The Broken Care Continuum for Young Adults with Opioid Addiction

After two decades of rising opioid-related overdose mortality in the United States, gaps in addiction treatment remain large, common, and detrimental [1]. True as this is for people of all ages, the reality is even more dire for young adults (defined here as aged 18–25 years). Young adults are the only age group whose rate of receipt of evidence-based addiction treatment is declining amid otherwise improving rates nationally [2,3]. This age disparity is widening even further for youth of color. After increasing for years, the overall opioid overdose death rate in the United States stabilized from 2017 to 2018, but increased in Black and Hispanic individuals by 9% and 10%, respectively [4]. Once in treatment, young adults are significantly more likely than other age groups to experience relapse and leave care [2,5,6].

Against this backdrop, Fishman and colleagues present in this issue of Journal of Adolescent Health findings from a post hoc analysis of a highly consequential clinical trial in the field of addiction medicine [7]. The parent study, the X:BOT trial, was conducted among adults over 18 in eight residential addiction treatment programs from 2014 to 2016 and assessed the comparative effectiveness of long-acting injectable naltrexone, an opioid antagonist, relative to buprenorphine, a partial opioid agonist. In brief, X:BOT showed that only 72% of individuals randomized to receive long-acting injectable naltrexone were able to successfully start the medication compared to 94% of those randomized to receive buprenorphine. (Naltrexone requires a period of abstinence from all opioids prior to administration to avoid precipitating withdrawal—a high bar that some patients cannot reach.) Among individuals that successfully started treatment, efficacy of the two medications was comparable.

The secondary analysis of X:BOT by Fishman et al. compares treatment outcomes among young adults aged 18–25 to older adults over 25. Their analysis reconfirms national trends. During the trial’s 24-week follow-up period, young adults were 43% more likely than older adults to experience relapse. Ultimately, two-thirds of young adults who started treatment relapsed or left care by 24 weeks, compared to half of older adults. In other words, addiction treatment outcomes were poor overall, and yet even worse for young adults.

For clinicians who work with young adults with other chronic health conditions, these findings may not come as a surprise. Young adulthood is marked by neuropsychological changes in executive functioning and critical transitions in housing, education, employment, healthcare, and other domains. These transitions have long required clinicians and health systems to think beyond their traditional clinical approaches to optimize young adults’ engagement in care. But given the high mortality of opioid use disorder, the stakes may be higher than for other conditions, and addiction treatment poses unique challenges.

First, medical and behavioral addiction treatment have long been siloed off from one another and from general medical and mental healthcare. Young adults commonly receive medications like naltrexone, buprenorphine, or methadone from one provider and psychotherapy from a different provider, often in a different facility; these treatment settings are usually distinct from where a young adult receives primary care, which in turn is often separate from where they receive mental health treatment [8]. Second, young adults themselves may not have made the decision to pursue addiction treatment; they are often brought in by a family member or court-mandated to receive care [9]. Third, when young adults receive addiction treatment, it is often alongside older adults (including in group therapy) and may not account for the unique developmental considerations of youth [10]. Fourth, the commonly pursued outcome of abstinence may not be realistic, and a substance use- and harm-reduction approach might better align with young adults’ goals [11].

Last, young adults with addiction experience enormous stigma, labeling, and discrimination in healthcare settings and the broader community [12]. Once in treatment, additional stigma surrounding the use of evidence-based medications like naltrexone, buprenorphine, and methadone, prevents many young adults from receiving standard of care [13]. Young adults on medications, particularly the opioid agonists buprenorphine and methadone, are commonly told by trusted adults in their lives (including some clinicians) that they are not ‘truly in recovery’ if they are on a medication [14]. Such statements are inaccurate: opioid use disorder is defined by the presence of negative life consequences resulting from opioid use, and medications are highly effective treatments because they help individuals reduce these harmful consequences.

How can we address these limitations in addiction treatment and repair the broken care continuum for young adults? In this author’s opinion, what is needed is radical rethinking of our healthcare delivery and an ambitious research agenda. Clinicians of all disciplines need training to provide evidence-based care for youth with addiction, just as they do for other conditions. The long-standing separation of addiction treatment from general medical and mental healthcare has left many physicians, nurses, behavioral health specialists, pharmacists, and other professionals with little experience addressing substance use disorders. Health systems should provide and incentivize continuing education on addiction for practicing clinicians, and medical schools and residencies should include addiction in their curricula.

The goal of such training should be to integrate outpatient addiction treatment into young adults’ other healthcare, allowing them to address their substance use in the same place they receive routine healthcare services such as immunizations; reproductive health care; screening and treatment for sexually transmitted infections, human immunodeficiency virus, and viral hepatitis; and ideally, comprehensive mental healthcare [15,16]. Such integration helps support young adults’ engagement in addiction treatment by offering them additional reasons to seek care. This mainstreaming of addiction treatment will also reduce—though not eliminate—stigma, which health systems can confront by supporting clinical services that are affirming for young adults with addiction [17].

Reimbursement rates for addiction treatment should be competitive and reflect the complexity of caring for this condition [18]. Commensurate should be the expectation that addiction treatment meet quality standards such as those published by the Centers for Medicare and Medicaid Services [19], which include measures of continuity of care. Health systems should also prioritize other measures tailored to young adults’ needs, such as substance use reduction (as compared to abstinence only); provision of harm-reduction services; and receipt of housing, education, and employment support—all of which support continuous engagement in treatment [20]. To avoid exacerbating health inequities, such quality improvement should have an antiracist lens, explicitly measuring and seeking to improve differences by race and ethnicity.

Dovetailing these healthcare delivery changes, clinicians and investigators should pursue a comprehensive research agenda. Critical questions are unanswered. How should young adult and family preference help determine medication choice? What is the optimal duration of medication treatment for young adults? What behavioral health strategies accelerate young adults’ treatment and recovery? What are best practices to reengage young adults who relapse or leave care? What non-traditional approaches should be used (e.g., telemedicine, mobile device-based recovery support, street-based outreach)?

We should all feel a sense of urgency to overhaul addiction treatment for young adults. The work of Fishman and colleagues reminds us that currently, the norm is for young adults to relapse or leave care. Left unaddressed, poor addiction treatment outcomes will continue to result in the deaths of thousands of young adults each year.