Medication Treatment for Youth in Substance Use Disorder Residential Treatment

Abstract

Objective:

Residential is a common treatment setting for youth with high-severity substance use disorders (SUD). This study evaluated the prevalence of psychiatric symptoms and medication for youth in residential SUD treatment.

Methods:

Youth in Massachusetts state licensed and funded SUD residential programs completed questionnaires assessing demographics, primary substance of use, and psychopathology symptoms (Youth Self Report [YSR]/Adult Self Report [ASR]). De-identified medication lists were provided by the programs. Descriptive statistics were used to describe the sample.

Results:

Among the 47 youth who participated, 51.1% were male, 72.3% white, 83% non-Hispanic, mean age 20.7 years. Opioids were the most common primary substance identified by youth (51.1%), and 75% had at least one clinically elevated subscale on the YSR/ASR. Most youth were prescribed at least one medication (89.4%) with a mean of 2.9 medications.

Conclusion:

Youth in SUD residential treatment frequently have clinically elevated psychiatric symptoms, and psychotropic medication was commonly prescribed.

Keywords

adolescent young adult substance use disorder residential medication

Introduction

Treatment of substance use disorders (SUD) in the adolescent population is important in preventing later mental, physical, and social consequences associated with substance misuse (Carroll Chapman & Wu, 2013; Costello et al., 1999; Dembo et al., 2009; Racz et al., 2015). Residential treatment is a common treatment setting for youth with high-severity SUD, and among youth who received substance use treatment in 2019, 26.7% of adolescents aged 12 to 17 years, and 25.4% of young adults aged 18 to 25 years received treatment in a residential type setting (Substance Abuse and Mental Health Services Administration [SAMHSA], 2021a). Many of these youth have a co-occurring psychiatric disorder (ranging from 64% to 90%; Andersson et al., 2021; Chan et al., 2008). Common co-occurring psychiatric disorders for youth with SUD include attention deficit hyperactivity disorder (ADHD), conduct disorder, depressive disorders, and anxiety disorders (Chan et al., 2008; Couwenbergh et al., 2006; Wise et al., 2001). For youth with moderate to severe SUD and a psychiatric disorder, psychotropic medication for either or both disorders is often indicated (SAMHSA, 2021b).

Despite the conceptualization of using psychotropics in youth with SUD, there is remarkably limited data on the use of psychopharmacologic treatments in this group. One study of adolescents aged 13 to 18 years in SUD residential treatment reported 63.7% had a psychiatric disorder, and 26.4% were on psychotropic medication (Wise et al., 2001). Another study of young adults aged 18 to 24 years of age found 46.2% had a psychiatric disorder, and 46.2% were on psychotropic medication (Schuman-Olivier et al., 2014). While helpful, neither study included details of the type of psychotropic medication, or on the use of medication to treat co-occurring SUDs. Furthermore, both studies are older and may not reflect current evidence-based medication practices for youth with co-occurring psychiatric and SUDs.

When evaluating residential treatment for youth with co-occurring disorders details regarding medication treatment are important since there may be certain disorders, such as ADHD and opioid use disorders (OUD), where medication should be strongly considered. For example, in a multivariate analysis of factors associated with successful adolescent residential treatment, ADHD was the only factor identified with non-successful treatment participation (OR = 0.14, p = .034; Wise et al., 2001). Given this, the 2020 international consensus statement recommendation that stimulant treatment should be considered for an adolescent with co-occurring ADHD and SUD (Özgen et al., 2020), as well as evidence that stimulant treatment for adults with ADHD is associated with improved retention in outpatient substance use treatment (Kast et al., 2021), stimulant medication may be an important component of residential SUD treatment for youth with ADHD. Likewise, for youth with an OUD, buprenorphine is FDA approved for those ≥16 years of age, and multiple professional organizations recommend that medication to treat OUD be offered to youth to decrease risk for drug overdose and death (Committee on Substance Use and Prevention, 2016; Society for Adolescent Health and Medicine, 2021).

In contrast to the limited literature on the use of medication in youth SUD residential settings, a substantial number of studies have documented that psychotropic medication is commonly prescribed in general youth mental health residential settings (Breland-Noble et al., 2004; Pavkov et al., 2010; Spellman et al., 2010; van Wattum et al., 2013). For example, studies show 40% to 80% of youth entering mental health residential treatment receive psychotropic medications, and up to 80% have more than three prescriptions (Spellman et al., 2010). A qualitative study of child psychiatrists who worked in general youth mental health residential programs identified that medication management in this setting can be challenging due to the complexity associated with multiple co-occurring psychiatric disorders and psychotropic medications, as well as difficulty accessing information on past medication trials (Griffith et al., 2014).

