Treatment plus…? What additional components sustain treatment effects among youth?
Adolescents and emerging adults with substance use disorder have worse outcomes including higher substance use and treatment drop-out compared to their older adult counterparts. Strategies sensitive to their developmental realities that are helpful in reducing substance use and the need for additional treatment episodes can help to reduce the burdens associated with substance use. This study examined whether different components added to a standardized evidence-based treatment increased the time between treatment episodes and reduced criminal convictions among adolescents and emerging adults in Denmark.
WHAT PROBLEM DOES THIS STUDY ADDRESS?
Adolescents and emerging adults with substance use disorder have worse outcomes including higher substance use and treatment drop-out, on average, compared to their older counterparts. Unfortunately, even when clinicians use evidenced-based treatments for this age group, a high proportion still return to using substances within 30-60 days after completion of treatment. Also, some individuals who return to substance use may also engage in other risky behavior that leads to further negative consequences, including criminal activity.
Combined treatment approaches using cognitive behavioral therapy and motivational interviewing have been found helpful for adolescents and young adults because they can help them identify different ways to think about the choice to use substances (e.g., by helping them consider alternative approaches to coping) and to increase their motivation to stop.
Additionally, approaches like contingency management, which offer a small reward for a behavior and are repeated for a period of time, are also highly helpful in engaging adolescents and young adult populations in treatment as the immediate financial reward provided for desired behaviors can be motivating.
Simple text message reminders about session appointments may also be a helpful way to retain participants in treatment, as it targets one key barrier for engagement (remembering one’s appointment). Thus, the use of text messages could increase one’s chance of overall treatment success by helping them to continue in the treatment and receive a full treatment dose.
Finally, the provision of brief continuing care services (also known as aftercare), for example, check-in sessions, may provide a needed booster or simple reminder that there is a caring system in place for adolescents and young adults in their day-to-day lives.
Identifying treatments that are effective in reducing a return to use or in reducing the need for additional treatment episodes are necessary to reduce the burden that substance use and its consequences can have on an adolescent or young adult and their families.
This study examined whether different components added to a standardized evidence-based treatment increased time between treatments and reduced criminal behaviors among adolescents and emerging adults. The study also sought to identify which of these components might be most effective. Given that 40-60% of adolescents and young adults in substance use disorder treatment experience a co-occurring psychiatric disorder, including mood and anxiety disorders among others, they also tested whether the treatments worked equally well for individuals with and without current co-occurring psychiatric disorders.
HOW WAS THIS STUDY CONDUCTED?
The study used existing data from the YouthDAT study. The YouthDAT study was a randomized pragmatic clinical trial of adolescents and emerging adults in Denmark, ages 15-25, who were engaged in outpatient substance use disorder treatment.
Participants were eligible for the study if they were seeking treatment for a non-opioid drug use problem and had used drugs in the past 2 months. The treatment was a standardized 12-session manualized outpatient approach based on cognitive behavioral therapy (CBT) and motivational interviewing (MI).
The study examined four groups of youth: those who received the standard treatment compared to those who received the treatment and additional components in three comparison conditions. The three comparison conditions were: (1) Standard treatment and a contingency management-based approach using $30 vouchers for session attendance (every other session); (2) Standard treatment, text reminders, and low-intensity “aftercare” (hereafter referred to as continuing care and in the form of brief phone or in-person check-ins available to youth); and (3) Standard treatment, contingency management via $30 vouchers for session attendance, text reminders, and low-intensity continuing care.
The previously published results on treatment retention from this study found that the treatment combining text messages and vouchers for session attendance were the best at retaining participants in treatment. This set of analyses were focused on finding out which treatment was best for reducing treatment readmission, or increasing the time to treatment readmission, and reducing criminal behaviors.
They also focused on whether having a lifetime history of psychiatric symptoms influenced the outcomes from the four conditions. Treatment was 12 weeks and to identify treatment readmissions after the trial period, the study team used the date of the participant’s final primary treatment session in YouthDAT until December 31, 2018, which resulted in up to a 4-year window to capture treatment readmissions. To identify criminal behavior, the study team focused on any time after the minimal exposure period to treatment (30 days after randomization) and up to 18 months after that minimal exposure time.
To examine these outcomes, the authors used data collected from the YouthDAT study and data from four national data registries, where study participants could be linked: (1) Drug Users in Treatment register (dates/location for admissions and discharge from drug use treatment centers, demographics); (2) Danish National Crime register which captures youth 15 years or older; (3) Danish National Patient Registry – Psychiatry (duration/type of psychiatric treatment received); and the Danish National Prescription Registry (prescription medication issued by a physician and retrieved by a patient). To control for factors that could influence the relationship between treatment type and outcome, the authors included additional participant characteristics in their analysis: sex, age, being born in Denmark, baseline drug use, drug use treatment history, conviction history, and history of co-occurring psychiatric symptoms.
