Support services for young adults with substance use disorders

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This entry is our analysis of a review or synthesis of research findings considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original review was not published by Findings; click Title to order a copy. Free reprints may be available from the authors – click prepared e-mail. The summary conveys the findings and views expressed in the review. Below is a commentary from Drug and Alcohol Findings.

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Support services for young adults with substance use disorders.

Xuan Z., Choi J., Lobrutto L. et al.
Pediatrics: 2021, 147, S220.
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 Xuan at zxuan@bu.edu.

[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 recovery services for young adults. Support needs to be credible and integrated with other services in order to meet the multiple and complex needs of this cohort.

Summary Young adults in recovery from substance use disorders can benefit from a variety of support services throughout the process of recovery. The featured paper identifies three basic principles for recovery support services – reviewing the related evidence base and outlining clinical considerations.

Principle 1: Given their developmental needs, young adults affected by substance use disorder should have access to a wide variety of recovery support services regardless of the levels of care they need

Evidence. In an exploratory study among individuals who entered but subsequently left publicly funded urban addiction treatment programs, authors found that 54% expressed unmet needs for social services, particularly in areas of job training, stable housing, and further assistance with housing.19 Using data among community samples in abstinent recovery, researchers found that employment was the second most frequently mentioned priority at all stages of recovery.20 Initiatives from SAMHSA have yielded valuable knowledge about the typology and implementation of recovery support services. For example, the Recovery Community Services Program was a SAMHSA-funded initiative consistent with a social-ecological framework; it includes sober and stress management, building constructive family and social relationships, peer coaching and mentoring, and education and skills training (including help with housing), as well as enhancing access to system-level resources such as primary and behavioural care, child welfare, and criminal justice systems.21 Although there is empirical evidence to support formal professionally directed aftercare models in reducing substance use disorder among adolescents and young adults,22,23 informal peer-based social network support also contributes to recovery communities.24 In a randomized trial of volunteer recovery support for adolescents after residential treatment discharge, researchers found better engagement in recovery management activities, including sobriety-related activities and self-help, and increases in the number of pro-recovery persons surrounding the recovering individuals.25 In another observational study, researchers found improvement in employment status was associated with substance use disorder post-treatment recovery outcomes, including abstinence and reduced days missed from work due to substance use.26 This adds to the literature primarily based on trials and systematic reviews about the link between employment and recovery outcomes.2730 Authors of a review study found a moderate level of evidence that recovery housing is associated with improvements in functioning, including employment and criminal activity, and abstinence.31 Younger members participating in a substance abuse recovery housing intervention for $6 months experienced better outcomes in terms of substance use, self-regulation, and employment.32 For young adults, recovery support provided within the education setting, specifically, can be an important source of social support. Structured educational recovery support services have been growing in high school and college settings since the 1970s. There is substantial heterogeneity in the structure of recovery high schools and collegiate recovery programs, but the commonality is that both create environments to support relationships among peers with similar recovery goals. Recovery high schools are typically small programs embedded within another school or part of a set of alternative schools.33 The schools provide academic courses that are often self-paced, as well as therapeutic support, which generally includes individual therapy and support groups. In a quasi-experimental study, adolescents with substance use disorders who attended a recovery high school experienced an increased likelihood of abstinence, compared with those who did not.34 Collegiate recovery programs facilitate social support for college students in recovery but tend not to provide separate educational experiences.35 Services range from sponsoring on-campus mutual help meetings to structured programs that include a physical space where counselling and social events are hosted. There are no studies evaluating outcomes associated with these programs, but a survey of student experiences found that students were primarily motivated to participate in a college recovery program because of a need for a supportive peer network.36.

Practice considerations. There is general consensus that young adults with substance use disorder require developmentally-appropriate approaches for treatment and recovery. Although factors vary in influencing relapse and recovery (including addiction severity, individual motivation and skills, co-occurring mental health conditions, family environment, and the availability of supportive peers), formal inpatient adolescent and young adult treatment programmes tend to be short, lasting between one and three months. When the treatment ends, young adults return to their communities often unprepared for the competing demands of social integration. Practitioners should work with young adults to addresses the physical, psychological, interpersonal, and community factors that affect relapse and recovery.

