Drug use safety enhancement: A conceptual model for drug use education in rural schools 

Authors: Edward Dunbar, Katey Franklin, Ania Bartkowiak, Svea Wigert

Correspondence concerning this article can be sent to edward.dunbar@montana.edu

Abstract 

The Drug Use Safety Enhancement Model (DUSEM) is a comprehensive framework school counselors can use to promote students’ informed relationships with drugs. Despite the prevalence of drug use among adolescents and young adults, educational resources predominantly focus on abstinence-based approaches. DUSEM encompasses eight domains: Knowledge, Motivation, Set (Mindset), Setting, Dose, Administration, Recovery, and Evaluation, and provides practical strategies tailored for educators, school counselors, and students. By integrating interdisciplinary research, DUSEM aims to destigmatize drug use, foster more educated attitudes towards drugs, and enhance students’ safety.  

Keywords: harm reduction, drug use, school settings, school counselors, drug education 

Drug Use Safety Enhancement: A Conceptual Model for Drug Use Education 

Drug use is a natural behavior that can be traced back thousands of years (Saniotis & Henneberg, 2012). In 2018, nearly 165 million people in the United States over the age of 12 reported using tobacco, alcohol, or illicit drugs weekly or more often (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019). When we account for legal and socially acceptable drugs such as caffeine, nearly 90% of the world’s population regularly uses drugs (Mitchell et al., 2014). This drug use often begins in adolescence and can last throughout the lifespan (National Institute on Drug Abuse [NIDA], 2018). Although drug use dates back thousands of years, our knowledge and resources for promoting educated and safe drug use in the USA remain inadequate (Hart, 2021; Weil, 2004). Many of our clinical and educational interventions continue to emphasize abstinence-only approaches which are often based in stigma rather than science. The rigidity of abstinence-only methods further alienates and stigmatizes people who use drugs. Our lack of knowledge and methods for pragmatic drug education has promoted fear-based and restrictive relationships with drugs and contributed to various issues such as overdoses, addiction, financial issues, family issues, infectious disease transmissions, overburdened healthcare facilities, and the loss of personal and professional productivity.  

Because drug use and curiosity often begin during childhood and adolescence, school counselors are uniquely positioned to design and deliver programs that promote students’ wellbeing by enhancing their knowledge and skills for managing drug use throughout their lifespans (Aresi et al., 2023; Griffin & Botvin, 2010; SAMHSA, 2019). School counselors interact with students and their teachers over time; thus, they are often first to identify common early symptoms of unhealthy drug use such as changes in peer groups, behavior changes, changes in appearance, and truancy (SAMHSA, 2019).  

Harm reduction is a public health strategy focused on mitigating the adverse effects of drug use through overdose prevention, disease transmission reduction, and improve access to treatment resources. Although harm reduction strategies have proven effective (Logan & Marlatt, 2010), practical and unbiased resources for designing and delivering drug education programs remain limited. This article outlines an educational framework that school counselors can use to design and deliver drug use education and counseling programs to students. The DUSEM includes eight domains from which school counselors can enhance student's knowledge and skills for managing drug use throughout their lifespan.  

Adolescent Drug Use in the United States 

The Youth Risk Behavior Survey (YRBS), conducted annually by the Centers for Disease Control and Prevention (CDC), tracks health behaviors among high school students across the United States (CDC, 2023). This biennial survey covers various topics, including demographics, youth health behaviors, substance use, and student experiences, providing valuable insights into adolescent risk behaviors over time (CDC, 2023). 

Recent YRBS results indicate that although high school students continue to engage in behaviors like smoking, vaping, drinking alcohol, and using drugs, overall drug use among adolescents is decreasing. However, the rising rates of overdoses highlight the urgent need for practical and realistic methods to enhance students’ drug use safety. 

