Integrating substance use care into primary care for adolescents and young adults: Lessons learned

Abstract

Background:

Substance use disorders are common chronic conditions that often begin and develop during adolescence and young adulthood, yet the delivery of primary care is not developmentally tailored for youth who use substances. Very few primary care–based substance use treatment programs exist in the United States for adolescents and young adults and no clear guidance is available about how to provide substance use treatment in primary care.

Methods:

We conducted a retrospective evaluation from July 2016 to December 2018 of a newly established primary care–based, multidisciplinary, outpatient program for youth who use substances. Components of the program include primary care, addiction treatment, harm reduction, naloxone distribution, psychotherapy, recovery support, and navigation addressing social determinants of health. We report the following patient characteristics and outcomes: demographics; proportion with substance use and mental health diagnoses; receipt of medications for opioid use disorder; retention in care at three, six, nine, and 12 months; and re-engagement in medical care.

Results:

From July 2016 through December 2018, 148 patients had at least one visit. Demographic characteristics included: median age 21 years; 40.5% female; 94.0% spoke primarily English; 18.3% Black, 14.9% Hispanic, and 60.8% white. One-third of patients (33.8%) were homeless or housing insecure. The most common substance use disorder was opioid use disorder (60.8%), followed by nicotine (37.2%), cannabis (20.9%), and alcohol (18.2%). Overall, 29.7% of patients had depression, 32.4% had anxiety disorder, and 18.9% had post-traumatic stress disorder. Retention in care was 29.7% at six months and 12.2% at 12 months. Among the 90 patients with OUD, 90.0% received medication for OUD, and 35.5% and 15.5% of patients with OUD were retained at six and 12 months, respectively. For patients lost to follow-up (no contact during a three-month period), the median time to re-engagement was 4.8 months, and 33.3% (37/111) of patients re-engaged. The most common reason for re-engagement was to access mental health treatment (59.5%) and primary care (51.4%).

Conclusions:

Youth who sought care in a primary care–based substance use program presented most commonly with opioid, nicotine, cannabis, and alcohol use disorders. Co-morbid mental health diagnoses were common. While continuous retention at 12 months was low, one in three of the patients who fell out of care re-engaged. For youth receiving substance use care integrated into primary care, key components for pursing optimal retention in substance use treatment are a flexible model that anticipates the need for the treatment of mental health disorders and the use of re-engagement strategies.

1. Introduction

Substance use disorder (SUD) is a disease typically of pediatric onset that peaks in young adulthood (Substance Abuse and Mental Health Services Administration, 2019). Early use of substances is associated with a significant risk of developing an SUD as an adult (Hingson et al., 2006; McCabe et al., 2007; Winters & Lee, 2008). Adults with severe SUDs typically started using substances as adolescents and developed their SUD through adolescence and young adulthood. Although cannabis, alcohol, and nicotine use are the most common substances used among adolescents and young adults, the opioid epidemic has not spared adolescents and young adults (termed “youth”). Between 2001 and 2014, diagnoses of opioid use disorder (OUD) rose six-fold (Hadland et al., 2017) in this population. Among 15–19 year olds, opioid-related deaths increased three-fold between 1999 and 2016 (Gaither et al., 2018). Despite this, only approximately 20% of youth with OUD receive evidence-based medication treatment (Hadland et al., 2017, 2018). Furthermore, recent data suggest receipt of evidence-based buprenorphine treatment for OUD has been increasing for all age groups except 15–24 year olds (Olfson et al., 2020). Retention in care remains a consistent challenge as well, with most observational studies finding less than 20% of youth with OUD retained at one year (Borodovsky et al., 2018; Matson et al., 2014; Mutlu et al., 2016; Schuman-Olivier et al., 2014; Smyth et al., 2012). Research has not focused on re-engagement of youth in care, although re-engagement is an important outcome given the ambivalence of youth to engage and their high discontinuation rates. Therefore, a significant opportunity exists to identify, engage, retain, and re-engage youth who use substances, including opioids, in evidence-based care.

