National Trends in Adolescent Substance Use Disorders and Treatment Availability: 2003-2010

Impact of Illness Severity Tools on Adolescent Psychiatric Managed Care in California

Youth with mental illness struggle to receive essential behavioral health care. One obstacle is denial of coverage by insurance. In California, managed care consumers may apply for independent medical review (IMR) which potentially overturns an insurance denial through the California Department of Managed Healthcare (CDMHC). The authors aim to analyze IMR appeals for psychiatric treatment among adolescents and elucidate factors associated with obtaining coverage of care. We performed an analysis to identify factors that are associated with depression and substance use disorder (SUD) treatment claim denials in 11-20-year-olds from 2001 to 2022 using CDMHC data. Logistic regression modeling was used to identify specific factors related to claim characteristics and medical society instruments that are significantly associated with overturning a denial by IMR. Behavioral health IMRs are overturned at a higher rate than non-behavioral health claims. 54.5% of those with depression and 36.3% of those with SUD initially denied care coverage were overturned by IMR. For those seeking depression treatment, we found a significantly greater odds of overturn by IMR if there was a reference of CALOCUS [1.64, 95%CI (1.06-2.5)]. The odds of a SUD treatment denial being overturned was significantly greater if referencing CALOCUS [3.85 (1.54-9.62)] or ASAM [2.47, [4.3 (1.77-10.47)]. After the standardized implementation of illness severity tools in IMRs, the odds of a medically necessary claim being overturned was 2.5 times higher than before the standards. With a high percentage of claims being overturned after IMR, the findings suggest that health plans inappropriately deny medically necessary behavioral health treatment. The use of medical society instruments was associated with higher odds of overturning a denial. The recent decision of CDMHC to implement standard use of CALOCUS and similar illness severity criteria is supported by our findings and may facilitate more equitable care.

Psychological Interventions for Cannabis Use among Adolescents and Young Adults: A Systematic Review

Regular cannabis use during adolescence can lead to cognitive, psychological, and social consequences, causing significant distress. Although psychological interventions are the mainstay type of treatment for cannabis use disorder, the results remain mixed among youths. The objective of this review is twofold: to identify the existing psychological interventions for cannabis use among youths, and to assess the evidence regarding the effectiveness of those interventions. Randomized controlled trials focused exclusively on cannabis use among adolescents and young adults were included. Three databases-Embase, PsycInfo, and PubMed-were searched to identify relevant peer-reviewed manuscripts published before February 2022 in English and French. The risk of bias was assessed using the Cochrane Collaboration's tool. Twenty-five randomized controlled trials were included. Fourteen studies reported a significant outcome related to cannabis use. These were mainly non-intensive, online interventions that aimed to improve the patients' relationships and emotion regulation. This review highlights the need to conduct additional randomized control trials that target cannabis use disorder specifically among adolescents. These randomized control trials should also aim to reduce the risk of bias related to psychiatric comorbidities as well as detection and attrition problems.

Decoding the link between substance dependence and attention deficit hyperactivity disorder in adults: A cross-sectional study from North India

Background

Attention deficit hyperactivity disorder (ADHD) and Substance dependence are often thought to be linked as they are found to co-exist in many individuals. ADHD is estimated to be an essential indicator for the development of substance use disorder. Aim and Objective: To explore the relationship between different substance dependence and ADHD.

Methods and Materials

This cross-sectional single-interview study was done at a tertiary care hospital in which a total of 153 Cases presenting to the Psychiatry OPD in a period of 03 months were selected serially based on inclusion and exclusion criteria. The diagnosis of substance dependence was made as per ICD-10 criteria. These subjects were then evaluated for the presence of ADHD and physical and psychological symptoms using the Adult ADHD self-rating scale and Maudsley's Addiction Profile.

Results

The majority of our study subjects were aged between 24-29 years (45%) and were predominantly males (98.7%). Most of our subjects were dependent on smack (adulterated heroin) (38.5%) followed by cannabis (27.4%) and alcohol (18.3%). When evaluated for ADHD using the ADHD self-rating scale, we found that almost one-third of the study population had ADHD (33%). Prevalence of ADHD was maximum in the subjects with cannabis dependence (47.6%) followed by tobacco/smoking (38.8%), cocaine (33%), and alcohol (21.5%). This association was statistically significant for cannabis (p = 0.035). The standard mean of both the physical as well as psychological symptoms experienced by subjects was higher in the ADHD group compared to the non-ADHD group which was statistically significant (p < 0.05).