In American society, adolescents often experiment with drugs during their middle and high school years (Aresi et al., 2023; Griffin & Botvin, 2010). Most experimentation occurs in social settings with readily available drugs like alcohol and marijuana (Griffin & Botvin, 2010). While some youth may become regular users or progress to illicit drugs, most discontinue or decrease their use after the experimentation phase. However, because problematic use during adolescence may predict problematic adult use, prevention and interventions during adolescence may have longstanding positive effects.  

Drug Use in Rural Adolescence 

Rural adolescents have higher risks of negative outcomes from drug use (Spoth, et al., 2001). For example, recent separate analyses of the National Surveys on Drug Use and Health found that rural adolescents have greater alcohol and methamphetamine use, and prescription opioid use compared to their urban counterparts, and the more rural the greater prevalence of use (Carmona et al., 2020; Lambert et al., 2008; Monnat & Rigg, 2016; SAMHSA, 2024). Despite this, educational resources often focus on abstinence-based approaches, leaving a gap in addressing drug use safety practices.  

Prevention Programs   

Prevention programs can be categorized into three types: universal, selective, and indicated (Griffin & Botvin, 2010). Universal programs target the general population to delay substance use onset and are most common in schools. Selective programs focus on high-risk groups, such as children whose parents have problematic relationships with drugs, while indicated programs are for those already engaging in high-risk behaviors. These programs are designed to prevent or reduce the negative side effects of drug use.  

Many current prevention programs lack evidence-based support and fail to resonate with youth. They often use scare-tactics through over emphasizing the negative outcomes of drug use while ignoring the natural human drive toward altered states of consciousness (Weil, 2004). This approach erodes adolescents’ trust of these programs and promotes their trial-and-error approach as they gain information from peers, family, and the internet (Jenkins et al., 2017). Programs can provide strategies to minimize harmful effects (Griffin & Botvin, 2010), while normalizing their desire toward experimentation. Youth prefer short, concise programs addressing the biological mechanisms of drug use, benefits and side effects, and other relevant topics like sexual assault prevention and responding to peer overdose (Moreland et al., 2020). 

Harm Reduction Approach  

Harm reduction programs focus on reducing the problematic effects of drug use rather than promoting abstinence. These programs are successful because they align with youths’ lived experiences and involve their perspectives in development (Jenkins et al., 2017). Harm reduction includes pragmatic strategies to reduce harmful consequences and provides compassionate support. Although harm-reduction approaches show positive results, programs and practical interventions are limited. The DUSEM was developed to provide school counselors with a conceptual model from which they can design and deliver programs and interventions to help students learn about drug use safety.  

The Drug Use Safety Enhancement Model 

DUSEM is a pragmatic and interdisciplinary model which was developed to be used in various educational, research, and clinical settings to promote informed relationships with drugs (see Table 1). Drawing upon research from diverse fields such as education, addiction studies, medicine, nursing, psychology, and public health, the model aims to equip students with realistic knowledge about drugs and practical skills to enhance their drug use safety. 

This model was developed as a guidepost for professionals in various fields and is relevant to educators and counselors in school settings as they design and deliver interventions and programs. The DUSEM includes eight domains that serve as a comprehensive framework for guiding educators, helping professionals, and drug consumers in enhancing drug use safety and decreasing student overdose. These domains can be utilized sequentially or in any order deemed appropriate and tailored to align with the diverse educational levels, motivations, and learning preferences of individual students, group settings, and classroom settings  

The DUSEM resembles holistic models of human well-being, as its domains offer multidimensional strategies to enhance students’ drug use safety. School counselors can use these domains to educate and counsel students on the fundamental principles of drug use safety prior to their drug use experiences and can be used as a means of evaluation and planning following past drug use and prior to subsequent drug use events. Additionally, the interactions between the eight domains can also enhance drug use safety. For instance, if a student explores the knowledge domain, they may become aware of their own misconceptions related to the drug they are using, which, in turn, can heighten their understanding of the drug's impact within the set (mindset) domain and lead to behavioral changes in the dose and administration domains.  

