Principles of Evidence-Based Substance Use Treatment for Young Adults
Young adulthood, between the ages of 18 and 25, is a crucial developmental stage defined by newfound independence combined with still maturing executive functioning — making it a particularly vulnerable time to engage in high-risk behaviors, including substance use. Most people who develop a substance use disorder (SUD) do so before the age of 25, making medical intervention and seamless delivery of care for addiction for this age group imperative to preventing lifelong harm.
Medications for opioid use disorder, such as methadone, naltrexone, and buprenorphine, are proven treatments to combat the cycle of addiction. However, in the paper, “Evidence-Based Treatment for Young Adults with Substance Use” in January’s Pediatrics, addiction experts concur that pharmacotherapy and other evidence-based care is underutilized for young adults with SUD. The paper, part of a special supplement, features insights from an interdisciplinary convening by the Grayken Center for Addiction at Boston Medical Center (BMC) and argues that more targeted research and clinical outreach is necessary to treat SUD in this particularly vulnerable population.
Most pediatricians lack adequate training on screening and treatment for SUD in young adults, delaying evidence-based interventions for those who could benefit. Also, treatment for addiction in this age group often occurs involuntarily in residential programs with fragmented follow-up, leading to poor outcomes. The authors of the new paper argue more integration in services to improve the continuum of care for this chronic condition.
“Pediatricians are very comfortable working with this age group, and the addiction medicine specialists know how to treat addiction. So, if you imagine that Venn diagram, that intersection is where we have real potential to do something important,” explains Sharon Levy, MD, MPH, director of the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital and coauthor of the paper.
As the nation’s overdose crisis continues to claim lives, the authors outline six principles of evidence-based care to guide the management of young adults with SUD.
1. Young adults should be offered access to addiction treatment and services as soon as needs are identified.
Heavy alcohol, marijuana, and nicotine use in young adulthood, especially in collegiate settings, is often falsely dismissed as “normal.”The consequences of substance misuse are life-threatening, and clinicians need to be willing to engage young adults about treatment options. Left unaddressed, SUD becomes more challenging to treat and can lead to more severe disorders.
The authors emphasize that clinicians need to be vigilant in screening young adults for addiction and immediately connect patients to treatments, including medications when appropriate, at the outset of intervention.
The authors also acknowledge that there are many barriers to treating young adults with SUD. This age group is known to have the lowest participation in routine healthcare. Furthermore, when treatment is recommended, young adults are often hesitant to engage in it.
Recognizing the numerous challenges in caring for this population, the authors suggest widespread clinician training on evidence-based approaches for treating addiction and additional education and support for health systems to improve outreach and engagement among young adults. Resources should also be directed toward the recruitment and education of a specialized workforce to better meet young adults’ needs.
“We need a lot more people who have a lot more practice in working with this age group. It is its own specialty,” acknowledges Levy.
2. Young adults should have access to a comprehensive set of assessment, harm reduction, psychosocial, and pharmacological treatments and recovery services supported by evidence.
Addiction treatment requires a multidimensional approach that must respect the level of care that young adults with SUD are willing to engage in. Whether seeking recovery or looking to reduce drug-related harms, young adults with SUD should have access to comprehensive medical assessment, education on harm reduction, counseling, psychosocial supports, and medications that promote recovery.
The authors warn that many providers treat young adults one-dimensionally, referring them to behavioral health services for assessment and counseling for addiction — forgoing other evidence-based approaches to support recovery.
“There is a massive pharmacologic treatment gap across this country in which the vast majority of young adults who need treatment for opioid use disorder don’t receive the evidence-based recommended standard of care that includes medication,” says Scott E. Hadland, MD, MPH, addiction medicine specialist at BMC and lead author of the article. He underlines the importance of U.S. Food and Drug Administration (FDA)-approved medications methadone and buprenorphine to address opioid use disorder.
Studies indicate that only one in four young adults receive medication for opioid use disorder despite evidence suggesting that individuals who receive pharmacotherapy are more likely to adhere to addiction treatment than individuals who receive only behavioral therapy. The delay in initiating treatment for addiction could be because of deeply ingrained cultural beliefs that teens and young adults “experiment” with substances. Misconceptions also persist that pharmacotherapy is antithetical to recovery, says Hadland.