This sample of 460 adolescents and emerging adults in Denmark were on average 20 years old (SD = 2.63), mostly male (77%), and most reported cannabis as their primary substance (93%). Under half (38%) had a lifetime history of co-occurring psychiatric symptoms and 42% had used psychotropic medicine in their lifetime. Nearly half (49%) had a lifetime history of criminal justice involvement.
WHAT DID THIS STUDY FIND?
Text reminders, $30 vouchers, and continuing care reduced time to readmission.
Just over one third (34%) of participants were readmitted to treatment during the follow-up window of the study and the median time to readmission was 3.9 years. Two interventions resulted in longer time to readmission compared to the standard treatment (median = 2.9 years): (1) Standard treatment plus text reminders and low-intensity continuing care (median = 3.7 years) and (2) standard treatment plus $30 vouchers, text reminders, and low-intensity continuing care (median = 4 years). The highest annual rate of readmission was among those who were in the standard treatment alone compared to the other treatment enhanced treatment conditions.
Being female and having a history of lifetime psychiatric symptoms were risk factors for a slightly shorter time to readmission. For example, participants with this psychiatric history re-entered treatment about 1.2 months earlier than those without this history. Despite individuals with a history of co-occurring psychiatric symptoms having a shorter time to readmission, overall, they benefitted from the enhanced treatments (e.g., text reminders and continuing care) as much as those without a history of co-occurring psychiatric symptoms (i.e., a history of co-occurring psychiatric symptoms did not moderate the effect of different types of treatment on readmission).
Enhanced treatments reduced the likelihood of criminal convictions.
The majority (80%) of participants had no criminal convictions: 7% had 3 or more and 13% had one or two. All the enhanced treatments resulted in lower risk for convictions when compared to standard treatment. The highest annual number of convictions was among those in the standard treatment condition. Participants in this group had double the amount of average annual convictions than those in the three other groups.
Being female and younger were each associated with a lower risk for convictions. Using illicit drugs other than cannabis and having a conviction prior to study entry were also risk factors for having more convictions.
There was no association between having a history of co-occurring psychiatric symptoms and number of criminal convictions and those with and without psychiatric symptom history experienced the same criminal conviction likelihood regardless of treatment received (i.e., having a history of co-occurring psychiatric symptoms did not moderate the effect of different types of treatment on criminal convictions).
WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?
This study of 460 adolescents and young adults demonstrated the value in having add-on components to a 12-week CBT/MI standardized treatment. Specifically, the additional components of text message reminders and low-intensity continuing care served to increase the time to treatment readmission, suggesting these participants were doing well after their treatment episode for longer than those who had simply received the standard treatment. Participants who received the $30 vouchers, text message reminders, and low-intensity continuing care also had a longer time to treatment readmission. Finally, participants in every group with enhanced components had reduced likelihood of criminal conviction compared to participants in the standard treatment condition.
As common factors in both of the most effective enhanced treatments were the text message reminders and low-intensity continuing care, these are components which should be considered important for improving adolescent and emerging adult outcomes. That is, the text messages seem to enhance treatment retention, ultimately increasing the likelihood of greater treatment success. The continuing care approach may be the necessary component to help support adolescents and young adults in maintaining gains made outside of a formal treatment session. Research has demonstrated the need for approaching youth recovery from a long-term lens, a lens that focuses not just on the acute episode requiring treatment but on supporting their development and recovery after treatment, and by doing so through multiple avenues. Thus, these findings that suggest that the availability of low-intensity continuing care, such as a brief phone check-in, helps to prolong treatment readmission also support this perspective. An alternative approach to clinically-driven continuing care for this demographic are sober-focused peer groups or activities, such as alternative peer groups, The Phoenix organization offering sports and exercise, or Young People in Recovery chapters: these types of community supports can serve a similar purpose to the continuing care methods studied here and may help to build social recovery supportive resources (“social recovery capital”) by connecting adolescents and young adults to others like them and engaging them in fun activities that avoid the use of substances. Although the treatment with contingency management through vouchers for session attendance also produced better outcomes than the standard treatment, and may indeed help to increase adolescent and young adult participation in treatment, it may be less cost effective compared to the other enhanced approaches studied here, or available in the broader community.
