“No Excuses Anymore:” Substance Use Screening and Treatment for Justice-Involved Youth

Abstract

Objective

To present best practices for substance use disorder (SUD) screening and treatment in the juvenile justice setting.

Methods

Semi-structured qualitative interviews, informed by the Capacity-Opportunity-Motivation-Behavior (COM-B) Model, were conducted with medical and behavioral health providers with experience caring for justice-involved youth. Interviews were analyzed using thematic and content analysis to elucidate best practices and identify facilitators and barriers affecting implementation of evidence-based substance use screening and treatment.

Results

We interviewed 14 participants from twelve unique institutions and nine states. All participants described the populations in their facilities as predominately male and minoritized, with substance use being an exceedingly common problem. Eight main themes emerged from analysis of the barriers and facilitators discussed by participants. These included importance of: (1) ensuring substance use-specific training for all team members, (2) integrating medical and behavioral healthcare, (3) addressing staff reticence and stigma, (4) building an institutional culture which supports screening and treatment, (5) dedicating adequate resources with respect to time, staffing, and funding, (6) formalizing and standardizing screening and treatment protocols, (7) engaging youth using trauma-informed approaches that emphasize youth strengths and autonomy, and (8) collaborating with multidisciplinary teams and community partners to maximize linkage to follow-up care after release.

Conclusions

Our findings highlight an urgent need for improved implementation of evidence-based, developmentally-appropriate substance use treatment for justice-involved youth. While the majority of participants screen youth, they described variable implementation of behavioral health interventions and limited provision of on-site withdrawal management and treatment using medications for SUD.

Introduction

Every year, more than one million youth in the U.S. become involved in the juvenile justice system via arrest, probation, and/or juvenile detention.¹ The National Survey on Drug Use and Health indicates that up to 4.5% of all U.S. adolescents have had juvenile justice involvement.² Adolescents at all levels of the justice system are significantly more likely to meet criteria for a substance use disorder (SUD) compared to the general adolescent population, with prevalence of SUD recently estimated at 68%.³ SUD treatment reduces recidivism for justice-involved youth.⁴ For justice-involved adults, SUD treatment enhances treatment engagement after discharge, decreases relapse rates, improves recidivism, and reduces overdose deaths.^5,6 Despite the need and the demonstrated benefits, only a small proportion (4.4-27.95%) of justice-involved adolescents receive SUD treatment^7-10.

There is minimal literature available regarding best practices for addiction care specific to the juvenile justice setting. While some data is available regarding effective behavioral interventions for justice-involved youth with addiction,^12,13 there is no consensus on which approaches are standard of care. There are few studies about treatment with medications that are specific to justice-involved youth, even though both medication for opioid use disorder (MOUD) and medication for alcohol use disorder (MAUD) are established as safe and life-saving for adolescents.^14-18 Despite some juvenile detention centers having protocols for MOUD and MAUD, minimal literature has been published about their implementation and outcomes.^12,19

The present study seeks to address these gaps through qualitative interviews with providers caring for justice-involved youth across the country. We aim to elucidate best practices for substance use screening and treatment in the juvenile justice setting and describe barriers and facilitators to implementation.

Methods

Study participants

We used purposive sampling and recruited participants from the listserv for the Society for Adolescent Health and Medicine’s Special Interest Group in Juvenile Justice. We used snowball sampling as participants were able to refer other qualified colleagues to participate. Participants were required to be medical or behavioral health providers currently or previously employed in a U.S. juvenile justice setting with experience providing care to justice-involved youth. All participants had experience pertinent to youth in detainment. We continued recruitment until reaching thematic saturation.²⁰

Study design

This study consisted of 30-60 minute semi-structured qualitative interviews conducted between November 2021 and March 2022. Interviews were conducted by a single, trained interviewer. The study protocol was approved by the Institutional Review Board of the University of Pittsburgh on August 18, 2021.