“The DSM-V tells us that all substance use disorders are defined by persistent, continuous use of substances despite negative consequences. The reason that medications like buprenorphine and methadone are not ‘trading one addiction for another’ is that these medications actually reduce these negative consequences, getting rid of a hallmark of addiction,” he explains.
3. Respecting the diversity of young adults, addiction services should be tailored to individual strengths and needs, using the least restrictive environment possible.
Outpatient treatment settings that allow patients to retain independence are associated with better long-term outcomes. Nevertheless, experts acknowledge that there are too few outpatient programs across the country, often making residential and 30-day detox programs the only care options.
New models of addiction care can support the outpatient approach to treatment. The growth of telemedicine and telepsychiatry have increased access and flexibility for young adults seeking support. In addition, more integrated, specialized care such as hub-and-spoke referral systems provide individualized support, even for complex cases, while still allowing autonomy.
Once in SUD treatment, Levy emphasizes that more evidence is needed on the most effective methods to specifically engage young adults.
“There are a number of studies showing that it’s harder to engage young adults. It’s harder to keep them in treatment. They are more likely to drop out. There is a real question there about why that is happening. Is it because the treatment isn’t really speaking to them? There is something different about what they need, and we haven’t addressed it yet,” she says.
4. 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.
Young adults should be willing partners in their care, whenever possible. Though the article acknowledges that young adults with active SUD are often unwilling to engage in treatment, which is challenging for families, involuntary treatment can be associated with adverse outcomes, including overdose. As such, all efforts should be made to meet patients where they are.
Outreach efforts should be made where young adults with SUD intersect with care, even when recovery is not the explicit goal. Education and support for harm reduction is a good place to start. Physicians should be prepared to inform patients about needle exchange programs and pre-exposure prophylaxis, screen and treat for hepatitis C and sexually transmitted infections, distribute naloxone, and provide other harm reduction services.
"Some young adults may come to you not ready or able to reduce their substance use. That doesn’t mean that we turn our backs on them," Hadland says. “Engaging them in other health services can reduce the risk of their substance use and maximize their health.”
When involuntary treatment is absolutely necessary to ensure patient safety, providers should always strive for balance in treatment to help preserve, when possible, young adults’ pursuit of education, career, and social activities.
5. A goal of care should be continuous engagement, including during periods of relapse.
Levy points to fragmented care as a significant factor in relapse. It is a devastating cycle that separates SUD from many other chronic health conditions.
Continuous engagement involves multilevel outreach to young adults during treatment and recovery. These touchpoints include medication, follow-up from addiction specialists, psychosocial counseling to build skillsets to maintain recovery and treat comorbid psychological issues, and peer recovery coaches to help young adults reintegrate into the community.
Levy notes that patients often engage more heavily on one or more of these support modalities during different stages in their recoveries. “Having all those pieces available, that is what leads to the strong recovery,” she says.
6. 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.
Parity in evidence and quality improvement standards have been delayed by the historical segregation of addiction treatment from other medical services.
To support quality improvement, the authors highlighted that all stakeholders, including researchers, public health practitioners, and policymakers, need to commit to a research agenda to examine the effectiveness of addiction treatment interventions specifically in the young adult age group. Further evidence on the efficacy of interventions will, in turn, bolster confidence in treatment modalities and reduce stigma among members medical community hesitant to address substance use among young adults.
“I think the idea that we can treat this and we can treat it very successfully is an extremely positive message. If we could shift from ‘young people just experiment’ to ‘this is a problem, but we can treat it,’ patients can do very, very well,” Levy says. “Patients that have substance use disorder can go on to have beautiful, wonderful, fulfilling, and satisfying lives, and treatment is going to help them maintain a strong recovery. We shouldn’t shy away from it.”
Meryl is a freelance writer passionate about public health, social justice, and medical innovation. As part of her writing career, she worked as a communications specialist in both the healthcare and nonprofit sectors. She holds a bachelor's degree in English literature from Georgetown University.