Statewide Teleconsultation and Rapid Linkage to Services for Youth with Opioid Use Disorder and Other Substance Use

Abstract

Objective:

With rising U.S. adolescent overdose deaths, interventions are needed that overcome access-to-care barriers like stigma and limited availability of developmentally appropriate, best-practice services, including medications for opioid use disorder. Modeled on the widely-disseminated child psychiatry access program (CPAP) framework, the Indiana Adolescent Addiction Access (AAA) Program provides a statewide consultation line to connect healthcare providers with adolescent addiction specialists. This report summarizes the initial implementation of the AAA program.

Methods:

The AAA line is staffed by a coordinator, who fields initial questions, and on-call clinical specialists (social workers, nurse practitioner, psychiatrist, psychologists), who can be paged to complete telephone consultations and provide recommendations. When indicated, AAA providers offer urgent clinical assessments and initiate treatment. Descriptive analyses were performed for key variables over the first 21 months of AAA operations.

Results:

From July 2021 to March 2023, a total of 125 consultations were completed. Most callers were healthcare providers (71%) or parents (27%). Calls pertained to youths aged 10–18 (M=16.4, SD=1.3; 62% male, 84% white, 11% black), with concerns around cannabis (63%), opioids (34%), and other substances. Roughly 25% of calls related to an overdose, and 41% of cases were rated as severe. Recommendations included starting medications (17%) and/or therapy (83%), and 17% of consultations resulted in urgent evaluations.

Conclusions:

The Indiana AAA program helps overcome key barriers to adolescent substance use treatment. Capacity to initiate medication for opioid use disorder and other treatment rapidly through consultation and direct care is a promising, scalable approach for preventing youth overdose deaths.

Introduction

In the United States (US) in 2021, 20–25% of 12^th graders reported monthly use of alcohol, nicotine, and cannabis (1). In Indiana, average age of substance use onset has decreased (from 13.6 to 12.7 years) across substance classes in recent years (2). Earlier and more frequent substance use in adolescence is associated with increased risk for substance use disorders (3, 4, 5). Adolescent mortality due to unintentional overdose has more than doubled in the US between 2019 and 2020, surpassing mortality due to cancer (6). Adolescent overdose rates climbed through 2021, continuing into the COVID-19 pandemic (7). Most overdose deaths nationally and in Indiana were attributable to illicitly manufactured fentanyl and synthetic opioids (6, 7, 8). These alarming trends warrant a coordinated response.

Consistent with decades-long findings, recent US survey data show that only 7.6% of adolescents with substance use disorders received any treatment (9, 10, 11). Several barriers to substance use disorder treatment persist for youths nationally and in underserved states like Indiana, including unavailability of services, lack of transportation, scheduling issues, stigma, and an optimistic bias among youths toward overdose likelihood (6, 12). There is also inconsistent integration of medical and mental health care with substance use services for adolescents (4, 13). Physicians and other clinicians, including in mental healthcare settings (13), often lack the training or tools to assess adolescents for substance use disorders and either deliver or refer them to appropriate care (13, 14). Moreover, addiction specialists tend to focus on adults (4) and often lack expertise on the unique health and family-oriented needs of adolescents (13). Furthermore, treatment of adolescent substance use disorders is typically based on adult-oriented guidelines and often conducted in adult settings, which might not be developmentally appropriate (4, 13). Lastly, moreso than with adults, there is hesitancy – and sometimes inability (e.g., due to agency policies)– to provide medications for substance use disorders to adolescents despite their demonstrated efficacy for opioid, alcohol, and nicotine use disorders (4, 12, 13).

Given the dearth of adolescent substance use disorder specialists and the time needed to train new specialists, innovative models are urgently needed to address these gaps. One model involves adapting child psychiatry access programs (CPAPs) for addiction-focused provider-to-provider consultation. CPAPs usually entail a dedicated phone line staffed by child and adolescent psychiatrists who primary care providers (PCPs) can call and receive free, same-day consultations on patients, resources, and/or referral information for pertinent mental health services (15). CPAPs have been shown to significantly increase child mental health service use (16) and now operate in nearly every U.S. state (17). Recently, the Massachusetts Child Psychiatry Access Project (MCPAP) expanded their CPAP to include consultations focused on adolescent substance use, staffed by pediatric Addiction Medicine specialists (Adolescent Substance Use and Addiction Program [ASAP-MCPAP]). Over one year, ASAP-MCPAP provided 128 consultations calls to PCPs, demonstrating the utility of a substance use-focused consultation line for PCPs caring for adolescents (18).

