Support Services for Young Adults With Substance Use Disorders Ziming Xuan, ScD, SM, MA,a Jasmin Choi, MSW, MPH,a Lara Lobrutto, MPH,a Tiffany Cunningham, BA,b Sierra Castedo de Martell, MPH,c Jessica Cance, PhD,d Michael Silverstein, MD, MPH,e,g Amy M. Yule, MD,f Michael Botticelli, Med,g Lori Holleran Steiker, PhDb

abstract In summarizing the proceedings of a longitudinal meeting of experts in substance use disorders (SUDs) among young adults, this special article reviews principles of care concerning recovery support services for this population. Young adults in recovery from SUDs can benefit from a variety of support services throughout the process of recovery. These services take place in both traditional clinical settings and settings outside the health system, and they can be delivered by a wide variety of nonprofessional and paraprofessional individuals. In this article, we communicate fundamental points related to guidance, evidence, and clinical considerations about 3 basic principles for recovery support services: (1) given their developmental needs, young adults affected by SUDs should have access to a wide variety of recovery support services regardless of the levels of care they need, which could range from early intervention services to medically managed intensive inpatient services; (2) the workforce for addiction services for young adults benefits from the inclusion of individuals with lived experience in addiction; and (3) recovery support services should be integrated to promote recovery most effectively and provide the strongest possible social support.

aDepartment of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts; bSteve Hicks School of Social Work, The University of Texas at Austin, Austin, Texas; cSchool of Public Health, The University of Texas at Dallas, Dallas, Texas; dRTI International, Research Triangle Park, North Carolina; Departments of ePediatrics and fPsychiatry, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; and gGrayken Center for Addiction Medicine, Boston Medical Center, Boston, Massachusetts

The guidelines/recommendations in this article are not American Academy of Pediatrics policy, and publication herein does not imply endorsement. Dr Xuan conceptualized the study, supervised the literature review, and drafted and revised the manuscript; Ms Choi and Ms Lobrotto provided assistance in literature review and drafted the summary of research evidence; Dr Holleran Steiker contributed to the conceptualization and drafted and revised the manuscript; Ms Cunningham, Ms Castedo de Martell, and Drs Cance and Yule provided literature review and manuscript revision; Mr Botticelli and Dr Silverstein coordinated the conference proceeding and provided critical revision to the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. DOI: https://doi.org/10.1542/peds.2020-023523E Accepted for publication Oct 23, 2020 Address correspondence to Ziming Xuan, ScD, SM, MA, Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave, Crosstown CT453, Boston, MA 02118. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2021 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: Dr Xuan is supported by an internal fund from Boston Medical Center Accountable Care Organization research and evaluation unit. Dr Yule is supported by K12DA000357 from the National Institutes of Health. The sponsors did not participate in the work. Funded by the National Institutes of Health (NIH). POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Downloaded from www.aappublications.org/news by guest on September 29, 2021 SUPPLEMENT ARTICLE PEDIATRICS Volume 147, number s2, January 2021:e2020023523E Young adulthood (defined as ages view of recovery resources has been helping young adults with SUDs be 18–25 years) is defined by significant further subdivided into 3 types of well, manage symptoms, and achieve transitions from the dependence of recovery capital, including personal and maintain abstinence; increasing adolescence to the independence and capital (an individual’s physical and housing to support recovery; responsibilities of adulthood.1,2 human capital such as physical health, reducing barriers to employment, Substance use peaks during young financial assets, health insurance, safe education, and other life goals; and adulthood,3 and a significant body of shelter, food security, transportation, securing necessary social supports in research exists regarding factors education and/or vocational skills, an individual’s chosen community. associated with its onset, such as self-esteem, and confidence), family Considering this array of recovery unemployment, lower education, and/or social capital (intimate – support services and potential and noncustodial parenthood.4 6 relationships, family and kinship delivery systems to support them, However, less attention has been paid relationships, and social relationships a group of experts was convened as to the unique needs of young adults such as partner and family support), part of a longitudinal meeting, in recovery from substance use and community capital (community- supported by Boston Medical Center’s disorders (SUDs) and how best to level attitudes, policies, and resources Grayken Center for Addiction promote the recovery process for this such as education and training, Medicine, to derive principles of care particularly vulnerable population.7 employment, housing, legal related to recovery support services counseling, role models, and The Substance Abuse and Mental for young adults. In this article, we culturally prescribed pathways of Health Services Administration communicate fundamental points recovery).10 (SAMHSA) defines recovery as related to guidance, evidence, and a process of change through which The resources, or capital, that an practice considerations about 3 basic people improve their health and individual person needs depends on principles for recovery support wellness, live self-directed lives, and the severity of the individual’s SUD services to promote young adult strive to reach their full potential.8 and the resources the individual recovery. The recommendations in According to SAMHSA, a successful already has available. From a social- this article are not American recovery hinges on 4 key dimensions: ecological perspective,11 it is Academy of Pediatrics policy, and (1) overcoming or managing one’s necessary to act across multiple publication herein does not imply condition and symptoms; (2) having levels and dimensions to sustain full endorsement. a stable and safe place to live; (3) recovery over time and ensure long- conducting meaningful daily activities term success. SAMHSA has advanced and having the independence, income, the framework of Recovery-Oriented PRINCIPLES OF CARE and resources to participate in Systems of Care, which proposes Principle 1: Given Their society; and (4) having relationships a multisystem, person-centered Developmental Needs, Young Adults and social networks that provide continuum of care in which a variety Affected by SUD Should Have Access support, friendship, love, and hope. of coordinated support services are to a Wide Variety of Recovery SAMHSA’sdefinition of recovery tailored to patients’ recovery stage, Support Services Regardless of the implicitly recognizes the complex recovery pathway, and needs.12 Levels of Care They Need interplay among the individual, The focus of recovery support Guidance family, community, and other social services is responsive to calls from A key premise underlying recovery factors that influence the trajectory of the National Academy of Medicine for support services is that SUD is recovery. a change from an acute care model to a chronic condition.14 As a result, Recovery capital refers to the breadth one typically used for chronic clinicians caring for young adults and depth of internal and external conditions.13 The full range of with SUD should recognize that the resources that can be drawn on to recovery support services is intended recovery process takes place initiate and sustain recovery from to address the multitude of life areas primarily outside conventional alcohol and other drug problems.9 in response to patients’ changing medical settings. A treatment model Recovery capital is conceptually needs. Conceptually, the dimensions that focuses on acute care, or that linked to a broad range of recovery- of recovery support services call for takes place in isolation from other related terminologies such as natural promoting partnerships with people community-based services, is at odds recovery, solution-focused therapy, in recovery from SUDs and their with longitudinal studies that indicate strengths-based case management, family members to promote that more than half of patients recovery management, resilience, and individual, program, and system-level entering publicly funded addiction the ideas of overall wellness and approaches that foster health and programs require multiple episodes global health.10 This comprehensive resilience. These approaches include of treatment over several years to