While the findings of this study did not point to co-occurring psychiatric symptoms as a significant moderator of treatment outcomes, they nevertheless indicate that adolescents and young adults with a psychiatric history may re-enter treatment slightly earlier than youth without this history. This finding could be driven by several factors. That is, although it could indicate a more severe problem with substances and thus a need for additional formal services to address them, it could also indicate that these youth were simply more engaged in a larger system of behavioral health care that referred them to continued treatment as necessary. Further research to better understand the experience of those who have psychiatric or other comorbidity is necessary to ensure appropriate levels of treatment and continuing care.
- A delay in treatment readmission was seen as a positive outcome from the treatment, but it is also possible the length of time to readmission indicates a barrier to accessing needed services. That is, in some cases, earlier readmission, such as might be identified through the use of continuing care approaches like recovery management check-ups, can identify barriers and be vital for an individual to stay engaged in their recovery journey. In this study, it is not clear whether these youth who were readmitted were more severe at the time of readmission or experienced crises that were not adequately handled by the initial treatment.
- Although this study did not focus on the family environment of youth in treatment, given the importance of a supportive family and home environment for youth recovery, it would be useful for future research to consider these factors alongside the success of the treatment on the outcomes addressed here.
- The mechanisms by which the vouchers would have worked for the different outcomes is unclear. For example, it is not clear whether the vouchers are more effective in preventing certain types of criminal behaviors than others. Given that previous work has identified key participant differences as important to the success of contingency management, these aspects should be further explored in additional research.
This study of adolescents and emerging adults in a randomized controlled trial where all participants received CBT and MI demonstrated that the add-on components of text message reminders and low-intensity continuing care added benefit. That is, these enhanced components increased the amount of time to later treatment readmission, suggesting participants did well for a longer period of time than youth who had just received the standard treatment. Participants who received the $30 vouchers for session attendance, text message reminders, and low-intensity continuing care also had longer time to treatment readmission than the standard treatment condition. Participants in every group with enhanced components had reduced criminal convictions compared to participants in the standard treatment condition.
- For individuals and families seeking recovery: The recovery process for adolescents and young adults often takes time and multiple types of supportive resources. It can be difficult to consistently engage and retain adolescents and young adults in treatment, but this study offers some tools that may assist families with this process. First, discussing with youth barriers they see to engaging in treatment and ways they and/or their family can navigate them may help with treatment attendance and ultimately prolong successful treatment outcomes. One such problem may be a simple one of forgetting a treatment appointment; asking for text message reminders could help to solve that problem in a non-invasive way. Also, recognizing that some individuals may need some additional support outside treatment is vital; in this study the availability of low-intensity continuing care seemed to provide a helpful booster for adolescents and young adults. Seeking out youth-focused supports in the local community that can help to build recovery capital during this post-treatment period (e.g., alternative peer groups) may also help to maintain the gains youth made in treatment and increase the time to readmission or reduce the need for readmission altogether.
- For treatment professionals and treatment systems: One way of potentially increasing adolescent and young adult engagement in treatment may be to implement a reminder system using text messages – the most common way that this population communicates remotely. It may also be necessary to ask them if they would like these reminders as this may not be something they would consider on their own. In addition, identifying ways to increase motivation for treatment, or by initially providing motivation in the form of contingency management to create buy-in, may also help adolescents and young adults continue to attend treatment sessions. Working with parents to educate them on how they may help remove these barriers or increase motivation among their child may also help engage the adolescent or young adult in treatment. All these steps may ultimately help increase the effectiveness of the treatment and reduce the need for later formal treatment episodes.
- For scientists: Although this study highlights the potential utility of text message reminders, low-intensity continuing care, and even vouchers for lengthening the time to treatment readmission and reducing criminal convictions, future work should address substance use outcomes in addition to these clinical indicators of success as well as varying effectiveness for different types of substances. Work that seeks to incorporate and support the family in this process, as an additional way of building recovery capital to support post-treatment outcomes, may also demonstrate added value. As well, future research which examines the exact mechanisms by which these tools operate, for example, by examining different types of text messages and or different voucher payment or continuing care check-up schedules may further identify specific pathways of how these additional treatment components work to influence treatment success.
- For policy makers: Increasing the likelihood of treatment attendance is likely to result in improved substance use outcomes, and ultimately, reduced need for intensive follow-up treatment services. Policies that offer funding to enable treatment centers to provide reminders and follow-up support to adolescents and young adults as well as education for parents in supporting their child may yield improved benefits.
del Palacio-Gonzalez, A., Hesse, M., Thylstrup, B., Pedersen, M. U., & Pedersen, M. M. (2022). Effects of contingency management and use of reminders for drug use treatment on readmission and criminality among young people: A linkage study of a randomized trial. Journal of Substance Abuse Treatment, 133, 108617. doi: 10.1016/j.jsat.2021.108617