The American Academy of Pediatrics (AAP)’s Committee on Substance Use and Prevention has published guidelines for pediatricians related to (1) screening, brief intervention, and referral to treatment (SBIRT) in primary care (Levy et al., 2016); (2) addressing substance use in families (Smith et al., 2016); and (3) referral and treatment for OUD (including medication treatment) (Committee on Substance Use And Prevention, 2016). These important guidelines provide a framework for pediatricians and other pediatric providers to address substance use in health care settings. As a complement to the AAP Substance Use and Prevention guidelines for care, pediatric primary care providers need new models to address substance use in clinical settings. Primary care–based models provide multiple potential benefits, including identifying youth with sporadic use to prevent the development of SUD, counseling to minimize the harms associated with any substance use, and provision of SUD treatment in less restrictive settings relative to inpatient addiction programs. The primary care setting provides a medical home for ongoing coordination of care and support for families in addition to a setting for SUD treatment that is familiar to youth and their families. Most of the evidence-based treatment for SUD can be delivered in an outpatient setting. One example of such delivery is office-based addiction treatment (OBAT), which is a well-established and effective way of delivering SUD care in primary care settings for adults (Korthuis et al., 2017)3/19/2021 3:34:00 PM. In this model, nurse care managers partner with primary care providers to deliver collaborative team-based care.

Although effective and disseminated broadly to adults, research has not adapted or evaluated OBAT in youth. Indeed, to our knowledge, very few primary care–based SUD treatment models for youth exist nationwide. Youth are different from adults, including having higher prevalence of polysubstance use, higher co-occurring mental health disorders (Partnership for Drug-Free Kids et al., 2019), and more reliance on family and social support for medical decision-making. In addition, developmental qualities, including identity exploration, feelings of invincibility, and vulnerability to peer influence, may have a direct impact on engagement and retention in care (Arnett, 2000; Matson et al., 2014; Schuman-Olivier et al., 2014). Youth can view substance use, even use causing problems, as normative. Even for youth who desire abstinence, finding new social networks and supports can be an overwhelming task for them.

To address these unique developmental considerations, we implemented a program with adaptations to deliver care for youth who use substances based on the OBAT model at an urban health safety-net hospital. The objective of this study is to describe patients’ characteristics and outcomes, specifically retention in care, for those seen in the program.

2. Methods

2.1. Design

We conducted a retrospective study of the Center for Addiction Treatment for AdoLescent/Young adults who use SubsTances (CATALYST) program from July 2016 to December 2018.

2.2. Overview

2.2.1. Program description:

The team established CATALYST in July 2016. Its mission statement is “To help young people who use substances lead healthy lives through holistic, team-based care”. CATALYST accepts referrals for patients under 25 who use substances. When the program began, the team included, one physician trained in internal medicine, pediatrics, and subspecialty addiction certification (the program’s medical director), one pediatrician with subspecialty certification in adolescent and addiction medicine, one addiction psychiatrist, one licensed independent clinical social worker, one nurse care manager with addiction certification, a recovery coach, and a program manager. During the first year, the program hired an additional licensed clinical social worker and recovery coach (see Table 1 for detailed descriptions of CATALYST services). The medical director provides oversight of the program, including decisions about program development, new initiatives, and review of all clinical protocols. The physicians each see patients 1–2 half-days per week. All other staff are full time. The nurse care manager supports the care team by collaborating on patient intakes, managing medications including buprenorphine and naltrexone, and addressing social determinants of health. The full-time program manager oversees daily operations of the program and personnel, and is responsible for new program development. The CATALYST team provides care within the Adolescent Center in the Department of Pediatrics as well as the General Internal Medicine Clinic in the Department of Medicine at Boston Medical Center, and collaborates with the Department of Psychiatry. Providing care in both Medicine and Pediatrics allows for a transition from the pediatric to the adult setting.

Table 1.

Baseline characteristics of adolescents and young adults engaged in primary care-based outpatient substance use care (N = 148).

