key: cord-0777311-qyy418rg authors: Bagley, Sarah M.; Hadland, Scott E.; Yule, Amy title: A commentary on the impact of COVID-19 on engagement of youth with substance use and co-occurring psychiatric disorders date: 2020-10-21 journal: J Subst Abuse Treat DOI: 10.1016/j.jsat.2020.108175 sha: d8f885fedcdc16e7fdfc7a58fb28d2c0a9211fd0 doc_id: 777311 cord_uid: qyy418rg Adolescents and young adults (AYA) with substance use disorders (SUD) have low rates of engagement and retention in SUD treatment (Mericle et al., 2015). Engagement and retention refers to treatment attendance and regular communication with providers. The reason for this low rate is multifactorial and includes the stigma surrounding SUD and treatment (Bagley et al., 2017), and challenges accessing developmentally appropriate treatment (Mericle et al., 2015; Sterling et al., 2010). Yet engaging AYA early in their trajectory of substance use offers an invaluable opportunity to minimize the short-term and long-term consequences of use (Compton et al., 2019; Levy et al., 2016). As specialists in pediatric addiction, we made significant changes in how we provide care for youth in treatment due to the COVID-19 pandemic. In the following commentary, we discuss the potential positive and negative impacts of those changes and suggestions for future research. Adolescents and young adults (AYA) with substance use disorders (SUD) have low rates of engagement and retention in SUD treatment (Mericle et al., 2015) . Engagement and retention refers to treatment attendance and regular communication with providers. The reason for this low rate is multifactorial and includes the stigma surrounding SUD and treatment (Bagley et al., 2017) , and challenges accessing developmentally appropriate treatment (Mericle et al., 2015; Sterling et al., 2010) . Yet engaging AYA early in their trajectory of substance use offers an invaluable opportunity to minimize the short-term and long-term consequences of use (Compton et al., 2019; Levy et al., 2016) . As specialists in pediatric addiction, we made significant changes in how we provide care for youth in treatment due to the COVID-19 pandemic. In the following commentary, we discuss the potential positive and negative impacts of those changes and suggestions for future research. The Center for Addiction Treatment for AYA who use Substances (CATALYST) is a multidisciplinary outpatient program that was developed to provide developmentally tailored treatment for AYA with SUD (see Figure 1 ). Addiction-trained primary care providers, psychiatrists, an addiction-certified nurse care manager, and licensed clinical social workers provide evidence-based treatment in a primary care setting. The program also includes certified recovery coaches, a recovery support navigator, and program manager to help engage AYA through easily accessible, individualized support; and to aid with scheduling, appointment reminders, and interactions with outside agencies. The program also provides support for transportation through Uber Health and public transportation vouchers to decrease barriers to treatment attendance. J o u r n a l P r e -p r o o f Prior to the emergence of COVID-19, we conducted all patient visits in person. Despite offering a flexible model of care with several supports to address logistical challenges to treatment attendance there were certain patients who struggled to attend visits and would primarily only interact with providers through text messages and phone calls. We have discussed the possibility of telemedicine, but it was not available within our health system due to lack of reimbursement and HIPPA-compliant technology. Since the emergence of COVID-19, like many programs nationally, our program has completely transitioned to using telemedicine. In our program, providers caring for patients remotely defines telemedicine, through video or phone calls. Many people assume that this transition would be easiest for AYA given their comfort and familiarity with technology (Joshi et al., 2019) . Although there have been some positive outcomes, this transition has also presented challenges for our patient population. With the transition to telemedicine, we have been more successful in engaging AYA who live far from our hospital or have competing interests to treatment attendance, such as jobs or young children. We have also been able to engage patients in new ways, such as cooking classes over Facetime, or through reading stories to the children of patients who are young parents. With families at home together we have also increasingly found ways to naturally include parents for AYA who were previously reluctant to have their parents involved in their care. In addition, we have gained previously unattainable insight into patients' living conditions that has both provided reassurance in some cases and concern in others. Furthermore, the change to telemedicine has created increased opportunities to bill for clinical encounters to address urgent issues that arise between visits that previously were unbillable. Although we have found many positive developments with telemedicine, we have also experienced challenges that are specific to AYA and related to their developmental stage (Arnett, 2000 (Arnett, , 2005 . AYA can be inherently mistrustful of health care providers and providers may find it difficult to build rapport with new and existing patients over the phone or video (Bonnie et al., 2015) . There is something lost when we cannot simply sit with a patient, hold eye contact, and convey empathy. For this young population, who often have a history of significant trauma (Dube et al., 2003; Welsh et al., 2017) and have been asked to tell their -story‖ many times, this distance is challenging to overcome. It is also easier for patients to disengage from a clinical encounter during telemedicine compared to an in-person visit, since they can simply hang up the phone or disconnect from a video visit with one click. Furthermore, we have found it difficult to connect patients with the hospital's preferred platform for video visits since this requires AYA to follow through on several registration steps, including using a time-limited link to register for an electronic patient portal. Many of our patients also do not have access to confidential space for visits. Some have unstable housing and live in shelters (Greene et al., 1997) . Those with housing have crowded living conditions and are not able to access a private space within their home. We have completed visits while patients are walking outside or sitting in common living spaces in the