key: cord-1053545-bo7ibc07
authors: Hogue, Aaron; Becker, Sara J.; Fishman, Marc; Henderson, Craig E.; Levy, Sharon
title: Youth OUD Treatment During and After COVID: Increasing Family Involvement across the Services Continuum
date: 2020-10-07
journal: J Subst Abuse Treat
DOI: 10.1016/j.jsat.2020.108159
sha: ad2b0430f15430a9babf3f2e50ead2221264c5b3
doc_id: 1053545
cord_uid: bo7ibc07

Telehealth innovations in substance use treatment necessitated by the COVID-19 pandemic present a generational opportunity to increase family involvement in medication for opioid use disorders (MOUD) among youth. This commentary describes a conceptual framework for engaging and retaining youth and families across four stages of MOUD services: Preparation, Initiation, Stabilization, Remission & Recovery. Case vignettes illustrate provider-delivered and direct-to-family tele-interventions for augmenting family involvement in each MOUD stage: Family Outreach, Family Engagement, Family Training, Family Recovery Maintenance.

The COVID-19 pandemic has upended the healthcare system in our country. It has inflicted staggering rates of hospitalization and death and dramatically altered how Americans seek health services (US Dept Health and Human Services, 2020) . Moreover, COVID-19 erupted during another national health crisis: opioid misuse and overdose, which resulted in almost 450,000 deaths between 1999-2018 (https://www.cdc.gov/drugoverdose/epidemic/index.html).

Older adolescents (age 16-18) and young adults (age 18-26) are especially vulnerable to the opioid epidemic: Between 1999-2016 the rate of lethal overdoses attributable to opioids in adolescents increased 268% (Gaither, Shabanova, & Leventhal, 2018) , and 1.1% of young adults experienced an opioid use disorder (OUD) (Volkow et al., 2019) .

We believe the COVID-19 pandemic has also created a generational opportunity to transform routine care for youth OUD by spurring treatment providers to increase family involvement in services. Extensive research (see Ariss & Fairbairn, 2020; Hogue, Henderson, Becker, & Knight, 2018) suggests that family involvement is a key element of the most effective behavioral interventions for youth substance use. Due to the pandemic, substance use services of every kind are being reconfigured at unprecedented speed and scale to operate remotely via telehealth (Centers for Medicare & Medicaid Services, 2020). This commentary describes how tele-interventions enable pragmatic and sustainable changes in youth OUD services that clear a path for systematic integration of families into the national OUD treatment system.

J o u r n a l P r e -p r o o f Medication for opioid use disorders (MOUD), in the form of opioid agonist or antagonist medication, is the only evidence-based treatment for youth OUD (Committee on Substance Use and Prevention, 2016). Unfortunately, it has proven enormously difficult to engage youth in OUD treatment (Hadland et al., 2017) , and they drop out of care at alarmingly high rates (e.g., Schuman-Olivier et al., 2014) . To address this challenge we propose a conceptual framework to organize efforts to engage and retain youth and families across the continuum of MOUD services. Figure Journal Pre-proof introduced MB and his mother to OUD medication protocols, delineated family member roles during treatment, and set ground rules for ongoing family-patient-staff interactions.

by employing family engagement techniques, such as family alliance-building and goal-setting, known to increase treatment motivation and participation among youth (Becker et al., 2018) . AE was a 24-year-old attending a video session for initiation of buprenorphine treatment after moving back home following shelter-in-place edicts. He said his mother was skeptical of MOUD as "replacing one addiction with another." The physician asked him to bring his mother into the live session so the physician could explain the treatment plan and establish a foundation for her involvement-a spontaneous engagement opportunity not available via in-person care. During two additional tele-sessions the physician explored the mother's concerns about MOUD, explained why medications are the most effective treatment option, and elicited her commitment to assisting with AE's treatment and recovery.

training can help knit family members into the complex weave of MOUD services and teach caregivers to support youth recovery efforts (Hornberger & Smith, 2011; Ventura & Bagley, 2017) . This includes discussions about negotiating burgeoning independence, positive family communication, and anger management. GR was a 17-year-old in treatment for prescription opioid addiction. During the first six weeks of care her parents attended weekly virtual appointments-an extraordinary level of involvement under a usual-care model-to help them track treatment progress, communicate expectations, and set reasonable boundaries for her behavior. One day when GR left the family home intending not to return, the parents drove to meet her while remaining in audiovisual contact with the clinician via smartphone. The clinician J o u r n a l P r e -p r o o f Journal Pre-proof prepped the parents to express love and concern, and to use the positive communication skills they had been practicing, upon seeing her. Once reunited, the clinician facilitated a brief reconciliation and safety planning session before they returned home.

Family-focused recovery maintenance strategies can promote youth retention in ongoing services during OUD remission, formulate and monitor long-term recovery management plans, and encourage family members to enlist direct-to-family supports (Archer et al., 2020; Ventura & Bagley, 2017) . BG was a 21-year-old in treatment with extended-release naltrexone. During her period of remission, her counselor routinely texted BG's mother (individually and via three-way group messaging) to encourage medication dose and other appointments, and praise BG's progress. When she later relapsed and dropped out of care, based on prior agreement the counselor reached out repeatedly to both BG and her mother via text and managed to arrange BG's re-enrollment. The counselor then advised BG's mother to sign up for a text messaging service that provided daily persontailored texts about effective parenting, self-care, and coping with a child experiencing OUD.

The service featured options for COVID-specific texts, immediate keyword help messaging such as "overdose", and links to live peer-to-peer coaching (see Carpenter et al., 2020) .

The rapid shift towards telehealth during the COVID-19 pandemic has expanded the possibilities for outreach to families of youth with OUD, both planned and spontaneous, and may

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