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 147, number s2, January 2021 S221 achieve sustained recovery15 and that training (including help with housing), the commonality is that both create the recovery process is marked by as well as enhancing access to system- environments to support cycles of recovery, relapse, and level resources such as primary and relationships among peers with repeated treatment episodes.16,17 This behavioral care, child welfare, and similar recovery goals. Recovery high is particularly true for young adults.18 criminal justice systems.21 schools are typically small programs embedded within another school or In part because social contexts that Although there is empirical evidence part of a set of alternative schools.33 give rise to an individual’s substance to support formal professionally The schools provide academic use can remain largely unchanged, directed aftercare models in reducing courses that are often self-paced, as challenges can remain long after SUD among adolescents and young well as therapeutic support, which abstinence is attained, particularly adults,22,23 informal peer-based social generally includes individual therapy with respect to family and social network support also contributes to and support groups. In a quasi- relationships, housing, education, and “recovery communities.”24 In experimental study, adolescents with employment. Clinicians should a randomized trial of volunteer SUDs who attended a recovery high recognize that regardless of the level recovery support for adolescents school experienced an increased of treatment received, young adults after residential treatment discharge, likelihood of abstinence, compared without access to a variety of researchers found better engagement with those who did not.34 recovery social services risk in recovery management activities, experiencing a prolonged and often including sobriety-related activities Collegiate recovery programs insufficient recovery, which delays or and self-help, and increases in the facilitate social support for college prevents full integration into their number of prorecovery persons students in recovery but tend not to own communities. Recovery social surrounding the recovering provide separate educational services, when used appropriately for individuals.25 In another experiences.35 Services range from young adults, can link young adults to observational study, researchers sponsoring on-campus mutual help needed resources, empower them to found improvement in employment meetings to structured programs that sustain recovery, and help them status was associated with SUD include a physical space where regain independence. posttreatment recovery outcomes, counseling and social events are including abstinence and reduced hosted. There are no studies Evidence days missed from work due to evaluating outcomes associated with substance use.26 This adds to the these programs, but a survey of In an exploratory study among literature primarily based on trials student experiences found that individuals who entered but and systematic reviews about the link students were primarily motivated to subsequently left publicly funded between employment and recovery participate in a college recovery urban addiction treatment programs, – outcomes.27 30 Authors of a review program because of a need for authors found that 54% expressed study found a moderate level of a supportive peer network.36 unmet needs for social services, evidence that recovery housing is particularly in areas of job training, associated with improvements in stable housing, and further assistance Practice Considerations functioning, including employment with housing.19 Using data among There is general consensus that and criminal activity, and community samples in abstinent young adults with SUD require abstinence.31 Younger members recovery, researchers found that developmentally appropriate participating in a substance abuse employment was the second most approaches for treatment and recovery housing intervention for frequently mentioned priority at all recovery.37,38 Although factors vary in $6 months experienced better stages of recovery.20 Initiatives from influencing relapse and recovery outcomes in terms of substance use, SAMHSA have yielded valuable (including addiction severity, self-regulation, and employment.32 knowledge about the typology and individual motivation and skills, co- implementation of recovery support For young adults, recovery support occurring mental health conditions, services. For example, the Recovery provided within the education setting, family environment, and the Community Services Program was specifically, can be an important availability of supportive peers), a SAMHSA-funded initiative source of social support. Structured formal inpatient adolescent and consistent with a social-ecological educational recovery support services young adult treatment programs tend framework; it includes sober and have been growing in high school and to be short, lasting between 1 and 3 stress management, building college settings since the 1970s. months.39 When the treatment ends, constructive family and social There is substantial heterogeneity in young adults return to their relationships, peer coaching and the structure of recovery high schools communities often unprepared for mentoring, and education and skills and collegiate recovery programs, but the competing demands of social