Conclusion

While managing patients with substance dependence we need to target both underlying ADHD and any co-morbid physical and psychological illness if present for holistic recovery of the patient.

Buprenorphine Dispensing Among Youth Aged ≤19 Years in the United States: 2015-2020

BACKGROUND AND OBJECTIVES

Opioid related overdose among adolescents and young adults in the United States is rising. Medications for opioid use disorder (MOUD), including buprenorphine can reduce the risk of overdose, however they are underutilized. A better understanding of buprenorphine prescribing to youth will help inform interventions to expand access to treatment.

METHODS

We used IQVIA data to examine buprenorphine dispensing trends among youth aged ≤19 years from 2015 to 2020. Dispensing was examined by prescriber specialty, age, and sex. Data were weighted to provide national estimates.

RESULTS

The rate of buprenorphine dispensed to youth decreased 25% over the study period, from 0.84 to 0.63 prescriptions per 1000 youth per year. The proportion of youth dispensed buprenorphine also decreased 45%, from 7.6 to 4.2 persons per 100 000 per year. Over the same time, the proportion of adults aged ≥20 years dispensed buprenorphine increased 47%, from 378 to 593 persons per 100 000. Differences in dispensing by sex and temporal trends were also noted. Pediatricians accounted for less-than 2% of all prescriptions dispensed.

CONCLUSIONS

Buprenorphine dispensing to youth is low and declining in recent years. Given rates of opioid use disorder among youth, these findings suggest that many youth who could benefit from MOUD are not receiving it. Pediatricians could play a role in expanding access to MOUD for this high-risk population. Efforts to expand access to MOUD for adolescents could include improving training in opioid use disorder treatment of pediatricians and encouraging all clinicians who care for adolescents and young adults to obtain waivers to prescribe buprenorphine for MOUD.

Ambivalence and Stigma Beliefs About Medication Treatment Among Young Adults With Opioid Use Disorder: A Qualitative Exploration of Young Adults' Perspectives

PURPOSE

Young adults with opioid use disorder (OUD) have low engagement in treatment with medication for opioid use disorder (MOUD). The objective of this study is to explore the beliefs and attitudes about MOUD among young adults.

METHODS

We conducted a single-site qualitative study of 20 young adults ages 18-29 years with a diagnosis of OUD receiving care at an outpatient program and who spoke English. We used a flexible interview guide with the following domains: experience with MOUD, sources and impact of stigma, and interactions with family, healthcare professionals, and social networks. We conducted a thematic analysis based on deductive codes related to the domains and emergent codes from the interviews.

RESULTS

We identified three themes. First, participants perceived being on MOUD as stigmatizing. They regarded MOUD as lifesaving but ultimately as a "crutch" hindering their full recovery. Second, young adults expressed ambivalence, distinct from stigma, about MOUD. This ambivalence was related to fear of withdrawal symptoms and concerns about their ability to live independent lives, side effects, and unknown treatment duration. Third, participants felt that MOUD was more than just a means to reduce risk of overdose, it was a means to become fully functioning in their lives.

DISCUSSION

In this study of young adults in treatment for OUD, we found that stigma and ambivalence concerning MOUD could explain young adults' low engagement in care. Interventions addressing concerns about the stigmatizing effects of MOUD and the ambivalence young adults experience related to MOUD could improve engagement and retention of young adults.

"My Life Isn't Defined by Substance Use": Recovery Perspectives Among Young Adults with Substance Use Disorder

BACKGROUND

While substance use disorder remains a leading cause of morbidity and mortality for young adults, low rates of treatment engagement and retention persist. One explanation is that substance use disorder treatment approaches do not match young adults' expectations for recovery. While the concept of recovery has been explored among adult populations, less is known about how young adults think about recovery.

OBJECTIVE

To describe perspectives of recovery among young adults with substance use disorder.

DESIGN

Qualitative, in-depth interviews exploring young adults' definitions of recovery.

PARTICIPANTS

Twenty English-speaking young adults (7 women; 21-29 years old) diagnosed with substance use disorder recruited from an urban safety net hospital in Massachusetts.

APPROACH

Interviews were recorded and transcribed verbatim. An iterative categorization analytic approach was used to identify and interpret themes.