Variable	NO OUD N=58	OUD N=90	TOTAL N=148
Mean Age at First Visit (SD), Median	19.13 (3.10), 19	22.19(3.44), 23	21.1 (3.2), 21
Age at First Visit with a CATALYST Provider
12-17	19 (32.8%)	5 (5.6%)	24(16.2%)
18-23	32 (55.2%)	50 (55.6%)	82 (55.4%)
24-27	2(3.4%)	34 (37.8%)	36 (24.3%)
Patient Gender (as recorded in Electronic Medical Record)
Male	39 (67.2%)	49 (54.4%)	88 (59.5%)
Female	19 (32.8%)	41 (45.6%)	60 (40.5%)
Patient Language 1
English	54 (93.1%)	85 (94.4%)	139 (93.9%)
Non- English	4 (6.9%)	5 (5.6%)	9 (5.9%)
Race/Ethnicity
Hispanic	12 (20.7%)	10 (11.1%)	22 (14.9%)
White2	16 (27.6%)	74 (82.2%)	90 (60.8%)
Black2	26 (44.8%)	2 (2.2%)	28 (18.3%)
Other, including multi-racial2	1 (1.7%)	1 (1.1%)	2 (1.4%)
Declined/not available	3 (5.2%)	3 (3.3%)	6 (4.1%)
Homeless or Housing Insecure 3	12 (20.7%)	38 (42.2%)	50 (33.8%)
Insurance at First Visit with a CATALYST Provider 4
Public	42 (72.4%)	63 (70.0%)	105 (70.9%)
Private	11 (19.0%)	26 (28.9%)	37 (25%)
Unknown	5 (8.6%)	1 (1.1%)	6 (4.1%)
Patients with Co-Occurring Behavioral Health Disorders
Depression	19 (32.8%)	25 (27.8%)	44 (29.7%)
Anxiety	15 (25.9%)	33 (36.7%)	48 (32.4%)
Bipolar disorder	0 (0.0%)	7 (7.8%)	7 (4.7%)
ADHD or ADD	8 (13.8%)	12 (13.3%)	20 (13.5%)
Mood disorder	2 (3.4%)	12 (13.3%)	14 (9.5%)
PTSD	8 (13.8%)	20 (22.2%)	28 (18.9%)
Substance Use Disorder Diagnoses
Opioid use Disorder	NA	90 (100.0%)	90 (60.0%)
Alcohol use disorder	17 (29.3%)	10 (11.1%)	27 (18.2%)
Nicotine use disorder	9 (15.5%)	46 (51.1%)	55 (37.2%)
Cannabis use disorder	26 (44.8%)	5 (5.6%)	31 (20.9%)
Stimulant use disorder	2 (3.5%)	0 (0.0%)	2 (1.4%)
Prescribed Medication for OUD (Outpatient)		81 (90.0%)

¹Language is defined as patient language. This variable may not indicate other languages spoken.

²Non-Hispanic

³Defined as ever marking yes to either “I do not have a steady place to live,” or “I have a steady place today but am worried” on the THRIVE screener and/or ever experiencing three or more address changes in one year and/or ever having ICD-10 code for homelessness (Z59) marked in the patient’s chart. Homelessness may be underrepresented in this sample.

⁴Could be after a first completed office visit or after first completed clinical support visit.

2.2.2. Referrals, intake, and assessment:

Providers and families can refer to CATALYST by phone or internally through the electronic medical record or paging system. In addition, the program staff will meet with patients who are inpatient or in the emergency department. The youth makes a first appointment with a physician and a social worker for medical and mental health intakes, respectively. At the initial assessment, the physician and social worker work with the patient to formulate the goals of care for the patient and develop an initial treatment plan. Initial treatment plans may include scheduling a visit with the nurse care manager, the psychiatrist, meeting with a recovery coach, weekly psychotherapy, or medication for opioid or alcohol use disorder. In addition to the treatment plan, the team asks for permission to contact family and other involved providers to help coordinate care. The social worker, recovery coach, or nurse care manager reviews releases of information and establishes the parameters of what the treatment team can discuss with family and other providers. For example, some youth may not want a family member involved in the treatment but will allow us to establish the person for contact in an emergency. In Massachusetts, youth under 18 can receive substance use treatment without the consent of a parent or guardian, as is the case in approximately half of other U.S. states (National District Attorneys Association, 2013). Each week, the CATALYST team meets for an hour to discuss patients, review treatment plans, and make adjustments as needed.