Downloaded from www.aappublications.org/news by guest on September 29, 2021 S222 XUAN et al integration.40 Therefore, practitioners compensation is involved, the pay can Anonymous are the most popular should recognize that regardless of vary widely.44 Peers work in a variety peer support recovery approach held the levels of care the patient needs of settings, ranging from recovery outside the formal treatment setting (be they early intervention services community organizations in which for addiction.49 Alcoholics Anonymous or intensive, inpatient medical care), educational, advocacy, and sober affiliation has been linked to better young adults’ recovery is influenced social activities are organized, to self-efficacy, healthy coping, and by many individual-, family-, and churches or other faith-based reductions in alcohol and drug use.50,51 community-level factors. institutions, to recovery residences, Peer support services within Practitioners should work with young the criminal justice system, drug treatment and community settings adults to adopt a patient-centered courts, health service centers, and vary substantially in modalities of approach to care that addresses the addiction and mental health delivery, including in-person self-help physical, psychological, interpersonal, treatment agencies.45 The function of groups, peer-run or operated and community factors that affect the peer recovery support often services, peer partnerships, peer relapse and recovery. matches the vision and mission of the specialists, case managers, advocates individual settings and the needs of in health care settings, and Internet Principle 2: The Workforce for the community. The peer workforce support groups.52 Authors of 2 Addiction Services for Young Adults has been shown to be a key review studies found that active Benefits From the Inclusion of component of the community engagement in peer support groups Individuals With Lived Experience in reinforcement approach and has has shown to be a key predictor of Addiction demonstrated valuable social roles in treatment retention, improved Guidance helping youth with drug abuse relationships with treatment achieve recovery and maintain In addition to evidence supporting providers, social support, and abstinence.46,47 the benefit of comprehensive reduced relapse rates.53,54 recovery support services, evidence Evidence Methodologic limitations include suggests there may also be benefits to small sample sizes, absence of White41 defined “peer-based recovery having peer workers in the workforce appropriate comparison groups, and support” as the process of giving and to support youth recovering from the inability to disentangle the effects 41 receiving nonprofessional, nonclinical drug abuse. Typically, support of peer recovery support from other assistance to achieve long-term recovery services provided by those treatment and support activities. recovery. Other similar terminologies with lived experience in addiction do More rigorous investigations are are used in the literature to describe not replace the need for formal needed to assess the effectiveness of peer-related support and contexts, treatment or clinical guidance; rather, peer support recovery programs, with including peer support, peer support they offer an enhancement to special attention to the advantages of group, peer provider, and peer treatment that increases the peer support integration within the mentor.42,43 Extensive literature has likelihood of sustained recovery. substance use treatment continuum. Peers with lived experience can shown peer support groups as a key component of existing addiction provide support to substance-using Practice Considerations persons by sharing experiences and treatment and recovery approaches, knowledge, offering understanding, including residential and sober living, Although there are limited data on and suggesting coping strategies. 12-step programs, and treatment the effectiveness of peer support Personal, lived experience allows the programs in community settings. recovery services for treating opioid peer recovery support provider to be Sober living houses are drug-free use disorders among emerging youth, “experientially credentialed”41 and living environments for a group of the literature on the effectiveness of infuses interactions with a sense of peers to live and recover, and they peer support as an augmentation to mutuality designed to promote rely on mutual sobriety support and treat alcohol and other drugs for the fi connection and hope.42 Often, peer participation. In a randomized trial, general population con rms peer workers with lived experience in researchers found an Oxford House support as a key and popular addiction are well positioned to intervention (a self-run community in component for successful practice. motivate patients to cope with their which residents are expected to Clinical considerations focus on fi challenges and engage more fully in contribute, work, and pay bills) was exploring the multitude of speci c fi skills training, employment, and associated with a signi cant decrease service types and modalities, social integration.43 in substance use after discharge from including Internet-based peer inpatient treatment, as compared to support, and how to integrate with Peer workers may work on a usual-care condition.48 Twelve-step formal treatment services in various a volunteer basis or be paid. When programs such as Alcoholics community settings.

