Evidence-based treatment of young adults with substance use disorders

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Evidence-based treatment of young adults with substance use disorders.

Hadland S.E., Yule A.M., Levy S.J. et al.
Pediatrics: 2021, 147, S204.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Hadland at scott.hadland@bmc.org.

[Consultation draft subject to amendment and correction.] A group of paediatric addiction medicine experts in the US review the evidence base and agree on practice considerations for treatment services for young adults. The principles of care identified in this document serve as a roadmap for addressing various limitations, including inadequate clinician training, siloed systems, and the view that relapse is a failure rather than hallmark of a chronic illness.

Summary The objective of the featured article was to communicate a series of evidence-informed principles of care for young adults (defined as people aged 18–25) with substance use disorders, agreed by a national group of paediatric addiction medicine experts in the United States. The featured paper focuses on the treatment of young adults with substance use disorders – emphasising early intervention for young adults with SUD, comprehensive and tailored services, access to pharmacotherapy when indicated, voluntary entry into treatment, continuous engagement, and assurance of quality of care.

Principle 1: Young adults should be offered access to care and services as soon as the need is identified

Evidence. Almost all individuals receiving treatment for substance use disorders report that their first use of substances occurred by young adulthood. Often, alcohol or cannabis is the first substance that a young person uses, but it is common for clinicians to avoid addressing these substances in certain populations (eg, college students) because their use is common. Even when substance use problems are recognised, clinicians may delay providing the full complement of addiction services. Most young adults with opioid use disorders, for example, receive psychotherapy without pharmacotherapy, one of the single most effective interventions. In some cases, clinicians delay pharmacotherapy while determining if behavioural health services alone are sufficient. Such delays, however, may place young adults at risk for developing a more severe substance use disorders or experiencing drug use-related harm. Waiting to determine if a substance use disorder self-resolves represents a missed opportunity to intervene early.

Practice considerations. There are numerous barriers to identification and early intervention for substance use disorders among young adults, for example: addiction services have long been delivered outside traditional healthcare settings, and many clinicians have not received training on how to effectively screen and address substance use; young adults may be ambivalent about receiving substance use disorder treatment and decline services; and even when clinicians offer substance use disorder care, young adults have among the lowest rate of participation in routine healthcare of any age group (24 25). Addressing these numerous challenges will require widespread clinician training on evidence-based treatments for young adults and health-system improvements to support addiction care and improve outreach, engagement, and retention in care.

Principle 2: Young adults should have access to a comprehensive set of assessment, psychosocial and pharmacologic treatment, harm reduction, and recovery services supported by evidence

Evidence. Providing comprehensive treatment of young adults with substance use disorders improves outcomes. An initial, scoping assessment to identify young adults’ medical, mental health, and psychosocial needs can help clinicians deliver the full range of services needed.26,27 Traditionally, substance use treatment has been focused on achieving abstinence from all substances and, in many settings, has relied heavily, if not exclusively, on behavioural therapy and peer support through mutual help (ie, 12-step) organizations, such as Alcoholics Anonymous and Narcotics Anonymous, to attain this goal.36 For opioid, alcohol, and nicotine use disorders, evidence-based medications exist,17,26,29,30 but young adults infrequently receive this treatment. Recent studies indicate that only ?1 in 4 young adults receives a medication for OUD,3,5 and only 1 in 73 young adults receives a medication for nicotine use disorder.4 Medications reduce substance use and cravings, enhance retention in care, and, in some cases, reduce mortality.9,17,26,29,30 The decision to initiate pharmacotherapy is, ideally, based on patient preferences after counselling from clinicians on the benefits and risks. Providing accurate information is paramount because young adults may receive inaccurate information or stigmatizing messaging regarding pharmacotherapy from family, friends, and other individuals.37 Receipt of medications should not be contingent on whether a young adult is engaged with psychosocial treatment; although a comprehensive treatment approach is optimal, data suggest that outcomes may be improved with pharmacotherapy alone.3841 The evidence for harm reduction and recovery support services is reviewed elsewhere in this series (see accompanying articles by Kimmel et al42 and Xuan et al,43 respectively).

