Treatments Used Among Adolescent Residential Addiction Treatment Facilities in the US, 2022

Abstract

This study surveyed US adolescent residential addiction treatment facilities to assess treatments used for adolescents younger than 18 years seeking treatment for opioid use disorder.

An unprecedented number of adolescents were identified as having an opioid use disorder (OUD) in 2021.¹ Residential treatment facilities are part of the American Society for Addiction Medicine’s levels of care for adolescents with OUD,² yet little is known about treatment facility practices. Buprenorphine is the only OUD treatment approved by the US Food and Drug Administration for use in adolescents aged 16 years or older; the Society for Adolescent Health and Medicine states that medications for OUD, including buprenorphine, should be offered with behavior therapy (eg, family-based therapy) to all adolescents with OUD, although adolescents who do not pursue behavior therapy should not be denied medications for OUD.³ Despite this, buprenorphine treatment is limited among adolescents.⁴ This study surveyed US adolescent residential addiction treatment facilities (hereafter referred to as facilities) to assess treatments used for adolescents younger than 18 years seeking OUD treatment.

Methods

We adapted a “secret shopper” approach to simulate calls inquiring about treatment to all identified facilities in the US from October to December 2022.⁵ We identified facilities using the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Locator and SpyFu, a website that captures Google advertising data. We called as the aunt or uncle of a 16-year-old with a recent nonfatal fentanyl overdose to make calls more plausible if we did not have all requested information about the adolescent. Four investigators (C.K., N.S., D.B., and P.B.) called facilities in random order and asked to speak to someone about residential treatment. We called facilities up to 7 times on different days. We asked specific questions about buprenorphine use and open-ended questions about other available treatments (Supplement 1). Data were analyzed using StataIC version 16.1 (StataCorp). The Oregon Health & Science University institutional review board deemed this study non–human subject research.

Results

We identified 354 facilities, reached 327 (92.4%), and confirmed that 160 (45.2%) provided residential treatment to patients younger than 18 years (Figure). Of 160 facilities, 39 (24.4%) offered buprenorphine, including through partnership with outside clinicians, which varied by US region (18.0% in the West to 40.0% in the Northeast) (Table). Twelve facilities (7.5%) offered buprenorphine initiation but discontinued before discharge, 17 (10.6%) initiated buprenorphine and offered ongoing treatment, and 3 (1.9%) offered buprenorphine for ongoing treatment only. Twelve facilities (7.5%) offered buprenorphine to adolescents younger than 16 years. Four facilities (2.5%) offered long-acting injectable buprenorphine.

Figure. Inclusion of Facilities in a Study Assessing Adolescent Residential Treatment Facilities, 2022.

Table. Reported Treatment and Supportive Programming Used by Adolescent Residential Addiction Treatment Facilities (N = 160).

Treatment and support modalities	No. (%)a
Pharmacotherapyb
Offers any buprenorphine	39 (24.4)
Northeastc	6/15 (40.0)
Midwestc	11/32 (34.4)
Southc	11/52 (21.2)
Westc	11/61 (18.0)
Offers buprenorphine initiation with discontinuation prior to discharge	12 (7.5)
Offers buprenorphine initiation with ongoing treatment	17 (10.6)
Offers buprenorphine for ongoing treatment only	3 (1.9)
Offers buprenorphine to adolescents <16 y	12 (7.5)
Behavior treatmentb
Family therapyd	86 (53.8)
Cognitive behavior therapy	52 (32.5)
Community reinforcement approach	44 (27.5)
Community reinforcement and family training	26 (16.3)
Dialectical behavior therapy	17 (10.6)
Mutual help
12-step program or Alcoholics/Narcotics Anonymous	59 (36.9)
Other supportive programming
Equine therapy	40 (25.0)
Art therapy	40 (25.0)
Music therapy	37 (23.1)
Outdoor adventure	21 (13.1)

^a Percentages total greater than 100% because categories are not mutually exclusive

^b Recommended by the Society for Adolescent Health and Medicine.³

^c US census regions are defined as follows: Northeast includes CT, ME, MA, NH, RI, VT, NJ, NY, and PA; Midwest, IN, IL, MI, OH, WI, IA, KA, MN, MI, NE, ND, and SD; South, DE, DC, FL, GA, MD, NC, SC, VA, WV, AL, KY, MS, TN, AR, LA, OK, and TX; and West, AZ, CO, ID, NM, MO, UT, NV, WY, AK, CA, HI, OR, and WA.

^d Family therapy includes community reinforcement and family training.

Among the 121 facilities that did not offer buprenorphine or were unsure, 57 (47.1%) indicated that adolescents who were prescribed buprenorphine by their own clinician could continue receiving it, at least temporarily, although some facilities indicated they would discontinue it before discharge, and 27 (22.3%) required adolescents to not be receiving buprenorphine at admission. Sixty-three facilities (39.4%) indicated that adolescents could undergo on-site withdrawal. Of those facilities, 18 (28.6%) offered buprenorphine and some did not offer any medication adjuncts.

Of 160 facilities, 140 (87.5%) had someone available who could prescribe medications for psychiatric comorbidities (eg, depression). Overall, 124 (77.5%) had naloxone on site, 24 (15.0%) did not, and 11 (6.9%) were unsure.

Family members were included in adolescent treatment in 86 facilities (53.8%). Leading approaches for adolescent treatment included mutual help frameworks (eg, 12-step program; n = 59 [36.9%]), cognitive behavior therapy (n = 52 [32.5%]), community reinforcement/adolescent community approach (n = 44 [27.5%]), art therapy (n = 40 [25.0%]), and equine therapy (n = 40 [25.0%]) (Table).

Discussion

In contrast to the standard of care,² only 1 in 4 US facilities offered buprenorphine and 1 in 8 offered buprenorphine for ongoing treatment. By comparison, nearly two-thirds of adult residential facilities offer buprenorphine.⁵ The average parent would need to call 9 facilities on the SAMHSA Treatment Locator list to find one that offered buprenorphine and 29 to find one for an adolescent younger than 16 years.

Therapeutic programming across facilities was unstandardized. Only half of facilities reported including families in treatment. No other evidence-based treatment was used by more than one-third of facilities. Despite limited evidence of its efficacy, equine therapy was more common than buprenorphine use.⁶

Limitations include that 27 facilities were unreachable by phone and that other facilities not identified may have been excluded. Therapy types, other than buprenorphine, were not explicitly elicited during calls; this may have led to underreporting of other therapies.

Section Editors: Jody W. Zylke, MD, Deputy Editor; Kristin Walter, MD, Senior Editor.

Supplement 1.

eMethods

Supplement 2.

Data Sharing Statement