Downloaded from www.aappublications.org/news by guest on September 29, 2021 PEDIATRICS Volume 147, number s2, January 2021 S223 Barriers do exist. When implementing with SUDs are in a unique position to access to housing support organizations, in a unique setting, gaining a rapport gather frontline data on SUDs among mental health services, and collaborative with that community can present young adults. They can use learning among providers was effective a significant challenge unless guided a screening tool to assess health- in improving youth’s housing stability, by key informants from the recovery related social needs, work closely functioning, and illness severity.64 community. Recovery community with case managers to develop Recent review studies also reveal the organizations can serve as a hub to a patient-centered care plan, and value of emerging interventions connect to these services, reducing refer patients to social services. integrating recovery support services to the access barriers. When referring to Clinicians can be strong advocates for include skills training,65 employment support services, practitioners are in colocated services, staff training, and and placement,26,66 and budgetary a unique position to enlighten and information sharing. Hospitals and services.67 influence agencies and states to health centers can promote recognize the value of these services partnerships between their institutes Practice Considerations and advocate for the creation of and social services entities, share Because complex health-related social certifications for peer workers, their common agency goals, and promote needs are common among patients inclusion in Medicaid reimbursement, interdepartmental collaboration.56 with SUD, case management is or other measures to support the a common and practical model of uptake of these workers. Evidence service delivery for integrated care.68,69 Case management can be Principle 3: Recovery Support There is growing evidence that health intensive and often requires a long- Services Should Be Integrated to care and other social services can be Promote Recovery Most Effectively integrated into treating and term commitment, which may limit and Provide the Strongest Possible supporting patients with SUDs. There the ability of case managers to accept Social Support is success in integrating harm new clients. Pooling resources from community-based agencies to Guidance reduction strategies such as naloxone training and medication treatment to coordinate services offerings, match The goal of integrated care is to reduce SUD harms.57,58 In systematic with client needs, and enhance enhance the quality of care and reviews, authors generally report that referral systems may overcome quality of life, patient satisfaction, and clients receiving integrated care with constraints of case management. system efficiency for those with both SUD and mental health One major obstacle to integration is complex, long-term problems across counseling demonstrate improved organizational boundaries. Using multiple services, providers, and SUD and mental health outcomes (at a survey of 270 agencies offering settings.55 In the context of young least when mental health conditions services for women with addiction adult recovery support services, 59 are not severe). Reviews of studies problems, researchers found that integration of services can be thought on patients with severe mental health strong interagency relationships of as a means of delivering health and conditions, however, have revealed contributed to the success of social support services by 60,61 inconsistent results. integration.70 Whereas formal coordinating the efforts of services to interagency relationships help define respond more efficiently and With respect to integrating SUD and accountability, informal relationships effectively to the complex needs of support services, authors of through the development of youth with SUDs. Integration of care a pragmatic clinical trial of professional networks and should go beyond coordination coordinated care management found collaborative learning opportunities between formal treatment services that clients who received integrated can foster knowledge sharing around (ie, detoxification and residential care used more social services and a common purpose. rehabilitation) to ensure greater demonstrate greater abstinence rates continuity of care occurring between as compared with standard care At a clinical level, screening for systems of formal treatment and clients.62 In a meta-analysis of health-related social needs enables recovery support services that reflect integrating maternal substance use the identification of the need for individual patient’s needs and treatment and pregnancy, parenting, support services, although such community resources. Typically, or child services, authors found screening tends to focus on the concerted methods and models on reduced substance use associated general population. In addition to the funding, administrative and with integrated care.63 Among a small approaches of bringing the Screening, organizational, service delivery, and longitudinal cohort of homeless youth Brief Intervention, and Referral to clinical levels are needed to create suffering from a first episode of Treatment paradigm into a pediatric and maintain integrated services. addiction in Canada, an intensive medical setting and further Clinicians who treat young adults outreach intervention integrating integrating substance use counseling