home. For youth who are trying to keep their treatment private from their families, receiving treatment at home is a major barrier. Furthermore, telemedicine requires a reliable phone connection and/or Internet connection to which youth-particularly those with lower socioeconomic status or who are experiencing homelessness-may not have access. Journal Pre-proof For many youth, particularly those with difficulty focusing, the shift from a bland clinic exam room to their own home (or in some cases, their car or other space) can introduce distractions that draw the AYA's attention away from the clinical encounter. Similar to in-person visits some AYA forget that they had an appointment scheduled, and are reached while driving, using public transportation, at their employment, or spending time socially with friends. Providers have to subsequently quickly determine with the patient if it would make sense to reschedule the appointment or continue the visit with limited privacy; yet delaying visits is often undesirable since the patient may be difficult to reach or at high risk. Last, without the formal process of checking out after an appointment with front desk staff, we do not know whether, despite prompting, a patient is recording their next appointment or considering what other scheduling conflicts they may have. Multidisciplinary care is an important component of treatment for AYA with SUD given co-occurring psychiatric and medical conditions as well as family and system involvement (Brewer et al., 2017; Dunne et al., 2017; Levy et al., 2016) . Providers experience challenges when trying to coordinate care when separated and working from home. If an emergency arises during a patient visit, providers do not have the same flexibility to recruit others for support in managing the situation. For example, if a provider is on the phone with a patient, they may need to use a different phone to urgently contact another provider for consultation or call emergency services. Likewise, one unique aspect of our program has been the ability of interdisciplinary providers (e.g., the clinical social worker and physician) to meet with a patient together. Although some technological platforms allow multiple providers to join the same session, this can be challenging to coordinate. We have found that we are often contacting some patients multiple times to provide multidisciplinary support, which can be burdensome for the patient. Some of the key tasks during adolescence include establishing autonomy and increased reliance on peers (Arnett, 2000 (Arnett, , 2005 . COVID-19 has reversed this normal trajectory. AYA have decreased opportunities for regular peer interactions (both at school and socially) and are primarily at home with parents or other family. Concretely, this means that AYA have missed milestones such as in-person graduations, applying for jobs, and finding housing separate from parents (young adults). Although data on the impact of COVID-19 are emerging, past research demonstrates that pandemics and other natural disasters are associated with worsening AYA mental health (Guessoum et al., 2020) . Recent data from a survey of adults in the United States in June 2020 suggest that COVID-19 has had a greater impact on young adults' mental health relative to other age groups. Among youth ages 18 to 24 years, 25.5% endorsed serious thoughts suicide within the past month, and 24.7% started or increased substance use to cope with pandemic-related stress or emotions (Czeisler et al., 2020) . There is general consensus from the data that the risks for AYA mental health and substance use are significant (Loades et al., 2020) . As we reflect on the opportunities and challenges associated with telemedicine in the context of COVID-19 we are hopeful that some of the adaptations that have granted our patients increased flexibility will remain after the pandemic. This crisis has highlighted that not all of our work needs to be done in a formal clinical setting. Furthermore, because there is a paucity of AYA SUD programs, telemedicine may be a critical strategy for improving access to treatment for AYA and their families, particularly outside urban locations where addiction clinicians are often concentrated. Nevertheless, practitioners are concerned about access to reliable phones and Internet and how a lack of access could exacerbate inequities. The impact of COVID-19 on communities of color has clearly highlighted persistent inequities in our health care system. We must monitor access and engagement with telehealth by race/ethnicity to ensure that J o u r n a l P r e -p r o o f Journal Pre-proof telemedicine does not exacerbate this inequity. We do not yet know how best to build this hybrid model; for example, should an initial in-person visit be standard of care with a transition to telemedicine or alternating telemedicine visits? Likely the answers to those questions will be based on patient preferences, but research also needs to determine how outcomes for in-person visits compare to telemedicine. Although COVID-19 has forced the health care system to provide care in new and innovative ways, we must not lose the opportunity to evaluate the impact of those changes so that we can determine what changes should be sustained. However, we also worry about the missed opportunities to offer an in-person smile and reassurance during what is for many AYA a particularly challenging time due to lost opportunities to establish autonomy-a key developmental transition for this age group. We know that we may be one of the last clinical services to return to in-person visits since we can provide care through telemedicine in contrast to specialties that involve procedures. While we would like to have continued access to the option of telemedicine we are also concerned about the potential to exacerbate existing disparities in access to care for AYA with SUD. Going forward and based on our experience, we must determine how to assess which patients will be best served by in-person care, and work to improve virtual clinical systems to better coordinate care. J o u r n a l P r e -p r o o f Journal Pre-proof Emerging adulthood: A theory of development from the late teens through the twenties The developmental context of substance use in emerging adulthood Addressing stigma in medication treatment of adolescents with opioid use disorder The Health Care System. In Investing in the Health and Well-Being of Young Adults Treating mental health and substance use disorders in adolescents: What is on the menu? 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