2.3. Services and description of the program

2.3.1. Medical care:

The program offers all patients routine primary care, including preventive care, immunizations, sexually transmitted infection screening and treatment, viral hepatitis screening, and contraception. The program offers patients at risk of HIV pre-exposure prophylaxis and treats patients with hepatitis C with direct-acting antivirals. Patients can receive pharmacotherapy for OUD (buprenorphine and naltrexone) and alcohol use disorder (naltrexone, acamprosate, or disulfiram). The program also offers patients with OUD referrals to methadone treatment at a licensed opioid treatment program.

2.3.2. Behavioral health care:

The program encourages all patients to participate in a psychosocial assessment with a licensed independent clinical social worker and schedules them with addiction psychiatry for evaluation and diagnosis of co-occurring psychiatric disorders. The social workers provide evidence-based therapies, including motivational interviewing, cognitive behavioral therapy, and acceptance and commitment therapy.

2.3.3. Recovery support:

Two recovery coaches are available to provide recovery support to patients. This support may include accompanying patients to appointments, providing facilitated referrals to recovery services, being available to patients who are ambivalent about substance use, and being the point of contact for patients to stay engaged or to re-engage in care.

2.3.4. Philosophy:

From the onset of the program, the team recognized that the risks of overdose and other medical consequences of substance use were high, and that engaging and retaining youth in substance use care would be challenging. Thus, CATALYST provides high-risk substance-using youth with comprehensive services, including medical and mental health care, counseling, case management, harm reduction, and addiction treatment services as needed. The program does not require youth to be abstinent to receive any of the described services.

2.3.5. Family involvement:

The team invites families to be involved in care when the patient agrees. This can include not only parents but also other trusted adults. In the cases when a youth does not want parental involvement, the team respects that decision but works to incorporate the family over time. The team provides parents or guardians general information related to diagnosis, treatment, and education for SUD with permission from the patient.

2.3.6. Overdose education and prevention:

Through a Department of Public Health grant, the team dispenses naloxone kits to patients and families in clinic and provides information about recognizing and preventing overdose.

2.3.7. Clinical site for trainees:

CATALYST is a core rotation for the Boston University School of Medicine/Boston Medical Center Addiction Medicine Fellowship program. In addition, medical students and residents rotate weekly as part of Adolescent and Addiction Medicine electives.

2.4. Variables

2.4.1. Demographics and patients’ characteristics:

Using a centralized data warehouse at Boston Medical Center, we collected variables recorded as part of routine clinical care. We abstracted age, gender, race, behavioral health diagnoses, substance use disorder diagnosis, and medications for addiction treatment. We could access these variables for the entire study period. The team collected measures of social determinants of health (homeless/housing insecurity, need for employment or education, difficulty paying bills, difficulty paying for medications, and food insecurity) through a standardized screening tool, THRIVE (Tool for Health & Resilience In Vulnerable Environments), beginning in August 2017 (Buitron de la Vega et al., 2019).

2.4.2. Retention in care:

The research team determined retention status for all patients at three, six, nine, and 12 months after their first appointment. The study considered patients retained in care if there was contact within the prior 30 days at three, six, nine, and 12 months. This definition was based on the team’s clinical judgement of retention. The study defined contact as an in person visit or a phone contact. The study only included phone contact if there were documentation in the electronic medical record of the CATALYST team providing ongoing support for the patient. For patients with OUD, for each time point, we indicated whether they were receiving medication treatment with buprenorphine or naltrexone.

2.4.3. Re-engagement in care:

The study defined re-engagement as a new appointment after not being retained at three, six, nine, or 12 months. We collected the data and reason for re-engagement based on information reviewed in the electronic medical record.