This manuscript describes the evolution and early utilization of a substance use-focused CPAP in Indiana. Indiana launched a CPAP, the Indiana Behavioral Health Access Program for Youth (Be Happy), in 2018 (https://medicine.iu.edu/behappy). Be Happy provides no-cost, same-day consultations with child and adolescent psychiatrists for PCPs and other healthcare professionals (e.g., nurses, social workers) who have questions about management of pediatric mental health concerns. PCPs call a dedicated line, where a coordinator triages the call and connects the PCP to an on-call psychiatrist or provides resource referrals. Consultations give PCPs timely coaching and support for managing complex cases so patients can receive appropriate, evidence-based services in their communities.

Indiana’s state mental health agency funded an adaptation of Be Happy to increase capacity for consultation specific to adolescent substance use and to expand infrastructure for additional services, including direct patient care (screening, assessment, psychotherapy, medication management). This enhanced program, the Adolescent Addiction Access (AAA) program, launched in May 2021 and represents a key step in expanding access to evidence-based services for adolescents with substance use disorders. Similar to ASAP-MCPAP, the AAA program provides timely access to evidence-based patient care services and community referral support from experienced adolescent addiction specialists through a free provider-to-provider helpline for Indiana providers caring for youths with substance use concerns. This manuscript describes AAA’s first 21 months of operation and highlights opportunities for future refinements.

Methods

Program description

The goal of the Indiana AAA program is to provide a single channel through which healthcare providers caring for youths can gain timely access to answers and resources for any aspect of adolescent substance use or treatment. AAA maintains a dedicated phone number and email address, staffed by a coordinator from 9am-5pm Monday-Friday (excluding major holidays), with voicemail and email messages available otherwise. A non-clinical coordinator receives a call or message from a provider and triages the call based upon the caller’s needs. The coordinator sometimes provides requested resources or referrals independently. Otherwise, the coordinator pages an on-call adolescent addiction specialist (psychologist or social worker) who returns the call within 1 hour or at a requested callback time. When medication questions or other issues requiring input from a psychiatrist is needed, the specialist and/or coordinator contacts an on-call addiction psychiatrist who either calls the provider directly or staffs the case internally with the non-prescriber specialist and/or coordinator who then relays recommendations. Callers receive a securely faxed written recommendation summary.

The coordinator can access updated lists of statewide substance use resources and adolescent substance use disorder treatment centers. The adolescent addiction specialists can consult on any manner of adolescent substance use questions, such as which medications and doses are appropriate for youths with substance use disorders, level of care determinations, assistance with evaluation and diagnosis, and locating available services. In consultation-only interactions, the calling provider retains full responsibility for the care of the patient. AAA is staffed by licensed clinicians who provide care through an outpatient adolescent dual diagnosis program within an academic health center, where timely direct patient care services can be offered, when indicated. Services include diagnostic evaluations, initiation of psychotherapy, and induction of medications for opioid use disorder and other substance use disorders.

While the AAA program is intended for providers to call for consultation, AAA contact information is easily accessible online resulting in calls from caregivers concerned about their adolescent’s substance use. A similar call process is followed when caregivers call AAA.

Consultation call data

During each consultation, information is collected by the AAA coordinator and/or consultants using a secure web-based consultation form (online supplement): encounter type; caller role, credentials, and reason for contact; patient demographics, diagnostic impressions, severity, and mental health and substance use history; geographic distribution of caller and patient; reason for consultation; and call outcomes and recommendations. The caller’s diagnostic impressions based on historical data or their personal assessment were recorded. Case severity was rated subjectively by the consultant based on the complexity and acuity of the patient’s substance use and circumstances (e.g., rated severe if recent overdose or potentially lethal pattern of use). Call data were entered by program staff into a web-based form and stored in a secure HIPAA compliant database. Procedures were approved by the university institutional review board (IRB).

Analytic plan

During the first 21 months of the AAA program, 127 calls were received, and of these, two calls were deemed inappropriate for AAA. Data from the 125 remaining calls were summarized using descriptive statistics. Due to some calls being general questions (n = 18) and/or information not being provided by a caller, we had missing data across variables. Data also were missing due to quality improvement amendments to data collection procedures during the study period (e.g., items added, removed, edited). We report the percent valid in the results section, while also including the total percent and number missing in the tables. Analyses were performed using SPSSv28.

Results

Over the first 21 months of the AAA program, spanning July 2021 to March 2023, 125 appropriate consultation calls were fielded. The number of consultation calls has increased substantially over time (see Figure 1). Results of the 125 calls, including caller and patient characteristics, geographic distribution, consultation details, and outcomes are detailed below.

