Evidence-Based Treatment for Young Adults with Substance Use Disorders

Abstract

In summarizing the proceedings of a longitudinal meeting of experts in substance use disorders (SUD) among adolescents and young adults, this special article reviews principles of care related to SUD treatment for young adults. SUDs are most commonly diagnosed during young adulthood, but most of the evidence guiding treatment for this population has been obtained from older adult study participants. Extrapolating evidence from older populations, the expert group asserted the following principles for SUD treatment: It is important that clinicians who work with young adults effectively identify and address SUD to avert long term addiction and its associated adverse health outcomes. Young adults receiving addiction treatment should have access to a broad range of evidence-based assessment, psychosocial and pharmacologic treatments, harm reduction interventions, and recovery services. These evidence-based approaches should be tailored to young adults’ needs and provided in the least restrictive environment possible. Young adults should enter care voluntarily; civil commitment to treatment should be a last resort. In many settings, compulsory treatment does not use evidence-based approaches; thus, when treatment is involuntary, it should reflect recognized standards of care. Continuous engagement with young adults, particularly during periods of relapse, should be considered a goal of treatment and can be supported by care that is patient-centered and focused on the young adult’s goals. Lastly, substance use treatments for young adults should be held to the same evidence and quality standards as those for other chronic health conditions.

Table of Contents Summary:

This special article reviews evidence-based treatment of young adults with substance use disorders based on the input of experts from a range of disciplines.

Introduction

The continuum of care for young adults with substance use disorders (SUDs) is fragmented. Clinicians in traditional medical settings frequently lack the training and comfort to conduct comprehensive assessments of young adults with SUDs, and to ensure that young adults receive developmentally appropriate, evidence-based treatment, including pharmacotherapy for opioid use disorder (OUD). Thus, diagnosis and treatment are often delayed.

Young adults who do receive treatment commonly do so at a dedicated addiction treatment facility – often operating outside the mainstream medical system – where they may not receive standard-of-care pharmacotherapy and frequently receive care alongside older adults with little consideration of their unique developmental needs. Such treatment is commonly coerced or court-mandated, without the explicit consent of the young adult. For these reasons, among others, treatment for young adults is commonly marked by poor outcomes, loss to follow-up, and low quality.^1–3

Despite this suboptimal practice landscape, data from clinical trials and observational studies (Table 1) as well as expert consensus provide a clearer picture of how an effective continuum of care for young adults with SUDs should look. The principles described here – derived from a panel of experts convened by Boston Medical Center’s Grayken Center for Addition – emphasize early intervention for young adults with SUD, comprehensive and tailored services, access to pharmacotherapy when indicated, voluntary entry into treatment, continuous engagement, and assurance of quality of care. The recommendations in this article are not American Academy of Pediatrics policy, and publication herein does not imply endorsement.

Table 1.

Summary of Selected Studies Reviewed by Expert Panel (studies list alphabetically)