Conceptual framework

We selected a comprehensive behavioral change framework,²¹ the Capability-Opportunity-Motivation-Behavior (COM-B) model, to inform both the interview guide and the coding framework. In this model, behavior results from an individual having the physical and psychological capability to utilize social and physical opportunities via automatic or reflective motivators. COM-B allowed us to explore how capability, opportunity, and motivation interact to affect adoption of evidence-based substance use screening and treatment for justice-involved youth. COM-B has been used in multiple qualitative studies and systematic literature reviews as a comprehensive framework to describe barriers and facilitators to the adoption of diverse target behaviors.^22-24

Data analysis

Interviews were audio-recorded anonymously using a digital recorder and transcribed verbatim. Interviews were analyzed iteratively. Two coders (PG and IH) double-coded two interviews and met to adjudicate differences with DW. The intercoder agreement was 88%. As the intercoder agreement was high, the remaining transcripts were divided and coded by a member of the research team (either PG or IH). A codebook was developed using a priori codes from the COM-B framework as well as novel inductive codes generated from open coding of the interviews manually in Excel. The team (PG, IH, DW) met regularly to iteratively review codes and refine the codebook as new codes were generated from the data. The codebook was used as a basis for content and thematic analyses.^25,26 The study team (PG and IH) consolidated codes into themes with feedback from DW.

Results

Participant Demographics

Fourteen participants, representing twelve unique institutions, nine states, and a range of regions across the United States, were interviewed for this study (Table 1). Ten were clinical providers. Those remaining held administrative roles within state agencies that oversee health services for the juvenile justice system but also had clinical backgrounds.

Table 1.

Demographic characteristics of study participants

Characteristic	n (%)
Degree Held (n=14)
MD	3 (21)
MD, MPH or MD, MSc	4 (29)
MD, PhD	2 (14)
FNP	1 (7)
MSW, LCSW, PhD	1 (7)
MA (Clinical Psychology)	1 (7)
PhD (Clinical Psychology)	2 (14)
Medical Specialty for MD (n=9)
General Pediatrics	1 (11)
Adolescent Medicine	7 (78)
Pediatric Psychiatry	1 (11)
Age (n=14)
20-29	1 (7)
30-39	2 (14)
40-49	6 (43)
50-59	5 (36)
Gender(n=14)
Male	3 (21)
Female	11 (79)
Self-Identified Race/Ethnicity
White, non-latino/a	10 (71)
White, latino/a	1 (7)
Black	1 (7)
Southeast Asian	1 (7)
Mixed	1 (7)
Geographic Region
Mid-Atlantic (MD, PA)	3 (21)
Midwest (OH, IN, WI)	5 (36)
Northeast (RI)	1 (7)
Southeast (GA)	2 (14)
West (CA, WA)	3 (21)

Client Demographics

While we use the inclusive term “justice-involved youth,” the participants in this study predominantly interface with youth in detention centers or associated clinics. All participants described the populations they work with as predominantly male, minoritized youth. Overrepresented minoritized populations included Black, Latino, and American Indian youth, with seven informants estimating that more than 70% of clients were Black or Latino. Estimated percentages of male clients ranged from 75-90%. The age of clients varied, ranging from 8-25.

The majority of youth seen in juvenile justice settings engage in problematic substance use. Four participants estimated that at least 50% of youth meet criteria for SUD and one noted that the true rate may be more like 90%. Cannabis and synthetic cannabinoids were the most commonly used substances, followed by nicotine and alcohol. Prevalence of other substances varied, including cocaine, methamphetamines, benzodiazepines and opioids. Ten participants reported opioid use to be rare whereas four participants reported opioid use as a common, growing problem, with 20% of the population from one detention center meeting criteria for opioid use disorder. Most expressed caring for youth experiencing acute withdrawal infrequently or never.

State of Substance Use Care for Justice-Involved Youth

The current state of substance use care for justice-involved youth in detention settings varies widely (Table 2). The majority of participants implemented a protocol for universal screening (83%) at their facilities, however there is notable variation in the timing and method of screening. Most facilities had some behavioral therapy available on-site (75%), although there was variation in the type, intensity, and administrators of behavioral therapy. Many described motivational interviewing-based interventions such as the Seven Challenges program. Others described CBT and/or DBT as the foundation of behavioral interventions. Some sites offered primarily psychoeducation.

Table 2.

