(44) Non-Clinical Barriers and Facilitators to Treatment for Youth Who Use Opioids

Background & Introduction: There is increasing mortality from opioid overdoses among adolescents and young adults (AYAs) even in the setting of decreasing overall use (1). Clinical spaces treating opioid use disorder (OUD), which have historically excluded AYAs from care (2), must prepare to adjust their scope to include AYAs. AYA-facing clinicians must also consider how to best support AYAs who use opioids. Beyond making changes to structural elements of treatment programs, clinicians, public health officials, and policymakers must consider how societal, community, and family elements limit or promote an AYA’s ability to enter, engage in, and remain in treatment. In adults with substance use disorders, analysis of these barriers and facilitators has emphasized systems-level/structural elements over individual-level and social elements (3), but little is known about AYA-specific barriers and facilitators to care. The purpose of this study was to determine non-clinical barriers and facilitators to AYA initiation, engagement, and retention in treatment for OUD as defined by AYAs with a history of opioid use, their support people, and clinical and non-clinical informants.

Methods: This study combined data from two samples:

1) Indiana-based AYAs with past-year illicit opioid use, community-based individuals interfacing with AYAs using opioids, and OUD-treating clinicians, and
2) Massachusetts-based treatment-involved AYAs with a diagnosis of OUD, their support people, and clinicians treating AYAs with OUD.

We recruited participants through an AYA-specific OUD treatment program, a university-based research registry, community referrals, site visits, and direct peer contact. We conducted semi-structured interviews of Massachusetts participants by phone between 2017-2021 and Indiana participants using Zoom between 2022-2023. The interview guide included specific questions around barriers to initiation, engagement, and retention in treatment followed by questions about recommendations to overcome these barriers. We conducted interviews until reaching thematic saturation. We developed an initial codebook based on the interview guide and the Consolidated Framework for Implementation Research (CFIR) and used inductive and deductive coding to complete qualitative descriptive analysis of transcribed interviews using NVivo (14.23.0). Each transcript was coded by at least two individuals. After completion of coding reconciliation meetings and codebook finalization, a single coder applied final codes to all transcripts. We determined major themes based on frequency and depth of meaning across samples.

Results: We interviewed a total of 64 participants. In Indiana, we interviewed 11 AYAs (range 16-24, median 18 years; 3 with prior substance use treatment), 12 community-based organization representatives (including police, fire department, harm reduction/recovery, child protective services backgrounds), and 4 clinicians (psychiatry, addiction medicine, psychology, internal/addiction medicine/pediatrics backgrounds). In Massachusetts, we interviewed 15 OUD-treatment-engaged AYAs (range 17-25, median 23 years), 9 support people (family members, peers), and 13 clinicians (social work, nursing, pediatrics, internal medicine, psychiatry backgrounds).

Overall, all participants described lacking resources (i.e. insurance/money to cover treatment cost, transportation) as the most salient barrier and having/increasing support as the most important facilitator. For younger, non-treatment-involved Indiana youth, participants described the primary barrier as a lack of awareness of/misinformation around treatment, putting this above resource issues.

We organized further barriers/facilitators by levels: the individual patient, the inner setting (social/family milieu), and the outer setting (societal/structural environment), following levels of impact defined by CFIR.

1) Individual Level: A lack of awareness regarding the need for treatment among AYAs using opioids was cited across samples as a major barrier. In Indiana, participants ranked a fear of consequences of disclosing use, including disappointing adults, as the next most salient barrier, whereas Massachusetts-based participants cited isolation and a lack of readiness. Indiana participants emphasized self-efficacy/experiencing a crisis as facilitators, whereas Massachusetts participants highlighted readiness and accountability.

2) Inner Setting: Negative peer group influence was the primary inner setting barrier across participants. In Indiana, an unwell family was an additional barrier, but Massachusetts participants less commonly emphasized family-related barrier, likely given more description of AYAs in independent living situations, separate from family units. Similarly, Indiana participants highlighted facilitators including being encouraged (sometimes forced) into treatment by trusted adults over positive peer influence, whereas Massachusetts participants emphasized the important role of mutual help organizations.

3) Outer Setting: Indiana participants described stigma as the highest outer setting/societal/systems-level barrier, whereas Massachusetts participants emphasized environmental triggers (i.e. leaving a treatment facility and encountering people selling drugs directly outside, being exposed to substance use when unstably housed or engaging in peer-normative activities like parties), especially with regards to engagement and retention. Across samples, access issues were a major secondary outer setting barrier. Indiana participants described legal/school policies and their push toward treatment initiation (i.e. diversion programs, schools mandating treatment after discovering use) as major outer setting facilitators, whereas Massachusetts participants cited access/resource facilitators such as insurance coverage and transportation.

Conclusion & Discussion: By including perspectives from AYA patients, community-based representatives, caregivers, and clinicians, this study provides important information surrounding non-clinical barriers and facilitators for treatment programs for AYAs using opioids. AYAs experience non-clinical barriers and facilitators to OUD treatment depending on geographic location and trajectory of treatment engagement, including lack of awareness, isolation, lack of readiness, environmental triggers, and stigma and, conversely, accountability, social/familial support, and accessible resources. This work highlights the importance of establishing target population-specific barriers/facilitators to identify touchpoints for public health/community-based interventions supporting initiation, engagement, and retention in treatment. Limitations included differences in the makeup of the two samples, though this increased the diversity of perspectives incorporated. Future directions include quantitative surveys of individuals from diverse backgrounds across the United States evaluating salience of these findings. Clinicians can incorporate an understanding of this work to integrate the needs and strengths of AYAs seeking help with their opioid use. Community-based workers can utilize these barriers and facilitators to identify AYA struggling with opioid use and offer harm reduction strategies/treatment connections including holistic support. These findings can also be utilized by policymakers, caregivers, patients, and providers to advocate for health systems interventions addressing these non-clinical, but still essential, elements impacting care.

References: 1. Friedman, J., & Hadland, S. E. (2024). The Overdose Crisis among U.S. Adolescents. The New England journal of medicine, 390(2), 97–100. https://doi.org/10.1056/NEJMp2312084
2. King, C., Beetham, T., Smith, N., Englander, H., Hadland, S. E., Bagley, S. M., & Korthuis, P. T. (2023). Treatments Used Among Adolescent Residential Addiction Treatment Facilities in the US, 2022. JAMA, 329(22), 1983–1985. https://doi.org/10.1001/jama.2023.6266
3. Farhoudian, A., Razaghi, E., Hooshyari, Z., Noroozi, A., Pilevari, A., Mokri, A., Mohammadi, M. R., & Malekinejad, M. (2022). Barriers and Facilitators to Substance Use Disorder Treatment: An Overview of Systematic Reviews. Substance abuse: research and treatment, 16, 11782218221118462. https://doi.org/10.1177/11782218221118462