School counselors can use the following overview of the core domains of the DUSEM to enhance students’ drug use safety. Additionally, this overview includes examples of strategies and activities school counselors can use when developing programs and interventions relating to drug use. Although not exhaustive, these practical applications illustrate how school counselors can tailor the DUSEM concepts to their school settings and students’ needs.  

Table 1- Visual Representation of the Drug Use Safety Enhancement Model (DUSEM)

The Drug Use Safety Enhancement Model (DUSEM) is a non-linear, interconnected framework designed to promote informed and safe drug use behaviors. The model consists of eight domains, each of which contributes to a comprehensive approach to harm reduction and safety education. Below is a representation of the model and a guiding question to explore each domain.  

Note: The interconnected nature of these domains means that they can be engaged in any order or revisited dynamically as needed. This flexibility supports tailored interventions for diverse educational and counseling contexts. 

Knowledge Domain 

The first domain, termed 'knowledge,' pertains to students’ acquired information about the drugs they intend to use. As adolescents explore their drug use they often acquire knowledge about drugs through direct consumption or vicariously through friends or media portrayals, rather than through formal education (Jenkins et al., 2017; Stern, 2006; Stoelben et al., 2000). Simply put, adolescents often learn about drug use by using drugs, rather than by learning about drug use safety beforehand. This experiential approach may result in unhealthy relationships with drugs as adolescents transition into adulthood, as drug use trends in adolescence may predict adult use trends (Centers for Disease Control and Prevention [CDC], 2021). Additionally, advancements in drug use potency increase risks of this trial-and-error approach and can lead to accidental overdoses and other high-risk behaviors.  

Practical Applications 

School counselors can incorporate the knowledge domain of the DUSEM in their design and delivery of school counseling programs through activities such as exploring common drug use myths versus facts, education about neurotransmission, exploration of benefits and side effects of various drugs, education about drug interactions, and normalization of drug use as a means of altering consciousness. School counselors might employ interactive activities, low stakes quizzes, research projects on various drugs, and resource development and organization such as searches for internet sources, apps, or local resources relating to drug use safety. School counselors are encouraged to use caution in their program delivery to avoid the common bias of overemphasis on the negative side effects of drug use as scare tactics are ineffective and often detrimental to adolescents’ healthy attitudes and behaviors relating to drug use. Further, adolescents may experience feelings of distrust for authority figures such as school counselors who overemphasize the negative impacts of drug use instead of presenting a balanced educational format that includes benefits, side effects, and safety practices.For instance, when working with students interested in using cannabis products, school counselors can utilize this domain to assess their existing knowledge about how cannabis works, its potential benefits, and its side effects. In this example, this process also allows for the exploration and correction of common myths associated with cannabis which may have been obtained from unscientific sources such as peers, family, or the internet.   

Motivation Domain 

The second domain in the DUSEM termed ‘motivation’ conceptualizes why students’ use drugs at a given time. In this model, drug use motivation occurs along a continuum from enhancing pleasant experiences to escaping from negative cognitive, physical, emotional, or social states. This approach builds on previous research on drug use motivations (Kuntsche et al., 2005) by presenting drug use motivation as a spectrum ranging from escape to enhance which may aid in its applicability in educational settings.  

The motivation domain can be used to help students explore their motivation for use at a given time to determine any risks associated with their potential drug use. For example, people with mental health disorders have increased risks of problematic drug use (SAMHSA, 2020). This domain could help students determine if they are contemplating or engaging in drug use to escape from feelings of anxiety and depression, which may indicate high risk drug use and their need for further services outside of a school setting (Montano & Chung, 2019). Examples of enhancing experiences may include recreation, social drug use such as concerts or events, spiritual enhancement such as religious ceremonies, or seeking insights through altering consciousness by using drugs.  