Current state of SUD care for justice-involved youth

		Total informants 12
		N (%)
Screening
	Universal Screening	10 (83)
	Timing of Screening
	Within 2 hr	2 (17)
	Within 24 hr	1 (8)
	Within 48 hr	1 (8)
	At intake	4 (33)
	Yearly	1 (8)
	Inconsistent	3 (25)
	Administrator of Screening
	Officer	2 (17)
	Non-clinical staff	3 (25)
	Nurse	7 (58)
	Mental health provider	5 (42)
	Medical provider	9 (75)
	Multiple	7 (58)
	Screening Tool
	MAYSI	4 (33)
	SASSI	1 (8)
	GAIN	1 (8)
	CRAFFT	2 (17)
	SHADESS/HEADSSS	5 (42)
	Institution-specific	3 (25)
	Urine toxicology screen	2 (17)
Behavioral Therapy
	Available on-site	9 (75)
	Unavailable on-site	3 (25)
Pharmacotherapy
	Waivered providers available	7 (58)
	MOUD
	Initiated	3 (25)
	Continued by on-site provider	3 (25)
	Continued by off-site provider	3 (25)
	MAUD	3 (25)
Withdrawal Management
	On-site withdrawal monitoring	8 (67)
	With medication administration	5 (42)
	Without medication administration	3 (25)
	Transfer to ED	4 (33)

There was also variation in the availability of evidence-based pharmacotherapy for SUD. The majority described having provider(s) trained in buprenorphine prescribing (58%), but there was variation in whether MOUD was being actively prescribed and in what circumstances. Of the seven sites with waivered providers, three actively initiate buprenorphine therapy, three will continue buprenorphine therapy initiated before admission, and one has not yet identified an appropriate opportunity to prescribe. Some facilities without waivered providers allowed outside providers to continue to prescribe via telemedicine while a youth was admitted (25%). Few facilities offered MAUD such as extended-release naltrexone (25%).

Withdrawal management also varied across facilities. The majority of facilities provided some on-site withdrawal monitoring utilizing a clinical scoring tool (58%). Of the seven facilities offering on-site monitoring, two transferred to the Emergency Department for scores high enough to warrant medication, and five administered medications on-site. Facilities without capacity for on-site monitoring pursued immediate transfer to the Emergency Department if withdrawal was suspected (33%).

Themes, Barriers, and Facilitators

Codes and sub-themes were generated across each of the core domains of the COM-B framework (Tables 3 and 4, Figure 1). Eight themes emerged from analysis of the barriers and facilitators discussed by informants.

Table 3.

Key barriers to substance use care for justice-involved youth and illustrative quotes

COM-B Domain	Sub-Theme	Quotes
Psychological Capability	Inadequate SUD-specific training	Getting all of our clinicians appropriately waivered was step one. My hope had been that we would actually get to a place where we could do induction at the detention facility. But that also meant getting our nurses trained, and so on.
	Lack of MOUD knowledge	Lack of training for providers is a barrier. So we have talked about Buprenorphine training as a program but we haven't been able to get something like that coordinated because we are a small program.
	Variable provider comfort	Total volume is low, so it’s hard for providers to gain any comfort with bupe. Like, you need to be very comfortable using those medications, sending people out with Naloxone, that kind of thing.
	Limited behavioral health resources	We don't have any in-house mental health support - period. Much less substance use counseling. It really is the resource issue.
Physical Capability	Threats to youth safety	We ran into all kinds of safety issues.
	Influence of home environment	Since they’re kids, they go back to where they came from by and large. So in some cases, many cases, they're going back into the very situations that generated problems.
Reflective Motivation	Negative beliefs about SUD	Views on substance use are almost like political views. You know what I mean? So they can be set in their ways. It doesn't matter what kind of evidence you provide them.
	Negative beliefs about MOUD	And so what can happen depending on your nursing staff, your behavioral health staff, is almost how much they believe in the necessity of medication assisted treatment, they may or may not bring certain kids to your attention.
	Poor staff receptivity	I think we have faced what everybody faces, right? That, I'm gonna identify it, but then I don't have anything to give, and I don't have anybody to connect them to, and so I'm not gonna work so hard to identify it.
Automatic Motivation	Unsupportive leadership	If you're in a state agency, you also have to have your top management in agreement with what you're doing.
	Stigma	There can be biases against the kids that have really significant opioid use disorders. And again, changing that culture of the facility so that the staff aren't thinking in their minds "it's just a junky."
	Fear of diversion	The other barrier is removing that concern for contraband. I think Suboxone just has a bad rap, you know, because it's used in contraband in a lot in prisons…. I'm trying to remove the need for contraband because we're offering treatment.
Physical Opportunity	Inadequate time	There were so many people that just didn't want to do it, because it's another thing. And intakes take so long.
	Staffing shortages	The main barrier is person power. In any given time, you know, there's a certain number of vacancies in our system across the board and it is hard to get people into some of the positions.
	Insufficient funding	Lack of funding to support SUD treatment. I'm sure that funding is a problem.
	Lack of protocols	We would like to start it, but we actually have to have some sort of protocols in place.
	Difficulty stocking medications on-site	If you're gonna store a CDS, like buprenorphine is, you have to have a CDS registration and a DEA registration for the facility. Not just for the provider, but for the facility. And that is not an easy process to do.
	COVID	I would say that COVID has put a damper on anything because, with quarantine, kids can't interact with anybody. So as the precautions, hopefully, continue to lift, I think that we will have more opportunity to actually work with the kids.
Social Opportunity	Youth reticence to disclose substance use	I think it's hard because when we do our intakes, kids are hesitant to disclose substance use because of where they are.
	Youth ambivalence	Sometimes youth interest in treatment is not, you know, they are not there yet.
	Lack of community substance use resources	There are very few pediatric substance abuse services, right? And even fewer that insurance covers. Which is a problem.
	Difficulty continuing medications post-release	There's not great adolescent outpatient MAT available. That level of discontinuity of care is the biggest challenge for us.

