BOCA RATON, Fla. – An intensive outpatient program for transitional age youth with addiction shows promise for increasing treatment engagement and retention.
People aged 18-25 years with addiction are the most challenging to enroll and retain in treatment and, at the same time, have the highest rates of past-month illicit drug use and binge/heavy alcohol use, said Martha T. Kane, Ph.D.
A long-term focus that rewards short-term, smaller successes, and positive peer counseling are among the elements of a new integrated model devised by Dr. Kane and her colleagues at Massachusetts General Hospital in Boston. They combined common elements from several effective treatment modalities, including motivational enhancement therapy, group cognitive-behavioral therapy, and contingency management. There is also recognition of family support and counseling in this underserved, high-risk population.
The program is a work in progress, but early evidence is encouraging. Of 142 youths who initially entered the inpatient Addiction Recovery Management Service (ARMS) between October 2007 and April 2010, 48 enrolled in the intensive outpatient program. A majority, 31 or 65%, completed both intake and a follow-up assessment at 12 weeks, "so something we’re doing is working," Dr. Kane said at the meeting.
Typically 60%-70% of young adults discontinue addiction treatment before completion, said Dr. Kane, ARMS clinical director, Center for Addiction Medicine at Massachusetts General.
"I tell staff and trainees their first priority on day one is to get them to come back," Dr. Kane said. This group is least likely to adhere to continuing care, according to a study of injection drug users (Am. J. Alcohol Drug Abuse 2007;33:217-25).
Completers experienced a 69% increase in the number of days abstinent, 48% fewer days spent "intoxicated all day," and a 32% reduction in days where substance use prevented effective functioning. Other outcomes included a 39% improvement in substance dependence (measured with the Leeds Dependence Questionnaire); a 33% improvement in days bothered by emotional health issues; and a 47% reduction in the number of days where mental health problems prevented effective functioning.
More modest gains were demonstrated on standardized measures, including a 22% improvement in the Beck Depression Inventory; a 13% improvement in State-Trait Anxiety Inventory; and a 5% improvement on State-Trait anger scores. "That is something we need to figure out," Dr. Kane said, "how to make [these] kids less angry."
An average 7 young adults participate in the transitional youth intensive outpatient program at any one time (maximum number is 10). Services are offered 8-10 hours per week over 3-4 days. The intensity of services decreases gradually over the 12-week program. Every participant receives psychiatric evaluation and ongoing medication, as eligible. No medication is on site, but there is a prescriber, Dr. Kane said in response to a question from a meeting attendee.
The program recognizes that transitional youth do not always succeed in adult addiction programs where "these kids are told things will get better," Dr. Kane said. "They don’t have the capacity to wait 6 weeks or more" and instead need a more rapid, positive reinforcement. Patients leave with a goal to improve a small aspect of their life in the first week.
A great deal of flexibility is another feature of the program. Abstinence is not a requirement for enrollment, for example. Partial completion in the program is acknowledged, Dr. Kane said. Also, "if they want to meet at Dunkin’ Donuts instead of our office, we can do a little of that."
Dr. Kane said that it can take a while for some to feel connected to the program. "It’s okay with me if they don’t make another connection for another three weeks." At a minimum, participants are expected to come back to the program when things are not going well. "We never really let go entirely, and they know it."
The psychiatrists, social workers, and care coordinator communicate with the youth via text messaging, e-mail, and telephone. A meeting attendee asked about violating confidentiality. "Little confidential medical information is texted," Dr. Kane said. "We’re not using texting to do clinical care, but to maintain connection in a way that works for them." Examples of text messages are: "How are you today?", "Hope everything is okay," and "Let me know what happened about the job."
An acknowledgement that relapses are likely over time is part of the long-term recovery management approach. Dr. Kane said: "Do not discharge them if they relapse. That doesn’t mean that you tolerate it or ignore it, but incorporate it into your practice."
The program staff recognizes that young adulthood is a time with many development changes, including increased personal freedom and responsibility. For example, they work to help clients effectively manage impulses for autonomy and to successfully communicate with primary care providers, Dr. Kane said. They also learn to communicate during peer counseling. "We get our best outcomes when there are kids who are able to communicate constructively."