Author, Year	Sample	Setting	Study Period	Design	Outcome	Main Findings	Contribution to Summit Principles
Chadi et al., 2019	N=81144 youth aged 10 to 22 continuously enrolled in Medicaid for at least 6 months diagnosed with NUD	Insurance claims data from 11 states enrolled in Medicaid	1/2014–6/2015	Retrospective cohort study comparing youth who received treatment to those who did not	Receipt of treatment (counseling for NUD, varenicline, or sustained-release bupropion) within 6 months of NUD diagnosis	There was low receipt (5.5%) of treatment for NUD among youth enrolled in Medicaid. Among youth with NUD receiving treatment, older age and co-occurring mental health and SUD were associated with receipt of pharmacotherapy	Identifies gaps in the provision of any treatment for NUD among young adults, and in particular, gaps in the provision of pharmacotherapy for NUD. Suggests substantial area for improvement in treatment of NUD among young adults.
Hadland et al., 2017	N=20822 youth aged 13 to 25 diagnosed with OUD	Health insurance claims data from all 50 states enrolled in a large US commercial health insurer	1/2001–12/2014	Retrospective cohort study comparing youth who received medications for OUD to those who did not	Dispensing of medication (buprenorphine or naltrexone) within 6 months of first OUD diagnosis	Medication receipt increased over the study period, but only 1 in 4 individuals (26.8%) received pharmacotherapy. Younger individuals (P<0.001), females (P<0.001), and black and Hispanic youth (P<0.001) were less likely to receive a medication than older, male, and non-Hispanic white youth, respectively	Identifies gaps in provision of pharmacotherapy for young adults with OUD. Also identifies likely disparities in receipt of treatment by age, sex, and race/ethnicity that should be prioritized as access to and use of medications for OUD are expanded.
Hadland et al., 2018	N=4837 youth aged 13 to 22 diagnosed with OUD	Health insurance claims data from 11 states enrolled in Medicaid	1/2014–12/2015	Retrospective cohort study comparing youth who received any treatment (including medications for OUD and/or behavioral therapy)	Retention in care, with attrition defined as 60 days or more without any treatment-related claims	Youths who received buprenorphine, naltrexone, or methadone within 3 months of diagnosis of OUD were 42%, 46% or 68% less likely to discontinue treatment, compared with youths who received behavioral treatment only	Demonstrates the likely role of pharmacotherapy for OUD in supporting retention in care among young adults. Data suggest that retention in care may be improved with use of medications.
Marsch et al., 2016	N=53 youth aged 16 to 24 who met DSM-IV criteria for opioid dependence	New York City, NY, USA	2005–2010	Multicenter randomized controlled trial, double-blind and placebo controlled comparing duration of taper off buprenorphine (56 days vs. 28 days) following withdrawal treatment	Opioid abstinence and treatment retention	Individuals with a 56-day buprenorphine taper had a significantly higher percentage of opioid-negative urine tests (35% vs. 17%, P=0.039), and were retained in treatment significantly longer (37.5 vs. 26.4 days, P=0.027) than individuals with a 28-day buprenorphine taper	One of the only youth-focused trials to date. Sample comprised mostly of young adults and demonstrated superiority of maintenance buprenorphine given over 4 weeks compared to 2 weeks, suggesting better outcomes with longer buprenorphine treatment. Additionally, higher frequency of visits was associated with poorer treatment outcomes.
Rafful et al., 2018	N=671 individuals who inject drugs	Tijuana, Mexico	3/2011–7/2017	Longitudinal cohort study comparing individuals who received IDT to those who did not	Reported non-fatal overdose event in the past 6 months	IDT significantly increased the odds of reporting a non-fatal overdose event (AOR: 1.76; 95% CI: 1.04, 2.96)	Similar to the findings of the systematic review by Werb et al., suggests that compulsory treatment may be associated with harm.
Sordo et al., 2017	N=138716 individuals with opioid use disorder	19 prospective or retrospective cohort studies that reported deaths from all causes or overdose	Studies published until 9/2016	Systematic review and meta-analysis comparing individuals who received opioid agonist treatment to those who did not	Risk for all cause and overdose mortality during and after substitution treatment. Trends in mortality risk after initiation and cessation of treatment	Retention in methadone and buprenorphine treatment was associated with substantial reductions in the risk for all cause and overdose mortality. Mortality risk increased during the induction phase and time immediately after leaving treatment	Compiling data across numerous studies, highlights that maintaining young adults in treatment with an opioid agonist is likely highly protective.
Wakeman et al., 2019	N=2706 adult primary care patients (1353 matched pairs from practices with and without integrated addiction treatment)	Boston, MA, USA	11/2014–12/2015	Retrospective cohort study comparing individuals who received integrated primary care-based addiction treatment (medications for OUD and recovery coaching) to those who did not	Inpatient admissions, hospital bed days, ED visits, primary care visits	Intervention group had fewer inpatient days (997 vs. 1096 days with a mean difference of 7.3 days per 100 patients, P=0.03) and a lower number of ED visits (36.2 visits vs. 42.9 per 100 patients, P=0.005) than matched patients without pharmacotherapy and recovery coaching	Describes the experience of a hospital system that has been able to provide comprehensive outpatient care to individuals with SUDs, and some of the associated benefits, including shorter hospitalization and fewer ED visits.
Werb et al., 2016	N=10699 individuals with substance use disorders	9 peer-reviewed scientific studies presenting original data assessing outcomes of compulsory treatment	Studies published until 7/2015	Systematic review comparing those who received compulsory drug treatment to those who did not	Post-treatment drug use, criminal recidivism	The majority of studies (78%) did not detect any significant positive impacts of compulsory treatment on drug use or criminal recidivism, with some studies suggesting potential harms	Highlights that compulsory treatment—though commonly pursued—is not associated with improved treatment outcomes, and in fact, may be harmful.
Woody et al., 2008	N=152 youth aged 15–21 who met DSM-IV criteria for opioid dependence and sought outpatient treatment	6 community program sites in New Mexico (2), Delaware, Maine, Maryland, and North Carolina	07/2003– 12/2006	Randomized controlled clinical trial comparing 12 weeks of buprenorphine treatment to detoxification with buprenorphine over 14 days	Opioid-positive urine tests at weeks 4, 8, and 12	Individuals in the detox group (14-day taper) had higher proportions of opioid-positive urine test results compared to individuals in the 12 week buprenorphine-naloxone group at weeks 4 (P<0.001) and 8 (P=0.001), but not at week 12 (P=0.18).	One of the only youth-focused trials to date. Sample comprised mostly of young adults and demonstrated superiority of maintenance buprenorphine over detox only over 2 months.