2.5. Analysis

The study team calculated descriptive statistics to characterize the clinic patients for all variables, including referral sources. The team calculated retention and re-engagement in care for patients with each type of SUD (i.e., opioid, cannabis, alcohol); a patient could have more than one SUD. The study conducted a subanalysis examining retention and re-engagement for patients with OUD.

3. Results

3.1. Patient demographics and characteristics

In the clinic’s first 30 months of operation, CATALYST received 315 referrals from the hospital or the community. Of these referrals, 148 patients (47.0%) presented for a first visit, among whom 79.7% were between the ages of 18 and 27 years, 93.9 % were English speaking, 40.5% were female, and 33.8% were homeless. Opioid, nicotine, and cannabis use were most common—60.0%, 37.2%, and 20.9%, respectively. One-third of patients had a diagnosis of anxiety or depression, and 18.9% had a diagnosis of post-traumatic stress disorder (PTSD) (Table 1).

Of 93 patients with OUD, 93.4% were 18–27 years old, 94.4% were primarily English speaking, 82.2% were white, and 42.2% were homeless. Almost all patients were prescribed a medication for OUD (90.0%), with buprenorphine being the most common (83.3%). Half of the patients with OUD had a comorbid nicotine use disorder, and 11.1% had an alcohol use disorder. Approximately one-third had depression or anxiety, and 22.2% had a diagnosis of PTSD (Table 1).

3.2. Social determinants of health

Seventy-nine (53.4%) patients completed the THRIVE screen to assess social determinants of health. Of those who completed the screen, 13.9% reported difficulty with transportation to medical appointments, 24.1% reported unemployment and looking for a job, 29.1% reported housing insecurity or homelessness, and 29.1% reported food insecurity (Table 2).

Table 2.

Social determinants of health screening^* (N = 79).

Variables	N (%)
Trouble Paying for Medicines	8 (10.1%)
Trouble Getting Transportation for Medical Appointments	11 (13.9%)
Trouble Paying Heating/Electric Bill	1 (1.3%)
Trouble Taking Care of a Child, Family Member, or Friend	2 (2.5%)
Currently Unemployed and Looking for a Job	19 (24.1%)
Housing insecurity or homelessness1	23 (29.1%)
Food Insecurity2	23 (29.1%)

^*Social Determinants of Health screening began in August 2017

¹Ever marked yes to either “I do not have a steady place to live,” or “I have a steady place today but am worried.”

²Ever marked sometimes or often true to “Past 12 Months, Food Didn’t Last and No Money to Get it” or “Past 12 Months, Worried Whether Food Would Run Out,” or marked experiencing a food emergency.

3.3. Retention and re-engagement

For all patients, retention in care was 54.7% at 3 months, 29.7% at 6 months, 19.6% at 9 months, and 12.2% at 12 months (Figure 1). For those with OUD, it was 58.0%, 35.5%, 25.5%, and 15.5%. (Figure 2) There were 130 patients who became lost to follow-up and 37 of those (28.5%) re-engaged, and 22 (16.9%) were patients with OUD (Table 3). The median time to re-engagement was 4.8 months (interquartile range 3.0, 9.8). The most common reasons for re-engagement were mental health care (59.5%), primary care (51.4%), and restarting MOUD (24.3%).

Figure 1.

Retention in care of CATALYST patients at 3, 6, 9, and 12 months (N = 148).

*Engagement is defined by past 30-day phone or in-person visit

**Phone engagement: documented phone note in electronic medical record that includes either refill for medication, intent to stay engaged with CATALYST, or help with coordinating care

Figure 2.

Retention in care of CATALYST patients with OUD (N = 90).

*Engagement is defined by past 30-day phone or in-person visit

**Phone engagement: documented phone note in electronic medical record that includes either refill for medication, intent to stay engaged with CATALYST, or help with coordinating care

Table 3.

Re-engagement in care of CATALYST patients (N = 37).