Practical Applications 

School counselors can use the motivation domain to help students explore their motivations for drug use and understand how their motivations impact their overall drug use safety. School counselors can design activities that include representations of the spectrum of drug use motivations from escape to enhance, journaling activities addressing drug use intentions, and personalized identification of factors associated with escape and enhance motivational states. School counselors might also explore the role of peers and family on students’ drug use motivations. Case scenarios and role plays may be effective methods of increasing students’ awareness of their drug use motivation.  

Mindset (Set) 

The third domain of the Drug Use Safety Enhancement Model is called ‘Mindset’ or ‘Set’. This domain addresses states, traits, and expectations that impact students’ drug use experiences (Hartogsohn, 2017). Traits may be personality characteristics and belief systems, whereas states include temporary ways of being, such as mood, anxiety, and stress levels. 

State characteristics also include chronic and acute mental health issues, which influence students’ drug use experiences. Co-occurring issues are mental health issues that occur with drug issues such as addiction or other problematic drug use (SAMHSA, 2020) are emphasized in the set domain as a point of counseling, education, and prevention. Students with unaddressed mental health issues may be vulnerable to developing problematic relationships with drugs and engaging in unsafe behaviors during drug use. For example, school counselors educating from the set domain can teach students about the relationships between mental health and drug use. School counselors can help students understand the role of mental health in drug use safety.   

Expectations are included in the set domain as they may predict the outcomes of drug use events. The effects of drugs are more correlated with what people think the effects of the drug will be rather than the drugs’ actual effects (Hartogsohn, 2017; Health, 1998). For example, people who believe stimulants or alcohol cause aggression and violence are more likely to become aggressive and violent when they use alcohol or stimulants. The set domain can be used to explore students’ beliefs about a drug’s effect, which may also relate to the knowledge domain. For example, a student planning to use alcohol may expect it to decrease anxiety and increase sociability. Although this may be true, exploring these expectations may provide a school counselor the opportunity to educate, via the knowledge domain, this person about the relationship between anxiety and alcohol where alcohol may decrease acute anxiety but raise chronic anxiety levels (Kuhn, Swartzwelder, & Wilson, 2019).   

Practical applications. School counselors can use methods from the set domain such as journaling, mood/anxiety tracker apps and worksheets, biofeedback, stress reduction training, psychoeducation about drug use and mental health, drug use family mapping, and explorations of beliefs and expectations about drug use. 

Setting 

The fourth domain of the Drug Use Safety Enhancement Model is termed setting and refers to the environment in a student uses drugs. This includes the physical environment, the cultural environment, and the social environment in which drug use takes place (Metzner & Leary, 1967; Hartogsohn, 2015). In prior research on setting, the focus has been on the environment in which drugs were taken and the effects. However, the setting domain in this model emphasizes setting throughout the drug use experience. 

This longitudinal setting perspective of the DUSEM is considered along a continuum of drug use behaviors. This includes obtaining, preparing, ingesting, onset effects, metabolization, and elimination. School counselors can emphasize the setting domain to help students who use plan to use drugs consider behavioral steps to keep themselves safe throughout the experience. For example, this model includes the metabolization and elimination in setting because some people who use drugs may travel between locations after they believe they are no longer experiencing a drug’s effects, which may be an increased risk factor for clients in rural settings (Malek-Ahmadi, 2015). In this example, school counselors could help students consider the setting domain relating to their transportation to and from the environment where they use the drug while also helping them understand the duration of the drugs’ effects.  

Practical applications. School counselors can enhance student safety through the setting domain through methods such as helping students plan their drug use around other people, obtaining safe transportation to and from a drug use event, identifying safe people to use drugs around, and safety methods relevant to various settings. For example, common safety enhancement methods that would be categorized in the setting domain of this model is avoiding leaving beverages unattended and using a designated sober driver.  

Additionally, the people who are present in the social environment are of critical importance if an emergency, such as overdose, occurs. One potential application that combines the knowledge and setting domains would be universal training in basic bystander response skills for substance use crises, including identification of overdose signs, key supportive actions (e.g., putting a person into the recovery position), and awareness of legal protections directly related to drug use and handling of crisis situations (i.e., Good Samaritan laws). 