Table 4.

Select facilitators of substance use care for justice-involved youth and illustrative quotes

COM-B Domain	Sub-Theme	Quotes
Psychological Capability	SUD training for all team members	Training for staff, training for nurses, training for juvenile probation officers has to be part of it.
	Knowledge of adolescent development	The need to have an Adolescent Medicine specialist was really important to us. Most juvenile detention centers are under the supervision of Adolescent just because of the extra training with the population.
	Training in communication with youth	I do think that strength-based scripts for providers to practice. The difference between, "Do you drink?" versus, "How much would you say you drink, if any?" That kind of scripting.
	Comfort with motivational interviewing	I think another thing that is an underutilized tool that’s a lot easier to initiate is motivational interviewing based stuff.
	Trauma-sensitive approaches	Make sure that everybody is trauma-trained. Trauma, affect regulation, and substance use are the three legged stool.
	Addressing drivers of substance use	I think one of the things to recognize is the large number of dual diagnoses. And that managing the depression, the anxiety, the PTSD symptoms, all of that, really needs to be part of understanding substance use treatment.
Reflective Motivation	Staff empowerment	Anybody should be able to write the substance use assessment, do the intake, all that sort of thing…now it's not really an issue because it's just what we do. Everybody knows the language and the young people know the language.
	MOUD as standard of care	There's no excuse anymore. Juvenile and adult correctional facilities should be offering medication-assisted- treatment or medication-based treatment. There should be no more excuses.
Automatic Motivation	Institutional culture	So sometimes it's the culture of the facility, sometimes you have to move that slowly on the spectrum to where you want to get it to match best practices. And that takes, you know, kind of education of everybody.
	Leadership support	The biggest factor that sets that tone is the leader of the institution. Having leadership that's vocally supportive of the substance use program, that is also anti-racist and setting a tone that makes it a positive work environment.
	Addressing fears and stigma	I've had to have conversations with staff - I'm thinking of one staff member who is a recovering addict themself and they are biased that replacing one substance with another is not true recovery.
Physical Opportunity	Standardized protocols	I think it has to be in written into the forms or electronic medical record that you're using. You've got to have standard questions that you think you want to ask and you ask everyone.
	Staff availability	You know, it's really good to have 24/7 nursing coverage. To really do this work, and not put certain kids in the hospital, you really do have to have 24/7 nursing coverage.
	Securing funding	Be thinking in terms of the clinical outcomes. You get the programming, you get the money, that's awesome. You've got to be able to demonstrate the usage and the efficacy. Be thoughtful at the beginning to make sure you get what you need.
Social Opportunity	Honoring youth autonomy	Seven Challenges really empowers young people. I'm not here to get you to quit using drugs. That's not my job. My job is to really help you think things through. And help you be successful with whatever that might be for you.
	Strengths-based interviewing	Staff are all very well-trained in strength-based approaches to motivational interviewing. Really understanding what healing-centered approaches mean and how to bring that kind of more healing and recovery focus to it.
	Harm reduction approach to care	It’s about the risk reduction, which is a really different way of thinking about substance use treatment rather than saying: don't use it and if you use it, you're bad. Instead, let's talk about what change might look like.
	Incorporating family	When they leave and they go home, their family is a big piece of things. If you haven't included the families early on, that tends to not go as well. If the kid is okay with you enlisting the help of the parents, that can be really huge.
	Standardized discharge process	We do a youth centered reentry team (YCRT) meeting for every youth that comes in. At entry, we're getting ready for exit and getting after-care release plans for that youth to find out what they need. They all have that YCRT plan ready to go.
	Continuity of care	We've been trying for a while now to set up so that our clinicians can keep working with kids after they leave. A number of youth said yeah, they would like to do that if they could. They've connected with people here.