AOR = Adjusted odds ratio, CI = Confidence interval, ED = Emergency department IDT = Involuntary drug treatment, NUD = Nicotine use disorder, OUD = Opioid use disorder, SUD = substance use disorders

Principles of Care

Principle 1a: Young adults should be offered access to care and services as soon as needs are identified.

Guidance

The workgroup concluded that SUDs should be addressed as soon as they are detected by ensuring efficient access to evidence-based treatment and support services. Left untreated, SUDs for many individuals worsen, resulting in cumulative, lifelong harms. The workgroup felt that intervening with young adults early in the development of SUD is critical not only because it can avert worsening addiction, but also because intervening later in the life course, after an individual has a longer history of substance use, is far more difficult.⁴

The workgroup noted the importance of ensuring that the full complement of evidence-based services is offered immediately. Certain evidence-based practices – in particular, pharmacotherapy – are sometimes delayed while a young adult receives non-pharmacologic treatment, such as psychotherapy. In these cases, pharmacotherapy may only be offered after initial treatment attempts have been unsuccessful. The workgroup felt that offering a pharmacologic standard-of-care treatment immediately on detection of SUD (when applicable to the substance(s) being used) is important to optimize outcomes.

Evidence

More than nine in ten individuals receiving treatment for SUD report that their first use of substances occurred by young adulthood.⁵ Often, alcohol or marijuana is the first substance that a young person uses. It is common, furthermore, for clinicians to avoid addressing alcohol or cannabis use in certain populations (e.g. college students) when use of these substances is common.⁶ Alcohol and drug use, however, is associated with acute consequences—including motor vehicle crashes and other injuries, sexual assault, and mental health problems that can occur even among individuals who do not meet criteria for an SUD.^7,8 It is critical that clinicians working with young adults identify and address substance use as early as possible, since left untreated, more severe disorders and harm can result.^9,10 Waiting to determine whether an SUD self-resolves represents a missed opportunity to intervene early.

Even when problematic substance use is recognized, clinicians may delay providing the full complement of addiction services. Most young adults with OUD, for example, receive psychotherapy without pharmacotherapy, one of the single most effective interventions.^3,11 In some cases, clinicians delay pharmacotherapy while determining whether behavioral health services alone are sufficient.^12–14 Such delays, however, may place young adults at risk of developing a more severe SUD or experiencing drug use-related harm.

Practice Considerations

There are numerous barriers to identification and early intervention for SUD among young adults. First, addiction services have long been delivered outside traditional health care settings, and many clinicians have not received training on how to effectively screen and address substance use.^14,15 Second, young adults may be ambivalent about receiving SUD treatment and decline services.^16,17 Third, even when clinicians offer SUD care, young adults only receive services if they present for care. Young adults have among the lowest rate of participation in routine healthcare of any age group.^17,18 Addressing these numerous challenges will require widespread clinician training on evidence-based treatments for young adults, and health-system improvements to support addiction care and improve outreach, engagement, and retention in care.

Principle 1b: Young adults should have access to a comprehensive set of assessment, psychosocial and pharmacologic treatment, harm reduction, and recovery services supported by evidence.

