November 20, 2023

'Just say no' didn't actually protect students from drugs. Here's what could


Article origination All Things Considered
Photo illustration by LA Johnson/Getty Images/NPR

Photo illustration by LA Johnson/Getty Images/NPR

College sophomore Elias Myers thinks his friends are lucky to be alive.

The 19-year-old recounts a recent incident in which his friends got ahold of a drug that test strips showed was laced with fentanyl, a potent, often deadly, synthetic opioid.

"That's kind of when I decided that caution is not, like, a best practice, but a survival technique," says the University of California, Berkeley, student.

And yet those survival techniques were never talked about in Myers' middle and high school drug education classes. In fact Myers says they didn't mention fentanyl at all. He says those classes failed to prepare him and his peers for an increasingly dangerous drug landscape in which a single high can have deadly consequences.

Myers says everything he learned about fentanyl has been from friends and older siblings.

"But it didn't have to be that way. We could have learned safety way ahead of time," he says.

For decades, students like Myers have been told to just say no to drugs. The message was repeated in public service announcements and in classroom presentations. But research shows this approach alone doesn't work. And now, overdose deaths among teenagers have skyrocketed — largely due to fentanyl. The synthetic opioid was involved in the vast majority of teen overdose deaths in 2021, according to the Centers for Disease Control and Prevention. Many of those deaths involved fentanyl-laced counterfeit prescription pills that didn't come from a pharmacy. And the problem has followed teens onto college campuses.

Some experts say drug education that focuses on harm reduction techniques – designed to keep people safe when they do choose to use – could help save lives. Here's what that looks like.

Teaching safety measures for when students do choose to use

"The most important tenet of drug education is to be honest," says professor Bonnie Halpern-Felsher. "And to have a balanced perspective. We cannot lie, we cannot exaggerate to teens."

Halpern-Felsher directs Stanford University's REACH Lab, which focuses on understanding, preventing and reducing teen and young adult substance use, among other risky behaviors.

Her lab maintains a high school curriculum called Safety First (initially developed by the nonprofit Drug Policy Alliance), which encourages young people to abstain from drug use while also providing them with information to reduce their risk of addiction and death if they or their friends do choose to use. The concept is called harm reduction.

First, Halpern-Felsher says, students need to know the facts about drugs — including their benefits and their harms.

For example, opioids like fentanyl have been used safely in healthcare facilities for decades to treat patients' pain. But when used recreationally — either purposefully or unknowingly — it's extremely dangerous, because very small amounts can lead to an overdose.

Activities — not just lectures — should be used to demonstrate a lesson, Halpern-Felsher explains. The Safety First curriculum includes an activity that asks students to add sugar to one pitcher of water and salt to another.

"You cannot see the difference. But one can and potentially will really hurt you. And this is why it's so important for you to understand that you cannot just simply pick up a drug and go ahead and use it," she says.

The curriculum also outlines safety measures for when students or their friends do choose to use drugs. Messages like:

  • If you're using drugs, the healthiest choice is to stop using, or at least cut down on how much and how often you use. 
  • Ideally, you're using drugs only as recommended by a doctor or a pharmaceutical label. But if you're not, don't take a lot of any drug. Wait and see how it affects you before taking any more. 
  • Consider your mindset before using drugs. What you're thinking and feeling before and during substance use can affect your experience. 
  • Consider the setting. Where and with whom you're using drugs can reduce your chance of injury or death. 
  • Check the substance before you use it. Testing a drug for things like fentanyl can reduce the risk of harm. But even test strips aren't always 100% accurate. 
  • Don't mix drugs. The effects from combining drugs may be stronger and more unpredictable than one drug alone, and even deadly.  
  • Know how to respond in an emergency: Spot the signs of an overdose. Call 911. Place someone on their side to prevent choking. Administer the opioid reversal medication naloxone, often sold under the brand name Narcan.

Halpern-Felsher knows some people might interpret harm reduction as encouraging teens to use drugs. But she says that's a misperception.

"The most important piece of this curriculum is not to use, but if they are using or if they're in situations where they might be using, we are just trying to keep them safe," she says.

There are few studies that focus on harm reduction drug education programs in schools, and more research is needed to evaluate their efficacy. But experts told NPR that harm reduction could help save lives at a moment when teens are dying at alarming rates.

A pilot study of the Safety First curriculum found it significantly increased high school students' knowledge of harm reduction techniques and behaviors, and found a decrease in overall substance use.

What harm reduction looks like in the classroom

Last spring, Cameron McNeely stood in front of a group of high schoolers and told them they had a choice to make: will they or won't they use drugs.

"I'm not here to judge you for that," he told the Indianapolis teens. "But hopefully I can present you some information that gets you to understand the consequences of those choices — yes or no — a little bit better, and, hopefully, to get you to steer clear of substance use."

McNeely, 28, is the director of youth education for Overdose Lifeline, an Indianapolis-based nonprofit that created a drug education program, with an emphasis on opioids, for students in grades six through 12.