Figure 1:

Barriers and facilitators of implementing substance use care of justice-involved youth and corresponding subthemes mapped onto the COM-B (capability, opportunity, motivation and behavior) framework

Theme 1: Substance use-specific training for all team members is critical to increase comfort and build capacity. (Psychological Capability)

Staff & Provider Comfort

There was significant variability in staff members’ comfort with obtaining a substance use history and offering substance use treatment including pharmacotherapy to youth. This discomfort led to variation in screening for substance use, with some staff members resorting to closed-ended questions or truncated evaluations. Additionally, some staff were reluctant to alert providers to problems once identified. Facilitators of comfort included having team members with long-term experience working with justice-involved youth and/or with expertise in substance use.

Knowledge & Training

Lack of SUD-specific training, particularly related to MOUD and MAUD, was frequently cited as a barrier to providing substance use care to youth in detention settings. Many participants recommended the integration of SUD-specific training into routine training for all team members, including nurses, staff, juvenile probation officers, and ideally community partners. Participants who were unable to offer adequate training relied on contracted community providers; however, the majority aspired to enhance provider capacity to provide substance use care on-site.

An often-cited facilitator was training specific to care of adolescents. Multiple participants prioritized employing medical provider(s) board certified in Adolescent Medicine due to their expertise in tailoring SUD care to be developmentally appropriate for adolescent populations. Staff trainings in communication strategies utilizing strengths-based scripts and principles of motivational interviewing were highly valued.

Theme 2: Utilization of an integrated behavioral health model helps to address underlying reasons for substance use. (Psychological Capability)

Integrated Behavioral Healthcare

Many participants iterated that effective substance use care must address the underlying drivers of substance use, including anxiety, depression, sleep disturbance, stressful home environments and trauma. Participants who lacked behavioral health resources or had medical and behavioral health teams working in isolation from one another found this to be a significant barrier. Facilitators of effective care included an integrated, on-site behavioral health team in which all behavioral health providers were expected to have competence in both mental health and substance use. Those who moved from a siloed to integrated approach noted some resistance and challenges initially, but ultimately found that their teams had improved ability to address substance use. Behavioral health providers included certified drug and alcohol counselors, licensed clinical social workers, psychologists and licensed family therapists.

Theme 3: Staff reticence and beliefs about substance use create potential barriers that must be addressed. (Reflective Motivation)

Beliefs about Substance Use Disorder

While most participants denied encountering overtly stigmatizing behavior or biased language from staff, they described a wide range of staff beliefs about treatment of SUD, particularly with MOUD. Some encountered distrust of MOUD due to concerns about diversion. Some encountered staff who discouraged youth from using evidence-based pharmacotherapy due to the belief that this is replacing one substance with another and not true recovery. Others described that implementation of MOUD was facilitated when staff considered MOUD to be standard of care.

Theme 4: It is important to shape an institutional culture in which substance use screening and treatment is normative and expected. (Automatic Motivation)

Institutional Culture

Participants cited institutional culture as an important driver of automatic motivation, noting that leadership that supports treatment for SUD sets the tone for staff. Participants described slowly shifting institutional culture to align with best practices through collecting persuasive data, educating all team members, developing a shared language and approach around substance use, and establishing a universal expectation that all team members are comfortable identifying and addressing substance use.

Theme 5: Adequate resources must be secured with respect to time, staffing, and funding. (Physical Opportunity)

Time

Time is an important factor in substance use screening and successful youth engagement. Staff feel reluctant to perform screening when time is limited, thus protected time must be built into the intake process. Multiple participants cited COVID quarantine protocols as a barrier to engagement between youth and staff in detention settings.