Figure 1.

Frequency of AAA consultation calls, in 3-month intervals, across the first 21 months of the program (July 2021 – March 2023).

Caller characteristics

Calls were fielded from 24 (of 92) Indiana counties, with the greatest frequency from two of the most populous counties. Calls were taken from 85 health/behavioral health care providers (71%), 32 parents/caregivers (27%), and 2 youths (2%); the role of 6 (5%) callers was missing. Providers calling were predominantly behavioral or other healthcare providers (n = 54, 45%), PCPs (14%), emergency department providers (n = 11, 9%), or case manager/case workers (n = 3, 3%).

Patient characteristics

Most calls were made in reference to a specific patient rather than a general question. Although targeting youths (≤ 17 years), calls were fielded for patients ranging in age from 10–18 years old (M = 16.42, SD = 1.29). Most patients were older adolescents (i.e., 16–18 years; n = 74, 71%), with only two 18-year-olds. Patients were predominantly male (62%), white (84%), and non-Latino (82%). Patients were located in 46 Indiana counties, most frequently from Marion (Indianapolis; n = 27, 25%). The most frequently reported substances were cannabis (63%), opioids (34%), alcohol (28%), nicotine (18%), and stimulants (17%). Nearly half (n = 54, 43%) of patients were reported as having a mental health and/or substance use disorder, most frequently depression (n = 32, 26%), ADHD (n = 19, 15%), anxiety (n = 13, 10%), or a substance use disorder (n = 12, 10%). Patient characteristics are detailed in Table 1.

Table 1.

Characteristics of patients for whom calls were placed to AAA

Characteristic	n	Valid %	Total %
Patient gender
Cis-male	73	62	58
Cis-female	44	38	35
Missing	8	-	6
Patient race
White	76	84	61
Black or African American	10	11	8
American Indian or Alaska Native	3	3	2
Native Hawaiian or Pacific Islander	1	1	0.8
Multiracial	1	1	0.8
Missing	34	-	27
Patient ethnicity
Latino	15	18.5	12
Non-Latino	66	81.5	52.8
Missing	44	-	35
Substances used *
Alcohol	32	28	25.6
Nicotine	21	18	16.8
Cannabis/THC	72	63	57.6
Opioids	43	34	34
(Illicit)	34	29.8	27
(Rx)	19	16.7	15
Stimulants	19	16.7	15
(Illicit)	18	15.8	14
(Rx)	2	1.8	1.6
Other	27	23.7	21.6
Missing	11	-	8.8

Note.

^*More than one option could be selected

Consultation characteristics

Nearly all consultations were first-time calls (95%). The most common clinical reasons for contacting AAA included questions pertaining to referral and/or resources (57%), therapy/behavioral intervention (31%), triage/level of care (28%), and recent overdose (15%). Most calls were for multiple clinical reasons (n = 70, 56%). Non-prescribing specialists consulted with callers directly in 113 cases (90%); prescribing specialists were directly involved in 27 consultations (22%), though they were indirectly involved in other consultations through internal staffing discussions. Patient severity was typically determined to be moderate (50%) to severe (41%), per subjective AAA clinician rating, and consultations yielded elements of strong concern for patients, including lack of current mental health provider (41%) and an overdose event (25%). In caregiver-initiated calls, we learned about several access-to-care barriers families faced, including significant discomfort providing substance use disorder care by the adolescents’ PCPs or therapists. Families reported being given the AAA phone number and being told to call themselves, rather than the healthcare provider reaching out for consultation. Table 2 presents consultation details.

Table 2.

Characteristics of consultations with AAA coordinators and adolescent addiction specialists

Characteristic	n	Valid %	Total %
Consultation type
First time call	121	95	95
Follow up call	6	5	5
Clinical reason for contact *
Referral/resource	60	57	48
Therapy/behavioral intervention	32	31	26
Triage/level of care	29	28	23
Recent overdose	16	15	13
In withdrawal	14	13	11
Medication question	13	12	10
Diagnostic question or evaluation	8	8	6
General information	5	5	4
Second opinion	2	2	2
Call inappropriate for AAA	2	2	2
Other	1	1	1
Missing	20	-	16
Current mental health provider
Yes	52	46	42
No	47	41	38
Don't know	15	13	12
Missing	11	-	9
Overdose incident
Yes, with suicidal intent	4	4	3
Yes, without suicidal intent	12	12	10
Yes, unknown suicidal intent	10	10	8
No	77	75	62
Missing	22	-	18
History of opioid overdose
Yes	10	10	8
No	52	50	42
Unknown	43	41	34
Missing	20	-	16
Patient has naloxone
Yes	36	34	29
No	21	20	17
Unknown	48	46	38
Missing	20	-	16
Patient severity
Mild	10	10	8
Moderate	51	50	41
Severe	42	41	34
Missing	22	-	18

Note.