Medication management for youth with SUD and other psychiatric disorders may be exponentially more challenging due to increased case complexity, the addition of medication to treat SUD, and lack of infrastructure for integrated treatment (Griffith et al., 2014; Hawkins, 2009). Unfortunately, despite the case complexities, relatively little is available contemporarily on the prevalence and type of psychopathology and psychotropic use in youth SUD residential programs. To this end, we examined the prevalence of psychiatric symptoms and psychotropic use among youth in state licensed and funded SUD residential programs in Massachusetts.

Methods

A quality improvement project was completed at the request of the Massachusetts Department of Public Health (Bureau of Substance Abuse Services [BSAS] Office of Youth and Young Adults) from May to June 2020 for the purpose of evaluating medication management for youth ages 13 to 25 years in the six BSAS licensed and publicly funded SUD residential programs. Due to the COVID-19 pandemic, meetings were conducted over Zoom videoconference, correspondence was conducted by phone or email, and data was shared by secure email or fax. Information gathered from the project was shared with BSAS and the programs in fall 2020. When the six programs were re-contacted in fall 2021, five responded to outreach and agreed to have their program’s information included in this study. This study was deemed exempt by the Boston University Medical Center institutional review board.

BSAS licensed and publicly funded youth SUD residential programs are longer term residential programs (typical lengths of stay >28 days). Among the five programs included in this sample, one of the programs had part-time nursing staff that helped oversee medication management, and two of the programs had prescribers (nurse practitioner and/or psychiatrist) who worked directly with the program. Medications were securely stored on-site, and staff supervised youth when they self-administered their medication. Other services offered in the programs included individual and group therapy as well as case management.

Program directors discussed this voluntary medication management evaluation with all youth their program. Youth who chose to participate completed anonymous questionnaires on paper with pencil which were collected by residential treatment staff. The questionnaires assessed basic demographic information including age, gender, race, ethnicity, and primary substance of use as well as a broad band self-assessment of psychopathology (Youth Self Report [YSR]/Adult Self Report [ASR]; Achenbach & Rescorla, 2001, 2003). Youth under age 18 years were instructed to complete the YSR, and youth aged ≥18 years were instructed to complete the ASR.

The YSR includes 112 questions, and the ASR includes 126 questions including a free text question regarding tobacco use (Achenbach & Ruffle, 2000; Achenbach et al., 2008). Both the YSR and ASR query youth about their behavior in the past 6 months with a three-point Likert scale ranging from “not true” to “very true or often true,” and aggregates this data into behavioral problem t-scores that are standardized by gender and age. A minimum t-score of 50 is assigned to scores that fall at percentiles of ≤50 on the syndrome scales. t-Scores ≥60 (1 SD) indicate a subclinical disorder and t-scores ≥70 indicate a clinical disorder (2 SD). Both the YSR and ASR include the Aggressive Behavior, Anxious/Depressed, Attention Problems, Rule Breaking Behavior, Somatic Complaints, and Thought Problems subscales. The YSR also includes the Social Problems subscale, and the ASR includes the Intrusive subscale.

If a response to a question on the YSR/ASR was missing the question was scored as a zero and included in the analysis. If it was unclear what number was circled on the YSR/ASR, or if it looked as though a circle encompassed two scores, we scored the question as the higher of the two scores. If a participant responded with a range in frequency for tobacco use on the ASR the highest number was used. Lastly, YSR/ASR questionnaires were excluded from the analysis if a participant circled the same value for all questions.

De-identified medication lists for participants were also provided by program directors and linked to demographic and questionnaire responses. Medications were categorized using the American Hospital Formulary Service (AHFS) classification system (American Hospital Formulary System, n.d.)

Demographic information, YSR/ASR data, and medication regimens were summarized using descriptive statistics. Youth were classified as having symptoms of ADHD if they had an Attention Problem subscale t-score ≥60 since this t-score cut-off point has been associated with excellent diagnostic discrimination for ADHD (Biederman et al., 1993; Chen et al., 1994). Youth were classified as having problems with opioid misuse if they identified opioids as their primary substance of use. A Pearson’s r correlation examined if the number of subscales with a t-score ≥70 correspond with number of medications prescribed.

Results

Youth Participation and Demographics

Forty-seven out of 49 youth in the SUD residential programs participated in the project (95.9%). Participants were 51.1% male and predominantly white, non-Hispanic (72.3%, 83%) with a mean age of 20.7 ± 3.7 years (Table 1).

Table 1.

Demographic and Clinical Characteristics of Youth in Substance Use Disorder (SUD) Treatment (n = 47).