Guidance

The workgroup asserted that young adults with a potential SUD should undergo a broad medical, mental health and psychosocial assessment.¹⁹ Recommended components include a medical history; physical examination; relevant laboratory testing (e.g., studies for the sequelae of substance use disorders, such as a comprehensive metabolic panel in the setting of an alcohol use disorder; and testing for sexually transmitted and blood-borne infections including human immunodeficiency virus [HIV]); assessment for psychiatric disorders, other SUDs, and tobacco use; and contraception and HIV pre-exposure prophylaxis.^19–21 Ascertaining the young adult’s goals for care, prior treatment experiences, family and other supports, education, employment, and prosocial activities may also help to individualize treatment.

The workgroup clarified that young adults with opioid, alcohol, and tobacco use disorders should uniformly be offered US Food and Drug Administration (FDA)-approved medications to address cravings and withdrawal.^9,19,22–27 Options include buprenorphine, methadone, and naltrexone for OUD; naltrexone, acamprosate, and disulfiram for alcohol use disorder; and varenicline, bupropion, and nicotine replacement therapy and nicotine use disorder.²⁸

All young adults with SUD (regardless of readiness for treatment) can benefit from harm reduction services. Overdose education should include naloxone provision to all patients who use opioids and their family members.^20,29,30 Additionally, the workgroup highlighted that support services (such as that offered by a recovery coach) can be layered onto treatment to promote recovery, support achievement of educational and employment goals, and resume prosocial and other recreational activities.

Evidence

Providing comprehensive treatment for young adults with SUD improves outcomes.¹⁹ An initial, scoping assessment to identify young adults’ medical, mental health, and psychosocial needs can help clinicians deliver the full range of services needed.^19,20 Traditionally, substance use treatment has focused on achieving abstinence from all substances and in many settings has relied heavily – if not exclusively – on behavioral therapy and peer support through mutual help (i.e., 12-step) organizations, such as Alcoholics Anonymous and Narcotics Anonymous, to attain this goal.³¹ For opioid, alcohol, and nicotine use disorders, evidence-based medications exist,^9,19,22,23 but young adults infrequently receive this treatment. Recent studies indicate that only approximately 1 in 4 young adults receives a medication for OUD,^3,11 and only 1 in 73 young adults receives a medication for nicotine use disorder.³² Medications reduce substance use and cravings, enhance retention in care, and in some cases, reduce mortality.^{9,19,22,23,33} The decision to initiate pharmacotherapy is ideally based on patient preferences following counseling from clinicians on benefits and risks. Providing accurate information is paramount since young adults may receive inaccurate information or stigmatizing messaging regarding pharmacotherapy from family, friends, and other individuals.³⁴ Receipt of medications should not be contingent on whether a young adult is engaged with psychosocial treatment; although a comprehensive treatment approach is optimal, data suggest that outcomes may be improved with pharmacotherapy alone.^35–38

The evidence for harm reduction and recovery support services is reviewed elsewhere in this series (See accompanying articles by Kimmel et al and Xuan et al, respectively).

Practice Considerations

Establishing comprehensive services in many settings is difficult. Many specialty addiction treatment settings – particularly those not routinely staffed by a medical clinician – are not equipped to conduct a full medical and psychiatric assessment. Many traditional medical offices are well-poised to perform a medical and psychiatric assessment, but clinicians may lack experience caring for young adults with SUDs.

Improving access to pharmacotherapy for youth is hampered by numerous barriers. First, many treatment programs have policies that preclude use of pharmacotherapy, and some even deny entry to young adults who take medications prescribed elsewhere. Of 11,532 national treatment programs for OUD that treat young adults, 52% do not accept individuals on pharmacotherapy.³⁹

Second, there is a national shortage of clinicians to prescribe medications.⁴⁰ This is particularly true for buprenorphine, an effective OUD medication that requires completing extensive mandatory education (eight hours of training for physicians and 24 hours of training for nurse practitioners and physician assistants) for a waiver to prescribe.⁴¹ Even still, medications that do not require extensive training, such as those for alcohol use disorder and nicotine use disorder, are only infrequently prescribed,^42,43 thus highlighting additional barriers, including clinician unease or unfamiliarity with pharmacotherapy for SUD treatment.

Third, there is widespread stigma surrounding use of medications for SUD treatment. Many young adults receive messaging that they are not truly in recovery if they are on pharmacotherapy, particularly when receiving agonist treatment, such as methadone or buprenorphine to treat OUD.³⁴ Often, this messaging comes from trusted adults in the young person’s life, such as treatment providers, mutual support group members, other individuals in recovery, parents, family members, or friends.

