We don’t need science to tell us that what works for adults doesn’t always work for young people.
But researchers say finding proven solutions tailored to young people is critical to helping stem the tide of opioid overdose deaths from the opioid epidemic.
Now, results from a recently completed randomized controlled trial indicate a way forward. And every component of the wraparound approach includes intensive, customized support for both the young patient and the family.
With funding from Arnold Ventures, a team from Potomac Healthcare Foundation and the Johns Hopkins School of Medicine led by Dr. Marc Fishman piloted a new treatment model specifically for young adults that tested the role of proactive engagement in keeping individuals in treatment. The randomized control trial included patients ages 18 to 26 years old, over the course of six months.
Adolescents and young adults tend to have poorer engagement in, and response to, treatment than their older counterparts. And they have the highest per capita rate of opioid use. There are things about being young, experts say, that may contribute to the challenge of recovery — feeling invincible, not wanting to admit to illness, not wanting to be told what to do. Medical professionals have questioned how to effectively deliver prevention medications paired with behavioral support to young people for exactly those reasons.
“We know that the medication used to treat opioid use disorder is effective, but despite that fact, few people — and very few young people — have access to it on a consistent, long-term basis,” said Arnold Ventures Public Health Manager Julie Wiegandt. “We hope that researching new ways to engage and retain people in treatment will lead to long-term improvements in the addiction treatment system.”
The approach in the randomized controlled trial, called Youth Opioid Recovery Services (YORS), has four major components: family engagement, assertive outreach, home delivery of relapse prevention medications, and incentives for receiving treatment.
The initial results indicate that the comprehensive approach worked: Patients who received YORS had lower rates of relapse at three and six months and got more doses of medication. They were also more likely to take every dose than patients who had the regular course of treatment, which required that they make the effort on their own to stay engaged and travel to a clinic to get each dose of medication.
One 21-year-old had five inpatient rehabilitation admissions over a year and a half before participating in the study. He received his first dose of naltrexone each time, but never returned for a second. With YORS, he received all six doses over the course of the treatment period.
By literally meeting patients and their families where they are — at home, in recovery residences, in restaurant bathrooms — study staff were better able to provide the monthly doses to patients and get more face-to-face time with family members outside of formal sessions.
YORS operates on the idea that empowering both young adults and their families are compatible objectives and that treatment proceeds best when it’s a collaboration between the individual, the family, and the treatment team, according to Fishman.
It’s often difficult for families to participate in their loved one’s treatment for a simple reason: It’s hard for everyone involved. It’s time consuming. Patient confidentiality is a concern. And patients often push back against restrictions from or feeling dependent on their parents — as most young adults do.
In the study, the team found that parental figures especially, including mothers and fathers themselves, but also aunts, uncles, and grandparents, have natural leverage and more positive influence in the situation than they may think.
Phones, Social Media Play a Role
Relapse prevention medications are the clear standard of care for the treatment of opioid addiction in adults, but transportation, time constraints, work schedules, and limited financial resources can get in the way when treating young adults. By literally meeting patients and their families where they are — at home, in recovery residences, in restaurant bathrooms — study staff were better able to provide the monthly doses to patients and get more face-to-face time with family members outside of formal sessions.
Instead of waiting for the patient to seek treatment, the staff also took an assertive approach to engaging patients. That meant texting, calling, or Facebook messaging multiple times a week or even a day with reminders, scheduling for medication or other sessions, and managing insurance and other logistics. With group text, treatment staff combined persistent outreach and the accountability provided by including family members and keeping them informed.
Finally, the YORS model offered increasing monetary incentives for each dose of medication, which is sometimes used as a tactic to increase engagement in treatment.
“The study demonstrates just how tough the problem of treating youth opioid use disorder is. Of the patients who received the regular course of treatment, the average number of outpatient doses received was less than one. But at the same time, it may be hard to sustain the high level of proactive outreach that YORS involves,” Wiegandt said.
Five-Year Study Ahead
People with opioid use disorder often require long-term treatment because addiction can change the biology of the brain. Moving forward, a refined treatment model may build in a transition back into clinic-based care after a limited period of YORS. It may also expand the family engagement component to include multi-family groups and peer-to-peer counseling.
“We hear a lot of, ‘You’re the first people who have been willing to talk to me,’ from parents,” Fishman said. “Their experience has not been one of being welcomed and included, and that seems to make a difference.”
Recovery doesn’t happen in a straight line. Individuals will miss a dose of medication or relapse and for each patient, it was important to develop a Plan B and a Plan C and do the work of bringing them back into treatment when things didn’t go as planned, he said.
“As long as you work hard on engagement and are thoughtful, the patients and the parents get it,” Fishman said. “The young adults agree to the treatment model including the involvement of their parents, and even if they change their minds temporarily, they usually come around to agree again.”
On the strength of the results from the Arnold Ventures-funded pilot, the study team will next launch a new $826,573 five-year study funded by the National Institute on Drug Abuse to further refine the YORS model and evaluate its efficacy in a randomized controlled trial.
“We’re excited that our support led to this opportunity to build more definitive evidence about the YORS program,” Wiegandt said.