Practice considerations. Establishing comprehensive services in many settings is difficult. Many specialty addiction treatment settings, particularly those not routinely staffed by a medical clinician, are not equipped to conduct a full medical and psychiatric assessment. Many traditional medical offices are well poised to perform a medical and psychiatric assessment, but clinicians may lack experience caring for young adults with SUDs. Improving access to pharmacotherapy for youth is hampered by numerous barriers. First, many treatment programs have policies that preclude the use of pharmacotherapy, and some even deny entry to young adults who take medications prescribed elsewhere. Of 11 532 national treatment programs for OUD that treat young adults, 52% do not accept individuals on pharmacotherapy.44 Second, there is a national shortage of clinicians to prescribe medications.45 This is particularly true for buprenorphine, an effective OUD medication that requires completing extensive mandatory education (8 hours of training for physicians and 24 hours of training for nurse practitioners and physician assistants) for a waiver to prescribe.46 Even still, medications that do not require extensive training, such as those for alcohol use disorder and nicotine use disorder, are only infrequently prescribed,47,48 thus highlighting additional barriers, including clinician unease or unfamiliarity with pharmacotherapy for SUD treatment. Third, there is widespread stigma surrounding the use of medications for SUD treatment. Many young adults receive messaging that they are not truly in recovery if they are on pharmacotherapy, particularly when receiving an agonist treatment, such as methadone or buprenorphine to treat OUD.37 Often, this messaging comes from trusted adults in the young person’s life, such as treatment providers, mutual support group members, other individuals in recovery, parents, family members, or friends. To address workforce limitations, health systems can ensure that clinicians receive the training and resources necessary to establish comprehensive addiction treatment, harm reduction, and recovery support services or, at a minimum, ensure that local referrals are available that are youth friendly. Integrating allied health professionals such as social workers into primary care settings allows practices to offer on-site counselling, case management, and referrals to community recovery support services. Health care systems should consider eliminating rules that restrict young adults from receiving pharmacotherapy, and clinicians should receive training to become buprenorphine waivered and improve their familiarity with other medications for addiction treatment. National resources are available. For example, the Prescribers Clinical Support System (https://pcssnow.org/) provides free training. Offering medications in primary care, promoting the medical model of addiction (as opposed to narratives that portray addiction as a moral failing), and highlighting the pathophysiological rationale for pharmacotherapy may help to reduce stigma and correct common misperceptions among young adults and their families.

Principle 3: Respecting the diversity of young adults, services should be tailored to individual strengths and needs, by using the least restrictive environment possible

Evidence. The evidence base is inconclusive on whether more intensive addiction treatment (eg, inpatient, residential, partial hospitalisation, or intensive outpatient programmes) improve substance use disorder outcomes compared with outpatient treatment alone for young adults. Numerous factors influence the decision to seek a higher level of addiction care, including the presence of withdrawal symptoms, co-occurring medical and psychiatric conditions, readiness to change, ongoing use of drugs and risk of relapse, and the young person’s living environment. At higher levels of care, young people generally have less autonomy and are less able to pursue their educational and employment goals or engage in prosocial activities, all of which are critical to their continued development and sustained recovery. The most restrictive environments, particularly those imposed by involuntary commitment to addiction treatment, almost entirely limit young adults’ autonomy and may be associated with adverse outcomes, such as overdose. Furthermore, outpatient management of substance use disorders is often possible, not inferior to higher levels of care, and associated with better long-term outcomes.