Principle 2: The workforce for addiction services for young adults benefits from the inclusion of individuals with lived experience in addiction

Evidence. White41 defined peer-based recovery support as the process of giving and receiving nonprofessional, nonclinical assistance to achieve long-term recovery. Other similar terminologies are used in the literature to describe peer-related support and contexts, including peer support, peer support group, peer provider, and peer mentor.42,43 Extensive literature has shown peer support groups as a key component of existing addiction treatment and recovery approaches, including residential and sober living, 12-step programs, and treatment programs in community settings. Sober living houses are drug-free living environments for a group of peers to live and recover, and they rely on mutual sobriety support and participation. In a randomized trial, researchers found an Oxford House intervention (a self-run community in which residents are expected to contribute, work, and pay bills) was associated with a significant decrease in substance use after discharge from inpatient treatment, as compared to a usual-care condition.48 Twelve-step programs such as Alcoholics Anonymous are the most popular peer support recovery approach held outside the formal treatment setting for addiction.49 Alcoholics Anonymous affiliation has been linked to better self-efficacy, healthy coping, and reductions in alcohol and drug use.50,51 Peer support services within treatment and community settings vary substantially in modalities of delivery, including in-person self-help groups, peer-run or operated services, peer partnerships, peer specialists, case managers, advocates in health care settings, and Internet support groups.52 Authors of 2 review studies found that active engagement in peer support groups has shown to be a key predictor of treatment retention, improved relationships with treatment providers, social support, and reduced relapse rates.53,54 Methodologic limitations include small sample sizes, absence of appropriate comparison groups, and the inability to disentangle the effects of peer recovery support from other treatment and support activities. More rigorous investigations are needed to assess the effectiveness of peer support recovery programs, with special attention to the advantages of peer support integration within the substance use treatment continuum.

Practice considerations. The literature on the effectiveness of peer support as an augmentation to drug and alcohol treatment for the general population confirms that it is a key and popular component for successful practice. Clinical considerations focus on exploring the multitude of specific service types and modalities, including Internet-based peer support, and how to integrate with formal treatment services in various community settings. Barriers do exist. When implementing in a unique setting, gaining a rapport with that community can present a significant challenge unless guided by key informants from the recovery community. Recovery community organizations can serve as a hub to connect to these services, reducing the access barriers. When referring to support services, practitioners are in a unique position to enlighten and influence agencies and states to recognize the value of these services and advocate for the creation of certifications for peer workers, their inclusion in Medicaid reimbursement, or other measures to support the uptake of these workers.

Principle 3: Recovery support services should be integrated to promote recovery most effectively and provide the strongest possible social support

Evidence. There is growing evidence that health care and other social services can be integrated into treating and supporting patients with substance use disorders (for example, integrating harm reduction strategies such as naloxone training and medication treatment 57 58). In systematic reviews, authors generally report that clients receiving integrated care with both substance use disorder and mental health counselling demonstrate improved substance use disorder and mental health outcomes (at least when mental health conditions are not severe) (59). Reviews of studies on patients with severe mental health conditions, however, have revealed inconsistent results (60 61). With respect to integrating substance use disorder and support services, authors of a pragmatic clinical trial of coordinated care management found that clients who received integrated care used more social services and demonstrate greater abstinence rates as compared with standard care clients (62). In a meta-analysis of integrating maternal substance use treatment and pregnancy, parenting, or child services, authors found reduced substance use associated with integrated care (63). Among a small longitudinal cohort of homeless young people suffering from a first episode of addiction in Canada, an intensive outreach intervention integrating access to housing support organizations, mental health services, and collaborative learning among providers was effective in improving young people’s housing stability, functioning, and illness severity (64). Recent review studies also reveal the value of emerging interventions integrating recovery support services to include skills training (65), employment and placement,26,66 and budgetary services (67).

Practice considerations. Because complex health-related social needs are common among patients with substance use disorders, case management is a common and practical model of service delivery for integrated care. Case management can be intensive and often requires a long-term commitment, which may limit the ability of case managers to accept new clients. Pooling resources from community-based agencies may overcome constraints of case management. One major obstacle to integration is organisational boundaries. Whereas formal inter-agency relationships help define accountability, informal relationships through the development of professional networks and collaborative learning opportunities can foster knowledge-sharing around a common purpose. At a clinical level, screening for health-related social needs enables the identification of the need for different support services. Given the ubiquity of mobile phone use and improved engagement among young adults, more evaluation is needed to assess practical feasibility and effectiveness of using mobile technology to provide integrated services and enhance uptake of potentiating timely and much-needed interventions.

The authors’ conclusions

It is critical to enhance recovery support services for young people in recovery, including through improving the credibility of services. It is also critical to integrate these recovery services for young adults into existing treatment structures and community resources.

Although the principles in the featured article derive from the research literature that may tend to focus on the general population or on a certain type of substance (ie, alcohol) and not necessarily on opioid use among young adults, these principles should serve as a useful guiding roadmap for overcoming barriers and achieving better efficiency and quality of care.


Findings logo commentary The featured paper described recovery services for young adults. This is the third 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 is of interest and relevance to UK practitioners to the degree that it 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.

Last revised 19 February 2021. First uploaded 19 February 2021

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