In this presentation at Perry Meridian High School, McNeely shared statistics on drug-related deaths, explained how opioids affect the body, emphasized addiction is a disease — not a moral failing — and explained why it's a good idea to carry naloxone.

To hammer that point home, McNeely shared a personal story: One night, while in college, he and his friend took some pills to relax. Shortly after, he noticed his friend had fallen asleep, and it looked like he was struggling to breathe.

"Little did I know, about five feet away from me, my friend was having an overdose," McNeely told the students. He called 911 and emergency responders were able to revive his friend with Narcan.

"It saved his life," he said. "Narcan buys time, which is the most important thing to have in an overdose."

After the presentation, McNeely told NPR he had little to no drug education in high school.

"Nobody ever told me about how to drink safely and how, if I use pills, you know, they have different effects on you and what those effects are, and how it could just kill you — just one night, bad pill, it could all go down the drain."

McNeely's experience isn't uncommon. Drug education across the country is ad-hoc, often outdated or not provided at all. In a 2021 National Survey of Drug Use and Health, only about 60% of 12-17-year-olds self-reported that they saw or heard drug or alcohol prevention messaging in school. And there's no way to track what type of drug education programming is being offered in schools nationwide.

"I just wanted to fill in those gaps that I felt as I was growing up in my drug education," McNeely said.

The "just say no" messaging of the past didn't work

McNeely's presentation is a far cry from the drug education of prior decades — like the Drug Abuse Resistance Education program, commonly known by the acronym D.A.R.E. Launched in 1983, D.A.R.E. was taught by police officers in classrooms nationwide. Their presentations warned students about the dangers of substance use and told kids to say no to drugs. It was a message that was repeated in PSAs and cheesy songs. Former First Lady Nancy Reagan even made it one of her major causes.

Teaching drug abstinence remains popular among some groups, and the U.S. Drug Enforcement Administration's messaging to teenagers still focuses on the goal that they should be "drug-free." But numerous studies published in the 1990s and early 2000s concluded programs like D.A.R.E. had no significant impact on drug use. And one study actually found a slight uptick in drug use among suburban students after participation in D.A.R.E. In 2009, D.A.R.E. rebranded with new curriculums for students dubbed "keepin' it REAL." But the programming doesn't focus on how students can minimize their risk of harm if they do choose to use drugs.

"It is clear that just saying no is not sufficient," says Nora Volkow, director of the National Institute on Drug Abuse. "We'd like the theoretical perfect: don't touch a drug — abstinence. But that's not necessarily the reality for everyone."

Volkow says the failures of past drug education programs haunt current efforts to inform young people of the risks of fentanyl.

For years, anti-drug curriculums exaggerated the effects of certain types of substance use, she says. For example: Students were taught that using cannabis would destroy their brain or make them dumb. And while there is data to suggest cannabis use can have detrimental effects — particularly for young people — that messaging didn't always match students' lived experiences.

College sophomore Elias Myers remembers the dire warnings. But he also had classmates who used the drug.

"I couldn't understand, like, if these people can smoke weed after class and be totally fine, how can this curriculum be true?" Myers says. "I remember coming away from that in like middle school and early high school feeling really unsatisfied with the education. I remember feeling as though what I was being told perhaps wasn't the truth."

Volkow says that loss of credibility makes it harder to give students life-saving information about drugs now.

"It has weakened our position because a lot of people know others that take marijuana and they are functioning and they don't see any evidence of ill effects," she says.

And now the consequences of drug use are deadlier than ever. Teens are dying after taking what they thought was Adderall or Percocet, but turn out to be fentanyl-laced counterfeit pills.

"They actually taught us when we were children: If you cry wolf too many times, when the wolf really comes, no one is paying attention," Volkow says. "And this is, I fear, where we are a little bit with fentanyl, because it is such a dangerous moment in the history of illicit drugs right now."

Meet young people where they are, not where you want them to be

Volkow and Bonnie Halpern-Felsher say school curriculums that teach kids how to reduce the harms related to drug use can help save lives — but they're not a cure-all.

Halpern-Felsher says schools alone can't solve the fentanyl crisis; rather, it requires a cultural shift. Educators, families and communities at large need to start having honest conversations about drug use.

"And until we do, you know, just having a 50-minute class on fentanyl is not going to be the sole defining moment for anybody."

Myers, in California, serves on the Youth Action Board for Halpern-Felsher's REACH Lab, and he's familiar with the Safety First curriculum.

"I think it's realistic," Myers says of the program. "You've got to meet children and teens and youths where they are, rather than meeting them where you want them to be."

Myers says he wishes he and his peers had had access to drug curriculums like this when he was in high school.

"I think that we would have adopted ideas of safety through school and not through having to actually experience times of danger," Myers says.

"I think that we were very lucky in so many different ways... You hear often about those who don't experience that luck. And I feel like those lives could have been saved."

Edited by Nicole Cohen
Visual design and development by LA Johnson
Audio story produced by Janet Woojeong Lee

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