^*More than one option could be selected

Care recommendation characteristics

Regarding care recommendations, 27 patients (21%) received a medication recommendation, typically to start a medication (e.g., buprenorphine, naltrexone, N-acetyl cysteine), and most received therapy recommendations (n = 115, 92%). The most frequent therapy recommendations included: refer to an outpatient dual diagnosis program for a comprehensive behavioral health evaluation (45%), start therapy in the community (33%), refer to residential program (17%), and schedule another evaluation with AAA consultant (17%). Care recommendations are summarized in Table 3.

Table 3.

Characteristics of AAA adolescent addiction specialist recommendations and patient outcomes

Characteristic	n	Valid %	Total%
Medication recommendation *
No medication recommendations	77	82	62
Start new medication(s)	16	17	13
Change existing dose(s)	2	2	2
Change medication frequency	1	1	1
Stop existing medication(s)	1	1	1
Missing	31	-	25
Therapy recommendation *
Start therapy in community	34	33	27
Refer to Dual Diagnosis Program for semi-urgent evaluation (within 1 week)	27	26	22
Refer to Dual Diagnosis Program for non-urgent evaluation (2-3 weeks)	19	18	15
Refer to residential programs	17	17	14
Schedule urgent evaluation with AAA clinician (within 48 hrs per family availability)	17	17	14
Add additional therapy resource	9	9	7
Not applicable	8	8	6
Increase frequency of therapy sessions	3	3	2
Refer to inpatient programs	3	3	2
Refer to wraparound services	2	2	2
Missing	22	-	18
Patient care outcome *
Referral to Dual Diagnosis Program	43	53	34
Remain with full management with provider (no need for psychiatry referral)	17	21	14
Immediate referral to psychiatry without provider intervention	14	17	11
Continue management with provider until psychiatry appointment is obtained	4	4	3
Referral to emergency services	3	4	2
Missing	44	-	35

Note.

^*More than one option could be selected

Discussion

The Indiana AAA program expanded an already-existing statewide CPAP to specifically address the needs of providers of adolescent substance use disorder care, by providing resources and on-call addiction specialist consultation. Consultations resulted in referrals across the continuum of addiction services, with outpatient therapy recommendations being most common. Occasionally, treatment centers to whom adolescents were referred by AAA subsequently contacted AAA to inquire about next steps in care. Thus, the consultation program can offer guidance across settings and levels of care. Importantly, the AAA program addresses a critical need in Indiana, as approximately half of patients were without a current mental health provider.

Over a third of AAA callers had concerns related to opioids, and 25% of calls related to an overdose. Medications for opioid use disorder have been shown to be effective in reducing overdoses and improving treatment retention (19, 20, 21). However, these medications are infrequently used with adolescents generally and compared to their use with adults (22, 23, 24). The AAA program can provide an avenue for timely evaluation and treatment, including initiating medications for opioid use disorder. Indeed, medication for opioid use disorder was recommended for several AAA patients. Additionally, access to and education on naloxone is a key harm reduction strategy for preventing overdose-related deaths (25), but receipt of naloxone is low, with one study finding naloxone to be prescribed for just 1 in 12 opioid overdose-related emergency department visits (26). AAA adolescent addiction specialists regularly inquired about naloxone access during consultation calls and made recommendations to healthcare professionals and families to obtain naloxone and provided direction on how it could be obtained.

Interestingly – and unexpectedly – some caregivers (rather than healthcare providers) called in to the AAA program. Families sometimes shared that their healthcare providers expressed discomfort with providing substance use disorder care. This is not surprising, as many providers report feeling unprepared to provide care for, and inadequately trained on, substance use disorders (27, 28). Additional provider training and education services are needed to ensure providers are equipped to identify and address problematic substance use and substance use disorders, including determining what level of care may be appropriate for a given adolescent. The Project ECHO (Extension of Community Healthcare Outcomes) continuing education model blends didactic and case-based discussions to train non-specialists in delivery of evidence-based care (29, 30). In Indiana, we have implemented ECHO tracks addressing substance use disorders in different settings and populations (31, 32, 33) – including adolescents – to help fill these training gaps (34).