Staffing

Participants consistently cited 24/7 nursing availability as a prerequisite for safe on-site withdrawal management and SUD treatment in detention settings. Facilities without consistent 24/7 nursing coverage, including those experiencing staffing shortages or vacancies related to the COVID pandemic, were often forced to send youth to the Emergency Department. Availability of behavioral health and medical providers was also an important facilitator.

Funding

Many participants described lack of funding as a barrier to providing substance use care, with several specifically noting lack of funding for behavioral counseling. Those who had secured consistent funding cited data collection as critical to demonstrate need and substantiate use of funds. Participants described system-level barriers to receiving funding from the Juvenile Justice System that were largely outside of their control, including administration turnover, bureaucratic hurdles requiring many layers of approvals, and legislated budget cuts.

Theme 6: Formalizing and standardizing protocols facilitates care that is uniform and comprehensive. (Physical Opportunity)

Protocols

Every participant who successfully implemented substance use treatment in the juvenile detention setting emphasized the importance of having formalized, standard protocols for screening, withdrawal management, and MOUD administration. For buprenorphine, informants emphasized safe storage and observed dosing. Some informants included urine screening as part of routine protocols while others ordered urine testing on a case-by-case basis.

Medication Availability

Participants identified a number of barriers to providing on-site medication for withdrawal management and SUD treatment in detention settings. Barriers to stocking medications on-site included low frequency of use, formulary limitations, and requirements for CDS and DEA registration in order to stock buprenorphine. Among facilities without medications on-site, some had processes in place to obtain medications quickly and some were able to store and dispense medications obtained through the Emergency Department.

Theme 7: Overcoming youth ambivalence about substance use requires effective youth engagement based on principles of supporting autonomy, focusing on youth strengths, and trauma-informed care. (Social Opportunity)

Disclosure of Substance Use

Many participants described youth reticence to disclose substance use as a significant barrier to addressing substance use in the juvenile justice setting. They noted youth often choose not to disclose substance use because they are not sure if the information may be used against them in court proceedings. Participants emphasized the importance of discussing principles of confidentiality and boundaries of confidentiality explicitly. They also recommended multiple layers of screening by different members of the care team so that youth have multiple opportunities to disclose.

Youth Ambivalence

Many informants described youth ambivalence about changing substance use behaviors and engaging with treatment. Barriers may arise if youth perceive substance use as normative with minimal consequences, which was described commonly with respect to cannabis use. Some participants incorporated peer perspectives to enhance motivation, for example in the form of written testimonials or by leveraging peer specialists. Others emphasized the importance of engaging families or other trusted adults when possible.

Effective Youth Engagement

Many participants advocated to engage youth utilizing principles of motivational interviewing. Some identified staff members with lived experience as potential leaders to model effective youth engagement around substance use. They emphasized that honoring youth autonomy and choice is important to empower and engage youth. They frequently applied a harm reduction lens, understanding that not all youth have the goal of abstinence, but we can still partner with them to reduce risk and meet their self-determined goals. Multiple participants highlighted the importance of applying a strengths-based approach centered around youth empowerment and healing.

Theme 8: Connecting youth to substance use care after detention is challenging, and standardized discharge processes, multidisciplinary care coordination teams, and community partnerships can help to overcome this challenge. (Social Opportunity)

Coordinating Care Post-Release

Most participants described difficulty connecting youth to SUD treatment after detention. Barriers included lack of providers for youth under 18, limited services in rural areas, inadequate programs offering a higher level of care such as inpatient care, short durations of detention that limit opportunity for referral, difficulty coordinating with parents and primary care providers, and problems with insurance coverage. Some providers did not feel comfortable initiating medications for SUD in detention because they could not be reliably continued after release. Facilitators included having a standardized discharge process for all detained youth that begins with a youth-centered re-entry team meeting at the time of entry. Several participants emphasized the importance of multidisciplinary teams. Some participants recommended partnering with probation officers, child welfare workers, and/or public defenders as part of the discharge planning team. Many highlighted the importance of developing community partnerships and providing support and warm hand-offs to community partners whenever possible.

Discussion

Our study affirmed the high prevalence of substance use among justice-involved youth and all study participants identified substance use as one of the most important issues to address for this population. While cannabis was identified as the most problematic substance, perspectives varied about the current threat posed by other substances including alcohol, opioids, benzodiazepines, and stimulants. This seems to reflect regional differences in substance use patterns but may also reflect differences in quality of screening protocols and youth comfort with disclosing use.