Dose 

The fifth domain of the Drug Use Safety Enhancement Model is dose which refers to the amount of active and inactive ingredients in a drug needed to achieve desired results (Prus, 2018). This domain considers drug content issues including sourcing, potency, and purity. This domain can be used to help students who use drugs apply practical measures to legal and illicit drugs to promote drug use safety.  

School counselors addressing the dose domain can consider promoting safety during the sourcing, or obtaining, of a drug by helping students consider where the drug will be sourced from, its reliability, and any possible risky behaviors that may arise during the sourcing process. School counselors can educate students about how drugs are manufactured, processed, and delivered as legal drugs, such as pharmaceutical drugs, have regulated ingredients, processes, and purity standards, whereas illicit drugs do not.  

Because more potent drug doses require smaller amounts than less potent drug doses, potency can also be considered efficiency. Because of their unregulated and unstandardized ingredients and processes, illicit drugs vary in potency when compared to legal drugs such as nicotine, alcohol, or cannabis. Additionally, adolescents and young adults tend to overestimate the prevalence, amounts, and frequency that their peers use drugs (Sanders, Stronger, Seibert, & Miller, 2014). Uncertainties in the drug potency due to unregulated sources and inaccurate beliefs about peer drug use may contribute to risky drug use through accidental overdosing.   

Practical application. School counselors can design programs to increase students’safety enhancement measures relating to dose may include identification of safety precautions during sourcing, identifying intended dosage prior to use, drug purity testing such as fentanyl test strips, drug replacement options, identification of desired effects, psychoeducation on dosing, psychoeducation about drug interactions, and exploration of myths about peer drug use such as amounts. 

Administration 

The Drug Use Safety Enhancement Model’s administration domain focuses on drug entry into the body, influenced by administration routes that affect onset, effects, duration, and safety. Some methods require equipment like smoking pipes, syringes, or vaporizers. The domain ensures safety during drug preparation and ingestion. Drug administration methods, categorized as enteral, parenteral, and others, continue to evolve. Each has benefits, disadvantages, and safety-enhancing strategies for consumers. 

Enteral administration, via the gastrointestinal tract, includes oral, sublingual, and rectal methods. It’s convenient, has moderate absorption rates, and reduces infection risk. However, it may cause unintentional overdosing, gastrointestinal irritation, variable effects, and is less efficient (Kim & Dejesus, 2023). 

Parenteral administration bypasses the gastrointestinal tract, involving injections like intravenous, intramuscular, and subcutaneous. It offers rapid onset, increased efficiency, and dosage control, but carries infection risks, potential overdoses, shorter effects, and requires specific equipment (Kim & Dejesus, 2023). 

Other methods include inhalation (smoking or vaporizing) and intranasal (nasal inhalers or snorting), absorbing drugs through nasal mucosa or lung capillaries. They offer rapid onset, reduced infection risk, and lower doses, but may cause dose regulation difficulty, airway irritation, and require expensive equipment (Rau, 2005) 

Practical applications. School counselors designing programs and interventions within the administration domain might include education on administration and absorption methods, overdose signs and symptoms, sterilization techniques, safe preparation methods, and infectious disease prevention protocols.  

Recovery  

The recovery process in drug administration starts before drug intake and covers recovery from both acute and chronic drug use. Given the variability in drug effects, administration, absorption, metabolism, and elimination, this domain necessitates understanding of other domains like knowledge, dose, and administration. Individual health variations also require consideration of domains like set and setting, and motivation. 

Key aspects of acute drug use recovery include proper hydration and nutrition before and during drug use, followed by adequate nutrition, rest, sleep, and hydration post-event. Education about remedies, such as aspirin or ibuprofen for alcohol hangovers (avoiding acetaminophen), can aid in acute recovery (Kuhn et al., 2019). Acute recovery also involves overdose responses and first aid education, including overdose prevention drugs like naloxone. 