KEY RESULTS

Four themes related to recovery were identified. First, young adults described recovery as a way to grow up and live a normal life not defined by the substance use. A second theme was recovery had to include multiple components, such as mental health treatment, to be successful. Third, young adults described recovery as a self-motivated process, and it was important that young adults had agency in recovery decision-making. Fourth, recovery was described as a lifelong pursuit that required vigilance and commitment.

CONCLUSIONS

In this qualitative study of young adults with substance use disorder, participants identified themes that have implications for treatment models. Participants recognized recovery as a complex and individually motivated process that includes multiple components such as mental health treatment and re-engagement in regular daily activities. Models of care for young adults should consider incorporating these treatment elements to improve engagement and retention.

Substance use screening and rates of treatment referral among justice-involved youth

BACKGROUND

Justice-involved youth report high rates of substance use and related problems that are associated with treatment needs; however, data on screening and linkage to treatment within the justice system is lacking. To further inform the juvenile justice behavioral health cascade of care, this study examined factors associated with identified problematic substance use and treatment referral using two screening tools.

METHOD

As part of a family court intake process, 348 justice-involved youth received two screening measures, the MAYSI-2 alcohol/drug use subscale and the CRAFFT. Both tools are designed to indicate early warning signs of substance use problems and signal referral for further clinical evaluation or treatment. Chart review analysis examined whether demographic variables (sex & race), severity of use, and type of substance used were associated with positive screens on either or both measures and subsequent treatment referral.

RESULTS

Half (51.2%) of youth were identified as having problematic substance use (a positive screen) on at least one of the screeners. Overall, 38.5% positively screened on the CRAFFT with only 0.3% positively screening on just the MAYSI-2 alcohol/drug scale. Cannabis only users were less likely to positively screen on the MAYSI-2 compared to youth who reported use of both alcohol and cannabis. Positively screening on one versus both screeners was not associated with referral, yet many (28%) who positively screened were not referred for services.

CONCLUSIONS

The CRAFFT may be more accurate at identifying youth specifically at risk for problematic cannabis use compared to the MAYSI-2 alcohol/drug subscale. Regardless of tool used, treatment referral was low, highlighting the need for accurate identification of treatment needs of substance-using, justice-involved youth. Interventions to facilitate referrals for youth with problematic substance use are needed.

Development and examination of the attribution questionnaire-substance use disorder (AQ-SUD) to measure public stigma towards adolescents experiencing substance use disorders

BACKGROUND

Public stigma may significantly impact adolescents with substance use disorders (SUDs), leading to limited treatment accessibility and utilization. However, few measures have been validated to assess public SUD stigma towards adolescents. In this study we developed the Attribution Questionnaire-Substance Use Disorder (AQ-SUD) by modifying the Attribution Questionnaire, a commonly used measure of public mental illness stigma. We examined 1) the psychometric properties of the AQ-SUD with supporting data from other stigma scales and 2) preliminary data on adults' perceptions of public stigma toward adolescents with SUDs.

METHODS

Adult participants (n = 304) were randomly assigned to one of four vignettes about an adolescent with a specific SUD diagnosis (opioid, marijuana, alcohol, and stimulant use disorders). Participants completed the AQ-SUD and three other measures of public stigma designed to assess convergent and divergent validity.

RESULTS

Analyses indicated that the modified AQ-SUD has good psychometric properties, and revealed a four-factor structure: negative emotions, assessment of responsibility, social disengagement, and lack of empathy. Additional public stigma scales demonstrated good psychometrics and provided evidence of both convergent and divergent validity for the AQ-SUD. Preliminary analysis of public stigma towards adolescents with a SUD suggests that attitudes about marijuana use disorder differ significantly from attitudes about other SUDs.

CONCLUSIONS

This study is the first to modify and validate a measure designed to assess perceptions of public SUD stigma towards adolescents, the AQ-SUD. Preliminary analyses suggest that adults view adolescent marijuana use disorders as less severe compared to other SUDs, which may have implications for adults' motivation to support youth in seeking treatment.

Do expansions in adolescent access to public insurance affect the decisions of substance use disorder treatment providers?

We apply a mixed-payer economy model to study the effects of changes in the generosity of children's public health insurance programs - measured by Medicaid and Children's Health Insurance Program income thresholds - on substance use disorder (SUD) treatment provider behavior. Using government data on specialty SUD treatment providers over the period 1997-2011 combined with a two-way fixed-effects model and local event study, we show that increases in the generosity of children's public health insurance induce providers to participate in some, but not all, public markets. Our effects appear to be driven by non-profit and government providers. Non-profit providers also appear to increase treatment quantity slightly in response to coverage expansions.