Time to re-engagement median months (IQR)	4.8 (3.0, 9.8)
Type of re-engagement
Phone only	9 (24.3%)
Phone, then	16 (43.2%)
In-person visit	12 (32.4%)
Reason for re-engagement *
Restart MOUD	9 (24.3%)
Primary Care	19 (51.4%)
Social Determinants of Health	2 (5.4%)
Mental Health	22 (59.5%)
Other	12 (32.4%)

^*Patients may have had multiple reasons for re-engagement.

4. Discussion

In this retrospective review of a novel office-based, primary care program developmentally tailored for youth who use substances, we found youth presented for care with a variety of SUDs, had a high prevalence of mental health disorders, and mental health care was the most common reason for reengaging in care. Many youth were also experiencing homelessness, housing insecurity, and food insecurity. Only one in 10 youth were continuously retained at 12 months, but almost one in three re-engaged at some point in the study period.

Prior studies of youth treated in office-based settings have found similar or lower treatment retention at 12 months. In a retrospective review of an outpatient program for youth with opioid use disorder, Matson et al reported 9% (10/103) were retained in treatment at 12 months (Matson et al., 2014). In another study of an adult-focused OBAT, 17% (12/70) of young adults (ages 18–25) compared to 45% (101/224) of older adults were retained at 12 months (Schuman-Olivier et al., 2014). Neither of these studies reported re-engagement of patients. Given the chronic relapsing nature of SUDs, treatment programs may want to increase focus on not only retention but also re-engagement. One study of adult OBAT patients reported that of patients who had disengaged early, only 11.9% re-engaged after two years. The authors did not find any characteristics associated with re-engagement (Hui et al., 2017). In our sample, although retention was low at 12 months for both youth with OUD and other SUDs, one-third subsequently re-engaged. Because of their psychological and neurobiological development, many youth are especially ambivalent about their substance use and engagement in care. Youth have competing priorities, such as spending time with friends or getting a job, that may lead to temporary disengagement. The multi-disciplinary CATAUYST team facilitated engagement and re-engagement via phone contact and walk-in in-person clinic options. At weekly meetings, the CATAUYST team reviews a patient list that includes patients who have missed appointments and makes a plan for outreach. Programs could further structure re-engagement efforts to the youth population through the adaptation of recovery management checkups (Scott et al., 2005).

While the team designed and developed CATALYST for youth, typically addiction care is not tailored to youth, perhaps causing some youth to not feel welcome or engaged by addiction care services. Moving forward, treatment providers should also consider how to make services more “youth-friendly”. A recent scoping review of programs focused on youth engagement identified the following key principles that providers should incorporate into program development: (1) improving access to care and early intervention, (2) youth and family participation and engagement, (3) youth-friendly settings and services, (4) evidence-informed approaches, and (5) partnerships and collaborations (Hawke et al., 2019). More qualitative studies of youth, families, and providers could inform improvement in youth care, with a focus on the 3- and 6-month marks when many patients disengaged.

Substance use and SUD diagnoses varied substantially by race and ethnicity, with OUD diagnoses clustering among white patients. In recent years, opioid overdose deaths significantly increased among the adult Black population (Lippold, 2019; SAMHSA, n.d.) Furthermore, research has identified inequities in receipt of MOUD, with higher receipt of buprenorphine among white patients with OUD (Hansen et al., 2016; Lagisetty et al., 2019). In studies of commercially and Medicaid insured youth with OUD, Black youth were less likely to have received MOUD (Hadland et al., 2017, 2018). The research team identified key areas of improvement for the CATALYST program, among them being more welcoming and engaging for non-white youth with OUDs, particularly given that the overall population of patients served at Boston Medical Center is more racially and ethnically diverse with white identified patients a minority.

Models of care for youth must account for the challenges of retention and ambivalence by encouraging flexibility to re-engage. As we noted in the background, access to buprenorphine care has worsened among 15–24-year-olds nationally. One recent study found that substance use facilities in the United States that treat adolescents are half as likely to offer MOUD as are adult-focused facilities (Alinsky et al., 2020). This finding is concerning given the significant increase in opioid-related mortality in the youth age group, evidence from randomized controlled trials that buprenorphine treatment improves retention, and the recommendations from the AAP and ASAM to offer medication treatment to youth with OUD.

