21) ====Use of community====
 * 22) ====Treatment within the criminal justice system====
 * 23) ====Medications are an important aspect to of treatment for many patients, especially when combined with counseling or other behavioral therapies====
 * 24) ====Medications can be used to minimize withdrawal symptoms====
 * 25) ====Medications for opiod addiction====
 * 26) ====Methadone====
 * 27) ====Buprenorphine====
 * 28) ====Naltrexone====
 * 29) ====Medications for alcohol addiction====
 * 30) ====Naltrexone====
 * 31) ====Acamprosate====
 * 32) ====Disulfiram====
 * 33) ====An individuals treatment and services plan must be assessed continually and modified as needed in order to meet the changing needs of the patient====
 * 34) ====Many drug-addicted individuals also have mental health disorders requiring treatment====
 * 35) ====Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long term drug abuse====
 * 36) ====Treatment does not have to be voluntary to be effective====
 * 37) ====Drug use during treatment must be monitored continuously====
 * 38) ====Treatment programs need to assess patients for HIV/AIDS, hepatitis B and C, tuberculosis, and other infections diseases as they are part of an at risk population as well as provide targeted risk-reduction counseling to help patients modify or change behaviors placing them at increased risk for contracting an infectious disease====

**Community Intervention**
====According to the Community Preventive Services Task Force (2011), there are steps communities can take in order to prevent excessive alcohol consumption. The following are intervention recommendations.====
 * 1) ====Dram shop liability: allows owners and servers of retail alcohol establishments to be be held legally responsible for harms caused by recently served customers====
 * 2) ====Increasing alcohol taxes====
 * 3) ====Maintaining limits on days of sales: state and local laws apply====
 * 4) ====Maintaining limits on hours of sales: state and local laws apply====
 * 5) ====Over-service law enforcement initiatives: proactive community efforts to increase the enforcement of laws prohibiting the sale of alcohol to already intoxicated customers====
 * 6) ====Privatization of retail alcohol sales: repeal of government control over alcohol sales====
 * 7) ====Regulation of alcohol outlet density====
 * 8) ====Responsible beverage service training: education of staff of retail establishments====
 * 9) ====Enhanced enforcement of laws prohibiting sales to minors====

**USPSTF Efficacy Grading**
<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The United States Preventive Services Task Force (USPSTF) grades the recommendations it provides. The grading system also includes suggestions for practice. Grades are A, B, C, D, and I. The following table displays the differing grades and the associated recommendations provided by the USPSTF (USPSTF, 2007).

The USPSTF (2007) also derives levels of certainty regarding net benefit for each recommendation. The levels of certainty are high, moderate, or low and reflect the amount and quality of evidence related to the recommendation.
 * GRADE || DEFINITION || SUGGESTION FOR PRACTICE ||
 * A || The USPSTF recommends the service. There is high certainty that the net benefit is substantial. || Offer or provide this service. ||
 * B || The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. || Offer or provide this service. ||
 * C || The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small. || Offer or provide this service only if other considerations support the offering or providing the service in an individual patient. ||
 * D || The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. || Discourage the use of this service. ||
 * I || The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. || Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms. ||

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**CDC Intervention Recommendations** <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The CDC is a government sponsored entity. As such, its recommendations garner respect from clinicians. There is a multitude of evidence both statistical and research based supporting the recommendations of the CDC (CDC, 2011). This verifies their efficacy.

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**NIDA Effective Treatment Principles** <span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The Effective Treatment Principles derived by the National Institutes of Health through NIDA are research-based. As such, there is adequate evidence supporting their efficacy (NIDA, 2009).

<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">**Community Intervention** ====<span style="font-family: Verdana,Geneva,sans-serif; font-size: 110%;">The community interventions suggested by the Community Preventive Services Task Force (CPSTF) have varying levels of efficacy. Based upon research, certain interventions are recommended, others are not recommended, and some have insufficient evidence to either support or deny their use. According to CPSTF only the privatization of retail alcohol sales is recommended against enactment. There is insufficient evidence for the interventions of responsible beverage service training and over-service law enforcement initiatives. All of the other interventions listed above under community intervention are recommended based upon research findings (CPSTF, 2011).====