Interactive Computer Simulation for Adolescent Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Substance Use in an Undergraduate Nursing Program

PURPOSE

Adolescent substance use has been identified as our nation's number one public health problem. Screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based approach to identify and address adolescent substance use. Despite recommendations for universal implementation, adolescent SBIRT training has been notably absent from undergraduate nursing curricula. This project describes and evaluates the effectiveness of using an interactive computer simulation for adolescent SBIRT in an undergraduate nursing program.

DESIGN AND METHOD

Undergraduate nursing students (n = 144) completed an adolescent SBIRT interactive computer simulation (SBI with Adolescents, Kognito). Self-perceived competence, confidence, and readiness to deliver adolescent SBIRT were measured via pre- and post-survey items. Student attitudes toward substance use and simulation-based learning were also studied. At the end of the simulation, students received an automatic assessment challenge score based on performance. We compared the pre- and post-SBIRT scores using the Wilcoxon signed rank test and the sign test for repeated measures using 2-tailed α = 0.05.

RESULTS

We saw significant (p < .05) improvement in overall student competence, confidence, and readiness to deliver SBIRT. Positive quantitative and qualitative feedback were also received regarding the simulation experience.

CONCLUSIONS

Adolescent SBIRT training was successfully integrated into an undergraduate nursing curriculum. There were significant improvements in self-reported competence, confidence, and readiness to deliver adolescent SBIRT.

PRACTICAL IMPLICATION

This project provided further support for the potential benefits of an interactive computer-based simulation in an undergraduate nursing curriculum.

How Should Remote Clinical Monitoring Be Used to Treat Alcohol Use Disorders?: Initial Findings From an Expert Round Table Discussion

Scientific evidence combined with new health insurance coverage now enable a chronic illness management approach to the treatment of alcohol use disorders (AUDs), including regular monitoring of blood alcohol content (BAC), as a useful indicator of disease control. Recent technical advances now permit many different types of remote, real-time monitoring of BAC. However, there is no body of research to empirically guide clinicians in how to maximize the clinical potential of remote BAC monitoring.As an initial step in guiding and supporting such research, the manufacturer of one remote BAC monitoring system sponsored a group of experienced clinicians and clinical researchers to discuss 8 issues that generally affect remote, clinical BAC monitoring of "adults in outpatient AUD treatment."The expert panel unanimously agreed that remote BAC monitoring for at least 12 months during and after the outpatient treatment of AUD was a clinically viable deterrent to relapse. There was also consensus that positive test results (ie, recent alcohol use) should lead to intensified care and monitoring. However, there was no agreement on specific types of clinical intensification after a positive test. The panel agreed that sharing positive and negative test results with members of the patient support group was helpful in reinforcing abstinence, yet they noted many practical issues regarding information sharing that remain concerning. Significant differences within the panel on several important clinical issues underline the need for more clinical and implementation research to produce empirically-supported guidelines for the use of remote BAC monitoring in AUD treatment.

Trends in Receipt of Buprenorphine and Naltrexone for Opioid Use Disorder Among Adolescents and Young Adults, 2001-2014

IMPORTANCE

Opioid use disorder (OUD) frequently begins in adolescence and young adulthood. Intervening early with pharmacotherapy is recommended by major professional organizations. No prior national studies have examined the extent to which adolescents and young adults (collectively termed youth) with OUD receive pharmacotherapy.

OBJECTIVE

To identify time trends and disparities in receipt of buprenorphine and naltrexone among youth with OUD in the United States.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted using deidentified data from a national commercial insurance database. Enrollment and complete health insurance claims of 9.7 million youth, aged 13 to 25 years were analyzed, identifying individuals who received a diagnosis of OUD between January 1, 2001, and June 30, 2014, with final follow-up date December 31, 2014. Analysis was conducted from April 25 to December 31, 2016. Time trends were identified and multivariable logistic regression was used to determine sociodemographic factors associated with medication receipt.

EXPOSURES

Sex, age, race/ethnicity, neighborhood education and poverty levels, geographic region, census region, and year of diagnosis.

MAIN OUTCOMES AND MEASURES

Dispensing of a medication (buprenorphine or naltrexone) within 6 months of first receiving an OUD diagnosis.