Chronic recovery education may discuss the psychophysiological pros and cons of continuous drug use. The recovery domain necessitates individualized attention to other domains and their role in drug use experiences. For instance, a student planning from the recovery domain may experience varied benefits and side effects from chronic cannabis use depending on the dose and administration. 

Practical applications. Applications from the recovery domain could include education about first aid, drug metabolism, administration of lifesaving drugs such as naloxone, overdose prevention methods, nutritional information, sleep tracking, and education about common psychophysiological risks and benefits of chronic and acute drug use experiences.  

Evaluation 

The evaluation domain of the Drug Use Safety Enhancement Model helps student evaluate their relationships with drugs. In this domain, students are prompted to reflect on the benefits and side effects they have experienced in their drug use. School counselors can help them evaluate their chronic or acute drug use experiences to determine future courses of action. School counselors can use Motivational Interviewing (SAMHSA, 2020) to help students determine if their drug use is causing any side effects which would necessitate behavior changes within any domain of the Drug Use Safety Enhancement Model such as changing dosage (dose), taking breaks (recovery), changing drugs (dose) or administration, or addressing underlying psychophysiological issues (motivation, set). 

Practical applications. School counselors can use journaling, comparing actual intake to pre-established goals, compiling pro/con lists of acute or chronic experiences, logging use events, and getting feedback from family/peers regarding their drug use.   

Best Practices  

The Drug Use Safety Enhancement Model (DUSEM) aligns with best practices in rural school counseling by providing practical and evidence-based strategies that are specifically tailored to the unique needs and challenges of rural communities. The model promotes harm reduction, a strategy that prioritizes minimizing the negative impacts of drug use over complete abstinence. The DUSEM offers students realistic and effective means of drug use exploration and normalizes drug use as a natural human behavior. As such this model helps destigmatizing drug use. By decreasing stigma, the model promotes a supportive, inclusive, and non-judgmental environment for students. This is crucial in encouraging open dialogue about drug use to help students feel safe to seek help when needed. 

Collaboration and Community Engagement  

The successful implementation of DUSEM requires collaboration and community engagement. School counselors, families, schools, and other stakeholders can collaborate to develop programs based on the concepts from the DUSEM model that fit their students’ and communities’ needs. School counselors and educators often interact with students daily. Families provide the home environment and influence their children’s behavior. Community organizations offer resources and can help extend the reach of drug use education beyond the school setting. By engaging all these stakeholders, DUSEM ensures a comprehensive approach to addressing drug use safety. This collective effort can reinforce messages conveyed to students and create a consistent, community-wide understanding and approach to drug use safety. This holistic approach can aid in creating a safe and supportive environment for students within the school and the wider community context. 

Recommendations for Future Practice and Research 

This model provides policymakers, educators, and practitioners with tangible harm reduction strategies for school counseling services and emphasizes the importance of destigmatizing drug use in rural communities. As such, this model is conceptual and has not been formally tested. Future studies based on this model can explore formalized curriculum development, and subsequent outcome studies. Additionally, principal components analysis and factor analyses could be used to determine the weighting of the various domains in relation to overall drug use safety.  

In this way, the DUSEM is a starting point rather than a finished product, in that the DUSEM provides school counselors with a means of implementing harm reduction approaches within their program development. Mixed methods studies can help determine its efficacy and future development.  

Conclusion 

The Drug Use Safety Enhancement Model (DUSEM) provides school counselors with a comprehensive framework for drug use education and addresses the need for realistic and practical strategies beyond abstinence-only approaches. This model emphasizes the role of school counselors in enhancing students’ knowledge and skills for managing drug use throughout their lifespan. The model offers a pragmatic and interdisciplinary approach to promote informed relationships with drugs, aiming to enhance drug use safety and decrease student overdose. This approach is crucial given the prevalence of drug use and the associated risks among adolescents. 

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