Practice considerations. Providing care in minimally restrictive settings hinges largely on the availability of outpatient treatment options for young adults. In many regions of the United States, the only available addiction treatment program is an inpatient or residential facility.44 Patients, families, and clinicians alike may believe that addiction treatment requires hospitalization (detox) or a 30-day residential program, yet many young adults can be safely treated in an outpatient setting.49 For families with a young adult unwilling to receive addiction care, some states allow involuntary commitment to treatment, although compulsory admission to a highly restrictive environment is not without risks. High-quality outpatient addiction treatment programs with minimally restrictive environments are needed in every community. Health care providers serving young adults can strive to expand the services offered within their practices and, also, advocate for the creation of specialty programs for the most complex patients. Outpatient delivery of care, even for young adults with a complex presentation, can be supported through numerous newly available addiction treatment and clinician education services, including telemedicine and tele-psychiatry, hub-and-spokes referral systems, and Project Extension for Community Healthcare Outcomes, as several examples.51,52.

Principle 4: To maximize engagement, young adults should enter care voluntarily; external leverage should be used strategically, but involuntary commitment should be a last resort and, when used, it must be as good as or better than non-coercive care

Evidence. Involuntary commitment to addiction treatment is not associated with improved treatment outcomes; in fact, involuntary commitment has been associated with increased risk of overdose. In the US, it is typically a family member (often a parent) who initiates the process of civil commitment and, in most states, must demonstrate that the individual with the SUD exhibits a danger to self or to others. The duration of compulsory treatment varies widely across states, with some states allowing up to 1 month and others allowing up to 1 year or longer. Although some may view involuntary commitment as an important way to compel a young adult with a SUD into treatment, there are reasons to be concerned about this approach. In some states, individuals who are committed are placed in jail settings where their autonomy and civil liberties are limited.54 In these settings, young adults are often housed with older individuals, often including those with more severe SUD. Critically, state laws generally do not specify that evidence-based treatment must be provided in mandatory treatment facilities, and pharmacotherapy is often withheld, placing individuals with SUD (particularly those with OUD) at an elevated risk for relapse and overdose after discharge.7,50 Further considerations regarding involuntary commitment are discussed elsewhere in this series (see the accompanying article by Perker and Chester55).

Practice considerations. Ensuring access to high-quality outpatient services for young adults with substance use disorders at all stages of readiness to change can mitigate the need for involuntary treatment. Offering comprehensive medical, mental health, and harm reduction services can help engage young adults in care, even if reducing substance use is not an explicit goal, and gives young adults a place to turn when they do decide to seek treatment for their substance use disorders. The perceived need for compulsory treatment reflects the poor availability of services for young adults not ready to seek addiction care. Young adults often view addiction treatment as punitive or requiring abstinence – and indeed, many treatment programmes have such a requirement – and, therefore, may be unwilling to seek care. Family members often feel as though they are powerless to compel young adults into treatment without judicial support. Evidence-based engagement strategies can help family members support young adults with substance use disorders who are otherwise not ready or able to seek treatment. One commonly-used engagement approach, community reinforcement and family training, capitalises on rewards and negative consequences of substance use to influence the motivation of individuals with substance use disorders to enter treatment. Notably, the young adult makes the ultimate decision about entering treatment.

Principle 5: A goal of care should be continuous engagement, including during periods of relapse

Evidence. People retained in treatment are less likely to experience early death, compared with those out of care. Continuous engagement to keep young adults in treatment, especially during high-risk times of relapse, offers an opportunity to reduce mortality and other substance userelated harm. Evidence-based services that can be provided during times of relapse include motivational enhancement to reduce or eliminate substance use, screening and treatment of sexually transmitted and blood-borne infections, and overdose education and naloxone provision, among other harm reduction and recovery support services. Supplementing services with recovery coaching is also associated with enhanced retention in the care of people with substance use disorders and reduced emergency department use.