RESULTS

Among 20 822 youth diagnosed with OUD (0.2% of the 9.7 million sample), 13 698 (65.8%) were male and 17 119 (82.2%) were non-Hispanic white. Mean (SD) age was 21.0 (2.5) years at the first observed diagnosis. The diagnosis rate of OUD increased nearly 6-fold from 2001 to 2014 (from 0.26 per 100 000 person-years to 1.51 per 100 000 person-years). Overall, 5580 (26.8%) youth were dispensed a medication within 6 months of diagnosis, with 4976 (89.2%) of medication-treated youth receiving buprenorphine and 604 (10.8%) receiving naltrexone. Medication receipt increased more than 10-fold, from 3.0% in 2002 (when buprenorphine was introduced) to 31.8% in 2009, but declined in subsequent years (27.5% in 2014). In multivariable analyses, younger individuals were less likely to receive medications, with adjusted probability for age 13 to 15 years, 1.4% (95% CI, 0.4%-2.3%); 16 to 17 years, 9.7% (95% CI, 8.4%-11.1%); 18 to 20 years, 22.0% (95% CI, 21.0%-23.0%); and 21 to 25 years, 30.5% (95% CI, 30.0%-31.5%) (P < .001 for difference). Females (7124 [20.3%]) were less likely than males (13 698 [24.4%]) to receive medications (P < .001), as were non-Hispanic black (105 [14.8%]) and Hispanic (1165 [20.0%]) youth compared with non-Hispanic white (17 119 [23.1%]) youth (P < .001).

CONCLUSIONS AND RELEVANCE

In this first national study of buprenorphine and naltrexone receipt among youth, dispensing increased over time. Nonetheless, only 1 in 4 commercially insured youth with OUD received pharmacotherapy, and disparities based on sex, age, and race/ethnicity were observed.

Working memory capacity and addiction treatment outcomes in adolescents

BACKGROUND

Brief addiction treatments including motivational interviewing (MI) have shown promise with adolescents, but the factors that influence treatment efficacy in this population remain unknown. One candidate is working memory, the ability to hold a fact or thought in mind. This is relevant, as in therapy, a client must maintain and manipulate ideas while working with a clinician. Working memory depends upon brain structures and functions that change markedly during neurodevelopment and that can be negatively impacted by substance use.

OBJECTIVES

In a secondary analysis of data from a clinical trial for adolescent substance use comparing alcohol/marijuana education and MI, we evaluated the relationship between working memory and three-month treatment-outcomes with the hypothesis that the relationship between intervention conditions and outcome would be moderated by working memory.

METHODS

With a diverse sample of adolescents currently using alcohol and/or marijuana (N = 153, 64.7% male, 70.6% Hispanic), we examined the relationship between baseline measures of working memory and alcohol and cannabis-related problem scores measured at the three-month follow-up.

RESULTS

The results showed that lower working memory scores were associated with poorer treatment response only for alcohol use, and only within the education group. No relationship was found between working memory and treatment outcomes in the MI group.

CONCLUSION

The results suggest that issues with working memory capacity may interfere with adolescents' ability to process and implement didactic alcohol and marijuana content in standard education interventions. These results also suggest that MI can be implemented equally effectively across the range of working memory functioning in youth.

Technology-based Interventions for Preventing and Treating Substance Use Among Youth

Preventing or mitigating substance use among youth generally involves 3 different intervention frameworks: universal prevention, selective prevention, and treatment. Each of these levels of intervention poses unique therapeutic and implementation challenges. Technology-based interventions provide solutions to many of these problems by delivering evidence-based interventions in a consistent and cost-effective manner. This article summarizes the current state of the science of technology-based interventions for preventing substance use initiation and mitigating substance use and associated consequences among youth.

Assessing Adolescent Substance Abuse Programs with Updated Quality Indicators: The Development of a Consumer Guide for Adolescent Treatment

When adolescent substance abuse requires treatment, few parents know which treatment features are important and which treatment programs are effective. There are few resources to help them select appropriate care. We describe early work on an evaluation method and comparative treatment guide for parents based upon the premise that the quality of a program and its potential effectiveness is a function of the number and frequency of evidence-based treatment practices (EBPs) delivered. Thus, we describe the development of and measurement approach for a set of EBPs toward the goal of developing a Consumer Guide to Adolescent Substance Abuse Treatment.