Another consideration for future research is whether settings other than primary care are optimal for substance use care for youth, including treatment of OUD. There are other settings, such as community-based youth drop-in centers that may be more appropriate for engaging youth. These models explicitly include other services such as support for education and employment, which may enhance retention in care (Settipani et al., 2019). Research should compare different models of care for youth that optimize engagement, retention, and re-engagement.

Co-occurring depression, anxiety, and PTSD were common among patients in our program, similar to other studies of youth with SUDs. Nearly one in three youth had co-occurring anxiety or depression and one in five had PTSD. A recent systematic review of integration of substance use and mental health treatment into primary care found few interventions to address either mental health or substance use. Only one of the studies specifically included a sample of youth with co-occurring SUD and mental health disorders (Richardson et al., 2017). Given the high prevalence of co-occurring disorders among this population, programs that address youth substance use should also have the capacity to offer evidence-based treatment for other mental health disorders. In addition, given that patients’ leading motivation for re-engagement in CATALYST was to address their mental health concerns, treatment providers could highlight this care to enhance engagement and re-engagement of this challenging-to-keep-engaged population. As CATALYST has grown, mental health treatment has become central to our model. Other programs that address youth substance use should include mental health providers from the inception of the program, and treatment plans should be a collaborative effort between addiction and mental health team members.

Although we did not explicitly address the roles of families in this evaluation, research should explore what role families play in improving youth engagement and retention in treatment. Families can be key partners in addressing youth substance use and their involvement can potentially improve engagement, retention, and substance use outcomes (Ventura & Bagley, 2017). Specifically, research has shown that family-based therapies, including functional family therapy, multidimensional family therapy, and brief strategic family therapy, improve outcomes for adolescents with SUD (Hogue et al., 2018; Horigian et al., 2016) For individuals not yet ready to engage in treatment, the Community Reinforcement and Family Training model provides support for families to learn new ways of communicating that improve likelihood of treatment engagement (Kirby et al., 2015; Meyers et al., 1998). Despite the evidence for family inclusion, research has not specifically studied these models in primary care–based models for youth. Future studies should look at including families when possible in the addiction care for youth.

Finally, many youth in our program reported housing and food insecurity. As we noted, many youth may drop out of care as a result of ambivalence toward treatment and/or competing interests. Programs that work with youth should consider offering support to address social determinants of health, including facilitating referrals to ensure that their basic needs are met.

4.1. Limitations

The main limitation of this study is that its data were collected as part of routine clinical care and not for research purposes; thus, under-diagnosis of SUDs and mental health disorders is possible. For example, no patients with OUD also had a recorded diagnosis of stimulant use disorder in the medical record, which undoubtedly indicates under-documentation of stimulant use disorders.

5. Conclusion

Programs that engage youth in care for substance use in primary care should be flexible and should include treatment of mental health disorders, address social determinants of health, and actively pursue re-engagement following the all-too-common discontinuation of care with this high-risk population. CATALYST is a clinical model that pursues these objectives and merits consideration in other pediatric primary care settings.

Behavioral Health

Assessment, diagnosis and treatment of psychiatric disorders

Evidence-based psychotherapy: Cognitive behavioral therapy, Acceptance and commitment therapy, Motivational interviewing

Medical Care

Primary care

Sexually Transmitted Infections screening and treatment

HIV screening and referral to treatment

Pre-exposure Prophylaxis for HIV

Hepatitis C screening and treatment

Birth control

Substance Use

Assessment and diagnosis of SUDs

Harm reduction education including overdose education and naloxone kits

Medication treatment – buprenorphine and naltrexone

Monitoring with urine drug testing

Referrals and coordination with more intense levels of care as needed

Other

Recovery coaching

Patient navigation

Guidance for family members and loved ones

Referrals to food pantry

Employment assistance

Highlights.

Engaging youth who use substances in primary care requires flexibility.

Youth programs must include treatment of mental health and address social determinants of health.

Re-engagement in care may be an important outcome to include in future studies of youth with substance use disorder.