In this initial phase, we observed lower rates of PCP utilization compared to other providers (e.g., behavioral health provider) and compared to substantially higher uptake of general pediatric mental health consultation (statewide CPAP). To address low rates of AAA use among PCPs, the AAA program will need to build connections and a reputation as a responsive and valuable resource for adolescent substance use-related questions and services in Indiana. AAA is able to provide more developmentally specific and accurate referrals and resources (e.g., level of care, location, insurance) than many publicly available online provider lists. Additionally, stigma around substance use disorders may play a role in the slower uptake of the AAA program by PCPs and for the tendency of some providers to direct the family to contact AAA rather than contacting the program themselves (35, 36). Future efforts should focus on combatting stigma around substance use disorders through targeted provider education and interventions. Seasonal patterns should also be examined over time. For instance, the late summer dip in AAA calls (Fig. 1, July-September) may reflect fewer substance-related incidents at school that would otherwise result in referrals to healthcare providers or calls from concerned caregivers.

This study has several limitations. First, this program is in its initial phases of implementation and is continuing to grow. Consequently, we had a considerable amount of missing data for several of the consultation variables being collected due to these variables not being asked or relevant for some callers (e.g., caregivers, those calling on behalf of a provider). The lack of standardized severity measures also may limit reliability of consultant ratings. As additional adolescents are served by AAA and the sample size increases, more advanced analyses can be leveraged to characterize these patients in a more clinically informative manner (e.g., latent class analysis; 37). Second, given this manuscript only describes the first 125 calls and AAA was only implemented in Indiana, findings may not be generalizable across all states or all Indiana healthcare providers. The youths about whom consultation was sought were also not representative of adolescents with substance use disorders in Indiana. An important future goal is to increase and expand provider use of AAA, particularly among providers who work with underserved populations and communities. We also do not have data on patient outcomes following the consultation recommendations. Future work should follow-up with consultees to inquire about follow-through on recommendations and suggestions for improvement.

Lastly, unlike the ASAP-MCPAP in Massachusetts, which offered virtual substance use counseling through primary care, substance use treatment is not currently available in primary care clinics throughout Indiana. Thus, AAA consultations had to rely on referrals to local treatment or to an adolescent dual diagnosis outpatient clinic. Ideally, an adolescent substance use-focused CPAP will be implemented in tandem with the expansion of evidence-based substance use services including virtual services to reduce access barriers (e.g., wait times, transportation. Referral to the adolescent dual diagnosis outpatient clinic was the most common AAA care recommendation. This clinic was expanded alongside the implementation of AAA, which allowed adolescents to receive timely evaluation and treatment (including virtually) following a consultation. Implementing integrated behavioral health care, including for adolescent substance use, in primary care settings throughout the state may also increase the capacity for adolescent substance use disorder treatment and improve the AAA referral process. For example, primary care clinics could implement standardized screening and brief intervention, such as the Screening, Brief Intervention, Referral to Treatment (SBIRT) model (38), with AAA providing support to providers in determining the level of care needed and what referrals for an adolescent may be appropriate based on the services and resources available at a provider’s clinic and in their area. Also, while elimination of the waiver requirement for prescribing buprenorphine may improve treatment accessibility, several barriers remain, including lack of provider training in substance use disorders and inadequate support from behavioral health specialists for providers (39, 40); AAA can provide both education and on-demand support to providers to help facilitate greater use of medications like buprenorphine to treat adolescents with opioid use disorder.

Conclusions

Innovative models are needed to address the shortage of adolescent substance use disorder specialists. The Indiana AAA program, adapted an existing CPAP to provide adolescent substance use-focused consultation to providers. Like ASAP-MCPAP in Massachusetts (18), the Indiana AAA program demonstrates expanding CPAPs to focus on adolescent substance use is feasible and useful. Future collaborative efforts across existing programs could guide replication efforts elsewhere. Many states already have CPAP infrastructure; AAA and ASAP-MCPAP show this infrastructure can be leveraged to increase capacity for facilitating timely access to evidence-based substance use disorder care for adolescents.

Highlights:

• A statewide adolescent addiction teleconsultation program (AAA) was modeled on the child psychiatry access program framework.

• AAA on-call coordinators fielded inquiries, providing resources and referrals, and if needed, arranged consultation with adolescent addiction specialists for assessment and treatment recommendations.

• Calls were initiated by healthcare providers (and parents) with a wide range of substance use concerns, and the number of calls increased dramatically over the reporting period.

• AAA presents a promising model for facilitating timely access to evidence-based substance use care, including medication and therapy recommendations.