To address workforce limitations, health systems can ensure that clinicians receive the training and resources necessary to establish comprehensive addiction treatment, harm reduction, and recovery support services—or at a minimum, ensure that local referrals are available that are youth-friendly. Integrating allied health professionals such as social workers into primary care settings allows practices to offer on-site counseling, case management, and referrals to community recovery support services.

Health care systems should consider eliminating rules that restrict young adults from receiving pharmacotherapy, and clinicians should receive training to become buprenorphine-waivered and improve their familiarity with other medications for addiction treatment. National resources are available. For example, the Prescribers Clinical Support System (https://pcssnow.org/) provides free training. Offering medications in primary care, promoting the medical model of addiction (as opposed to narratives that portray addiction as a moral failing), and highlighting the pathophysiological rationale for pharmacotherapy may help to reduce stigma and correct common misperceptions among young adults and their families.

Principle 1c: Respecting the diversity of young adults, services should be tailored to individual strengths and needs, using the least restrictive environment possible.

Guidance

The workgroup concluded that although high levels of care are often indicated when mental health or SUD symptoms threaten patient safety, the need for a more restrictive environment should be carefully balanced with the importance of preserving young adults’ autonomy and the need to stay engaged in school, work, and prosocial activities vital to long-term recovery. Once patients are stabilized in restrictive settings, return to the community should occur and ongoing monitoring and treatment should be conducted on an outpatient basis.

Evidence

Data are inconclusive whether higher levels of addiction treatment (e.g., inpatient, residential, partial hospitalization, or intensive outpatient programs) improve SUD outcomes as compared to outpatient treatment alone for young adults.^3,44 Numerous factors influence the decision to seek a higher level of addiction care. These include the presence of intoxication or withdrawal symptoms, comorbid medical and psychiatric conditions, readiness to change, ongoing use and risk for relapse, and a young adult’s living environment.⁴⁴ At higher levels of care, however, young adults generally have less autonomy and are less able to pursue their educational and employment goals or engage in prosocial activities, all of which are critical to their continued development and sustained recovery. The most restrictive environments—particularly those imposed by involuntary commitment to addiction treatment—almost entirely limit young adults’ autonomy and may be associated with adverse outcomes such as overdose.^45–47 Outpatient management of SUDs (even when severe) is often possible, not inferior to higher levels of care, and associated with better long term outcomes.^3,44

Practice Considerations

Providing care in minimally restrictive settings hinges largely on the availability of outpatient treatment options for young adults. In many regions of the US, the only available addiction treatment program is an inpatient or residential facility.³⁹ Patients, families, and clinicians alike may believe that addiction treatment requires hospitalization (“detox”) or a 30-day residential program, yet many young adults can be safely treated in an outpatient setting.⁴⁴ For families with a young adult unwilling to receive addiction care, some states allow involuntary commitment to treatment, though compulsory admission to a highly restrictive environment is not without risks.

High-quality outpatient addiction treatment programs with minimally restrictive environments are needed in every community. Health care providers serving young adults can strive to expand the services offered within their practices and also advocate for the creation of specialty programs for the most complex patients. Outpatient delivery of care, even for young adults with a complex presentation, can be supported through numerous newly available addiction treatment and clinician education services, including telemedicine and telepsychiatry, hub-and-spokes referral systems, and Project Extension for Community Healthcare Outcomes (ECHO), as several examples.^48,49

Principle 1d: To maximize engagement, young adults should enter care voluntarily. External leverage should be used strategically, but involuntary commitment should be a last resort and when used, it must be as good as or better than non-coercive care.

Guidance

The workgroup acknowledged that young adults with active SUD who are not willing or able to engage in treatment pose a challenge for families. In such cases, the workgroup highlighted that external leverage (such as offering conditional support for education or living expenses) can be used strategically to help the young person reduce their substance use and enter treatment.

Civil commitment, in jurisdictions where it is legal, was not recommended by the workgroup, which noted that it should be used only in the most extreme of circumstances (e.g., clear, imminent danger to self). Even then, families should be aware that involuntary treatment may be associated with adverse outcomes, such as subsequent overdose. When civil commitment to addiction treatment occurs, it is paramount that the care young adults receive be evidence-based to prevent harm associated with compulsory treatment.