Practice considerations. Changing the goals of addiction treatment to encompass a broader set of patient-centred objectives will require a substantial culture shift in many treatment programmes. In particular, the requirement for abstinence, which is common in many traditional treatment settings, is potentially detrimental and may be incompatible with engaging and retaining many young adults in treatment. Abstinence-only policies may drive young adults who are unable to cease all substance to be discharged; after such experiences, young adults may come to perceive that there are no services suitable to their needs. Health systems might consider eliminating requirements that young adults cease substance use altogether and instead promote continuous engagement by offering the full spectrum of comprehensive patient-centred services focused on the young person’s goals for care regardless of their ability to stop or reduce substance use.18,26.

Principle 6: Substance use care should be held to the same evidence and quality improvement standards as those expected in other areas of medical care for other chronic health conditions

Evidence. The quality of care for substance use disorders remains poor in many settings, and lags behind other health conditions. However, improvement has been generated in the areas of prevention, early detection, and treatment of other behavioural health conditions among young people, such as depression. Elements common to a successful behavioural health intervention to improve the quality of care include primary care-based management, a collaborative care approach involving an interdisciplinary team, and continuous patient engagement, all of which are principles readily applied to addiction care. Such interventions are associated with greater engagement in counselling, improved symptoms and quality of life, and higher patient satisfaction.

Practice considerations. As clinicians and health systems work to incorporate addiction care into traditional medical settings, quality improvement is likely to follow. However, young adults are likely to have a unique set of developmentally appropriate outcomes and for whom traditional measures of initiation, engagement, and retention in care are likely to require different definitions for individuals ambivalent about receiving treatment Clinicians and health systems should be aware that addiction quality improvement is currently hampered by a lack of evidence-based substance userelated measures or, in some cases, differing definitions for measures.66,71 These gaps are likely even more substantial in addiction treatment of . Thus, clinicians and health systems are likely to need to develop their own young adultspecific, substance userelated quality measures, continually reassess them, and adapt them to evolving national standards. In settings where quality measures have already been adopted, there is often insufficient infrastructure to assess, analyse, report, improve, and incentivize outcomes.

The authors’ conclusions

Effective addiction treatment for young adults has been hampered by insufficient evidence, poor quality of care, inadequate clinician training, siloed systems, punitive approaches, and the view that relapse is a failure rather than hallmark of a chronic illness. The principles in the featured document should serve as a roadmap for addressing these numerous limitations.

Findings logo commentary The featured paper described recovery services for young adults. This is the first in a set of papers covering the principles of care for young adults with substance use disorders. See the full set below:

  1. Evidence-based substance use treatment of young adults with substance use disorders
  2. Engaging the family in the care of young adults with substance use disorders
  3. Support services for young adults with substance use disorders
  4. Principles of care for young adults with co-occurring psychiatric and substance use disorders
  5. Principles of harm reduction for young people who use drugs
  6. The justice system and young adults with substance use disorders

This collection of papers provides an up-to-date review of the evidence base and offers policy and practice considerations from the perspective of a working group of paediatric addiction professionals in the US.

In the UK, there is no more important document for UK clinicians involved in treating problem drug use than the ‘Orange guidelines’ (last published in 2017) – based on evidence and professional consensus on how to provide treatment for most patients, in most instances. These guidelines highlight considerations for children and adolescents as well as older people, but do not specifically address the population of young adults with substance use problems.

One of the more salient points in the featured document was that abstinence-only policies may be driving young adults away. It recommended that the goal of care should be continuous engagement. The Orange guidelines acknowledge that while some patients and observers (families and clinicians) may believe that progress in treatment should lead towards abstinence, complete abstinence from all drugs (prescribed and non-prescribed) may not be a realistic or preferred goal at various times in a patient’s treatment journey. However, the broader socio-political environment does not necessarily support this. Much like the 2010 Drug Strategy before it, the 2017 Drug Strategy reflects a world view that the best way to tackle problem drug use is to encourage people to live drug-free lives. Though it affirms a commitment to evidence-based measures, the strategy only tentatively or partially (1 2) extends this commitment to harm reduction.

Last revised 19 February 2021. First uploaded 19 February 2021

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