Downloaded from www.aappublications.org/news by guest on September 29, 2021 S224 XUAN et al EITISVlm 4,nme 2 aur 2021 January s2, number 147, Volume PEDIATRICS TABLE 1 Summary of Selected Studies Reviewed by Expert Panel Content Author, y Sample Study Period Intervention Design Outcome Main Findings Contribution to Summit Principles Area Housing Jason et al48 2006 N = 150 with 24-mo study Either an Oxford House or RCT Substance use; Oxford House condition Rigorous RCT that reveals the effect substance use period with usual aftercare condition criminal activities; participants had significantly of mutual help-oriented recovery history in an baseline and (ie, outpatient treatment employment status lower substance use (31% vs housing in reducing substance urban setting interviews every or self-help groups) after 65%), significantly higher use and crime activities and 6mo they had received monthly income ($989 vs improving employment for inpatient treatment of $440), and significantly lower people with substance use substance abuse incarceration rates (3% vs history

Downloaded from 9%) than usual-care participants. Social Morgenstern N = 421 welfare Baseline, 1-, 3-, 6-, Randomly assigned to CCM Practical Social services use; Broad and significantly more A practical clinical trial revealing services et al,62 2009 applicants and 12-mo involving various social clinical abstinence status services use (eg, addiction, significant uptake of recovery identified via follow-up services and coordinated trial mental health, employment, support services and abstinence SUD screen in interviews referral system versus and basic needs) and increase as a result of

www.aappublications.org/news a large city usual care significantly higher rate of a coordinated system integrating abstinence (OR: 1.75; 95% CI: social services with substance 1.12–2.76; d = 0.31) were abuse treatment found among the CCM group as compared with the usual- care group. Peer Bassuk et al,54 N = 9 studies English literature US studies in PubMed, Systematic Substance use Despite limited evidence Extensive review study support 2016 of primary PsycInfo, and Web of review (primary involving strong summarizing evidence of peer empirical Science with the outcome); service methodologic rigor, peer support recovery in reducing quantitative following search terms: use, mental health, support was found to be substance use and other fi

byguest on September29, 2021 studies peer involvement; criminal justice bene cial and associated recovery-related outcomes, with 1998–2014 alcohol or drug status, and quality with improved recovery extensive recommendations for addiction; peer-led of life outcomes and reduced strengthening further studies on recovery interventions substance use. peer-delivered recovery support services Volunteer Godley et al,25 2019 N = 402 youth Assessed over 12 Randomly assigned to RCT Prorecovery peers, VRSA participants had greater Rigorous trial involving a large support aged 12–20 mo either 9 mo of recovery increases in drug-free sample and revealing and postdischarge posttreatment VRSA or management sobriety activities (d = 0.21), improvements in both proximal discharged continuing care services activities, substance abuse treatment (prorecovery activities) and from as usual substance use, and (d = 0.31), and self-help distal outcomes (reduced residential remission activities (d = 0.30), substance use) treatment indicating that they engaged in more mutual aid group activities and continuing care treatment than standard care participants. CM Vanderplasschen N = 31 studies English literature Embase, Web of Science, Review Treatment-related CM is more effective than Meta-analysis on a large No. trial et al,69 2019 January, 2006 to Medline (PubMed), the meta- outcomes; treatment as usual studies providing a rigorous May, 2017 Cochrane Drugs and analysis personal conditions for improving synthesis of the effect of CM for Alcohol Group functioning outcomes (SMD 0.18; 95% CI: integrated support services Specialized Register and outcomes 0.07–0.28), but this effect is S225 Cochrane Central significantly larger for and brief interventions into school REFERENCES 71 and college settings, providing 1. Arnett JJ. Emerging adulthood. A theory screening for health-related social of development from the late teens needs may help maximize the through the twenties. Am Psychol. 2000; accessibility of comprehensive and 55(5):469–480 integrated support services for youth 2. Cleveland MJ, Goldstein AL. with SUDs. Opportunities and challenges for There is an increased use of mHealth prevention and intervention in technology to support substance use emerging adulthood: introduction to recovery among youth.72,73 Given the the special issue. Prev Sci. 2019;20(3): – ubiquity of mobile phone use and 301 304 improved engagement among young 3. Kandel DB, Logan JA. Patterns of drug

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