Evidence

Involuntary commitment to addiction treatment is not associated with improved treatment outcomes;⁴⁵ in fact, involuntary commitment may be associated with increased risk of overdose.⁴⁶ The majority of US states have statutory provisions allowing civil commitment of individuals with SUD.⁵⁰ It is commonly a family member—often a parent, in the case of a young adult with SUD—who initiates the process of civil commitment and, in most states, must demonstrate that the individual with the SUD exhibits danger to self or to others. The duration of compulsory treatment varies widely across states, with some states allowing up to one month and others allowing up to one year or longer.

Although some may view involuntary commitment as an important way to compel a young adult with a SUD into treatment, there are reasons to be concerned about this approach. In some states, individuals who are committed are placed in jail settings where their autonomy and civil liberties are limited.⁵¹ In these settings, young adults are often housed with older individuals, often including those with more severe SUD. Critically, state laws generally do not specify that evidence-based treatment must be provided in mandatory treatment facilities, and pharmacotherapy is often withheld, placing individuals with SUD (particularly those with OUD) at elevated risk for relapse and overdose following discharge.^46,47 Further considerations regarding involuntary commitment are discussed elsewhere in this series (See accompanying article by Perker et al).

Practice Considerations

Ensuring access to high-quality outpatient services for young adults with SUDs at all stages of readiness to change can mitigate the need for involuntary treatment. Offering comprehensive medical, mental health, and harm reduction services can help engage young adults in care even if reducing substance use is not an explicit goal and gives young adults a place to turn when they do decide to seek addiction treatment.

The perceived need for compulsory treatment reflects the poor availability of services for young adults not ready to seek addiction care.¹⁰ Young adults often view addiction treatment as punitive or requiring abstinence (and indeed, many treatment programs have such a requirement⁵²), and therefore are unwilling to seek care.¹⁷ Family members often feel as though they are powerless to compel young adults into treatment without judicial support.

Evidence-based engagement strategies can help family members support young adults with SUDs who are otherwise not ready or able to seek treatment. One commonly used engagement approach, Community Reinforcement and Family Training (CRAFT),⁵³ capitalizes on rewards and negative consequences of substance use to influence the motivation of individuals with SUD to enter treatment. Notably, the young adult makes the ultimate decision about entering treatment. Further details on family-based interventions are discussed elsewhere in this series (See accompanying article by Bagley et al).

Principle 1e: A goal of care should be continuous engagement, including during periods of relapse.

Guidance

The workgroup asserted that goals of care for young adults with addiction are broad, extending well beyond substance use reduction. Continuous engagement and retention in care are themselves a goal of caring for young adults with SUDs. By broadening treatment to include comprehensive medical, mental health, harm reduction services, and family-based treatments, providers can ensure that young adults have numerous incentives to continue receiving care, even during periods of relapse. Critically, many individuals disengage from care when they relapse, precisely the time that they might most benefit from clinical support. The workgroup concluded that when young adults relapse, outreach with a goal of engagement should become a priority, since many patients are lost to follow-up during times of relapse and are at elevated risk of overdose and other harm.

To help support ongoing engagement and retention in care, the workgroup recommended considering integrating recovery coaches into addiction treatment services. Recovery coaches are individuals with lived history of SUD who can provide outreach to young adults with SUDs, recovery support, and assistance with navigating systems (including health care, housing, legal, and social services).^54,55 The role of recovery supports in addiction treatment is discussed elsewhere in this series (See accompanying article by Xuan et al).

Evidence

Individuals retained in SUD treatment are less likely to experience early death compared to those out of care.^33,56 Continuous engagement to keep young adults in treatment—especially during high-risk times of relapse—offers an opportunity to reduce mortality and other substance use-related harm.⁵⁷ Evidence-based services that can be provided during times of relapse include motivational enhancement to reduce or eliminate substance use, screening and treatment for sexually transmitted and blood-borne infections, and overdose education and naloxone provision, among other harm reduction and recovery support services.^19,29,57 Supplementing services with recovery coaching is associated with enhanced retention in care of individuals with SUD and reduced emergency department use.⁵⁴

Practice Considerations

Changing the goals of addiction treatment to encompass a broader set of patient-centered objectives will require substantial culture shift in many addiction treatment programs. In particular, the requirement for abstinence—which may be incompatible with engaging and retaining many young adults in treatment—is common in many traditional treatment settings and potentially detrimental. Abstinence-only policies may drive young adults who are unable to cease all substance to be discharged; after such experiences, young adults may come to perceive that there are no services suitable to their needs.³⁹ Health systems might consider eliminating requirements that youth cease substance use altogether and instead promote continuous engagement by offering the full spectrum of comprehensive patient-centered services focused on the young adult’s goals for care regardless of their ability to stop or reduce substance use.^10,19

Principle 1f: Substance use care should be held to the same evidence and quality improvement standards as those expected in other areas of medical care for other chronic health conditions.