While the majority of facilities represented by study participants had a protocol in place for universal screening, there was variation in the timing, administrators, and tools used. There was no consensus on a preferred screening tool for justice-involved youth among our participants nor evidence comparing screening tools in this population.^27-30 Our interviews suggested which screening tool is used may be less important than establishing a uniform, multi-layered screening process whereby youth are screened multiple times by multiple people. Participants highlighted the importance of universal staff training regarding appropriate screening techniques and formalized protocols to ensure screening is applied equally to all youth in detention settings.

The majority of facilities represented in the study offered some form of on-site behavioral therapy for SUD, although there was variability in intensity and type of intervention available. Numerous participants highlighted the benefits of having behavioral and medical healthcare integrated on-site and the importance of training staff to address both SUD and the trauma, anxiety, depression, or other mental health conditions that may be drivers of substance use. Other participants talked about the importance of engaging and empowering youth by supporting autonomy, emphasizing youth strengths, applying trauma-sensitive approaches, and incorporating family when possible. These findings are supported by randomized controlled trials and meta-analyses that substantiate the effectiveness of Multidimensional Family Therapy, Multisystemic Therapy, Motivational Interviewing and CBT for justice-involved youth with SUD.^12,13,31-34 Small studies also suggest that contingency management, mindfulness, helping others, positive reinforcement by parole officers, and text-messaging augmentation of therapy may be beneficial for justice-involved youth.^35-39 Extensive literature substantiates the importance of trauma-responsive programming.⁴⁰ Our work highlights the importance of not only offering behavioral interventions for SUD, but also integrating them as closely as possible with other services in the juvenile justice setting.

While more than half of the facilities included had processes in place for monitoring withdrawal symptoms, on-site management of withdrawal was limited and many facilities utilized the Emergency Department. Access to MOUD and MAUD also remained limited in most facilities. There are a number of important lessons that can be drawn from the few facilities that have robust programs for managing withdrawal and prescribing MOUD and MAUD on-site. Firstly, it is vital to build institutional support for prescribing MOUD and MAUD from leadership, clinicians, and staff. Consistent 24/7 nursing coverage is essential and nurses need protected time to administer buprenorphine. Detailed protocols must be delineated and there must be providers available to provide guidance when issues arise. Having outside mentors and consultants is valuable, especially as providers are developing comfort. While some expressed concern about diversion, the facilities storing and administering buprenorphine on-site developed straight-forward safety mechanisms including secure storage, sublingual application by nurses, verification of ingestion by checking under the tongue, and designation of a dedicated space and time for buprenorphine administration. One informant noted that having buprenorphine on-site and providing it to youth who needed it greatly reduced the risk for contraband.

One of the strengths of this study is the diversity of backgrounds, roles and geographic locations of participants. Perspectives ranged from providers with minimal SUD care capacity to those with comprehensive SUD programs in place, which allowed for insights to barriers and facilitators across different stages of implementation. We were able to reach thematic saturation because there was consensus around many critical themes. Of note, all participants had a clinical background, which may have contributed to shared beliefs and perspectives, and additional themes would be expected to emerge in future iterations of this study that should include administrators, parents, and youth. Additionally, our study applied an existing, evidence-based framework to a novel topic. Limitations included that participant inclusion was based on response from the pool of individuals initially contacted, which may have been a non-random sample. The interviews took place during the COVID-19 pandemic, which may have inhibited growth of SUD care and prevented certain facilitators from emerging. In addition, themes emerged that were not a focus of the interview script related to trauma and racial disproportionality, which could be further explored in the future.

Conclusions

In summary, our study demonstrates that sites across the country have made significant advances in the identification and treatment of SUD among justice-involved youth in detention settings; however, there is still a lot of work that needs to be done, especially in regards to on-site provision of MOUD and MAUD. Systemic inequities have led to an overrepresentation of youth from minoritized groups in the juvenile justice system and further harm is done when these youth do not get appropriate medical care while detained. We know that youth involved in the juvenile justice system are at much higher risk of SUD and that ongoing substance use increases risk of recidivism. We must find ways to enhance access to life-saving SUD treatment for justice-involved youth and build capacity within the community to continue care after their release while addressing underlying trauma, mental health conditions, and social determinants of health that are so often the drivers of adolescent substance use.

Abbreviations:

SUD

substance use disorder

MOUD

medication for opioid use disorder

MAUD

medication for alcohol use disorder