Guidance

The workgroup concluded that, based on the available evidence, clinicians and health systems should develop quality measures—including structure, process, and outcome measures—for young adult-focused interventions.^58–62 In many cases, quality measures will be the same for individuals of all ages receiving addiction treatment; however, special attention should be paid to the ways in which such measures are developmentally appropriate for young adults.

The workgroup also recommended that clinicians and health systems establish methods and incentives to implement and sustain interventions in routine clinical practice.^58,61 Training on interventions, measures, and quality improvement methodology is needed to support primary care clinicians and addiction specialists alike. Incentives for providers should be aligned with quality improvement to ensure implementation and sustainability.

To support quality improvement, the workgroup highlighted that researchers, public health practitioners, and policymakers will need to establish a research agenda to extend the evidence base on the effectiveness of young adult-focused interventions.^58,61 Particularly important is developing an understanding of the key elements of an intervention that drive its effectiveness. As the body of evidence for young adult interventions grows, it should be systematically reviewed to inform clinical guidelines.

Evidence

Care for a multitude of health conditions has been enhanced through attention to evidence-based principles of care and quality improvement methodologies targeting those principles. Addiction treatment, however, has lagged behind.^62,63 Despite a clear blueprint from the National Academy of Medicine for improving addiction treatment that applies the well-established Quality Chasm approach,^58,64 the quality of care for SUDs remains poor in many settings.⁶²

Numerous organizations have developed comprehensive strategies and performance measures to improve quality in substance use treatment, though many such strategies were developed with older populations of individuals with SUD in mind.^58–60,64 Nonetheless, quality improvement has been successfully applied to the prevention, early detection, and treatment of other youth behavioral health conditions, such as depression.^65,66 Such interventions are associated with greater engagement in counseling, improved symptoms and quality of life, and higher patient satisfaction. Elements common to a successful behavioral health quality improvement intervention include primary care-based management, a collaborative care approach involving an interdisciplinary team, and continuous patient engagement, all of which are principles readily applied to addiction care.^58,63–66

Practice Considerations

Lack of quality improvement in SUD care is in part attributable to the longstanding segregation of addiction treatment from general medical care, where quality improvement is increasingly required.⁶⁴ As clinicians and health systems work to incorporate addiction care into traditional medical settings, quality improvement is likely to follow.

Clinicians and health systems should be aware that addiction quality improvement is currently hampered by a lack of evidence-based substance use-related measures, or in some cases, differing definitions for measures.^62,67 These gaps are likely even more substantial in addiction treatment for young adults, who are likely to have a unique set of developmentally-appropriate outcomes, and for whom traditional measures of initiation, engagement, and retention in care are likely to require different definitions for individuals ambivalent about receiving treatment. Thus, clinicians and health systems are likely to need to develop their own young adult-specific, substance use-related quality measures, continually reassess them, and adapt them to evolving national standards.

In settings where quality measures have already been adopted, there is often insufficient infrastructure to assess, analyze, report, improve, and incentivize outcomes.⁶² It is critical that health systems and payers partner together to provide the education and financial support needed for clinicians to incorporate quality improvement into routine addiction care for young adults.

Conclusion

Effective addiction treatment for young adults has been hampered by insufficient evidence, poor quality of care, inadequate clinician training, siloed systems, punitive approaches, and the view that relapse is failure rather than a hallmark of a chronic illness. The Principles in this document should serve as a roadmap for addressing these numerous limitations. There is much work to do to upend the status quo, but in the face of unprecedented morbidity and mortality attributable to young adult substance use, action is now more urgent than ever.

Abbreviations:

CRAFT

Community Reinforcement and Family Training

OUD

opioid use disorder

SUD

substance use disorders