Demographics
Age (years; mean, SD)	20.7, 3.7
Male (n, %)	24, 51.1%
Race (n, %)
White	34, 72.3%
Multiracial	8, 17%
Black	4, 8.5%
American Indian	1, 2.1%
Non-Hispanic (n, %)	39, 83%
Substance use
Tobacco use (n, %)*
None	1, 2.7%
1–9 times per day	10, 27%
10–19 times per day	18, 48.6%
≥20 times per day	5, 13.5%
All day	3, 8.1%
Psychiatric symptoms
Number of youth self report or adult self report clinically elevated subscales (n, %)**
0	11, 25%
1	13, 29.5%
2	4, 9.1%
≥3	16, 36.4%

n = 37.

n = 44.

Primary Substance of Use

Nine participants (19.1%) listed more than one primary substance of use, and opioid was the most commonly identified primary substance of use (N = 24, 51.1%). Of the 37 participants assessed for tobacco use, 36 (97.3%) reported using tobacco on a daily basis (Figure 1).

Figure 1.

Frequency of the type of substance use identified as the primary substance of use by youth in substance use disorder residential treatment (n = 47).

Psychiatric Symptoms

Of the 47 participants, 44 (93.6%) youth completed the YSR (N = 7, 14.9%) or ASR (N = 37, 78.7%). One participant declined to complete an ASR and two ASRs were excluded. Nineteen responses were missing from 12 of the YSR/ASR questionnaires (most questionnaires were missing 1 to 2 responses, one of the questionnaires was missing 4 responses).

The rule-breaking behavior scale was the most commonly clinically elevated subscale (N = 23, 52.3%). The mean number of clinically elevated subscales for the sample was 2.3 ± 2.3, median 1.0, range 0 to 7 (Figure 2).

Figure 2.

Frequency of elevated t-scores on youth self report and adult self report scales in youth in substance use disorder residential treatment (n = 44).

Medications

Forty-two participants (89.4%) were prescribed at least one medication (mean number of medications prescribed 2.6 ± 1.7, median 2.0, range 0–8) (Table 2). Forty-one participants (87.2%) were prescribed a psychiatric medication, and 15 participants (31.9%) were prescribed medication for SUD. Antidepressants were the most commonly prescribed class of medication (N = 26, 55.3%), followed by medications to treat SUD (N = 15, 31.9%), and sedatives (N = 13, 27.7%).

Table 2.

Psychotropic Medications Prescribed to Youth in Substance Use Disorder (SUD) Treatment Organized by Medication Class (n = 42).

Medication class	n (%)	Medications prescribed within this class in the residential programs
Alpha agonist	11 (23.4%)	Clonidine Guanfacine
Anti-anxiety	12 (25.5%)	Buspirone Gabapentin Hydroxyzine Prazosin Propranolol
Antidepressant	27 (57.4%)	Amitriptyline Bupropion Citalopram Duloxetine Escitalopram Fluoxetine Mirtazapine Sertraline Venlafaxine Vortioxetine
Atypical anti-psychotic	12 (25.5%)	Aripiprazole Olanzapine Quetiapine Risperidone Ziprasidone
Mood stabilizer	8 (17%)	Carbamazepine Lamotrigine Lithium Oxcarbazepine Valproate acid
Sedatives/Hypnotics	18 (38.3%)	Doxepin Diphenhydramine Melatonin Trazodone Zolpidem
Stimulants	8 (17%)	Mixed amphetamines Methylphenidate Lisdexamfetamine
SUD	15 (31.9%)	Buprenorphine/naloxone Methadone N-acetylcysteine Naltrexone extended release Nicotine gum Topiramate
Number of medications	M (SD); median (range)
Total	2.9 (1.8); 3.0 (0–8)
Psychiatric	2.5 (1.6); 2 (0–6)
SUD	0.4 (0.7); 0 (0–3)

Participant self-report information (demographics, primary substance of use, and YSR/ASR scores) was able to be linked to the participant’s medication list for 37 youth. In this group, 24 participants had an Attention subscale t-score ≥60, and 7 (29.2%) were on stimulant medication. Among the 24 participants who identified opioids as their primary substance of choice, 12 (50.0%) were on medication for OUD (seven buprenorphine/naloxone, one methadone, and four naltrexone extended release). Eleven of the 12 participants on medication for OUD were in the same residential program. Among eight participants who identified alcohol as their primary substance of choice, one participant (12.5%) was on medication for an alcohol use disorder. Two participants were on nicotine replacement therapy.

Out of the 37 participants that provided a valid YSR/ASR questionnaire that was linked to their medication list, a Pearson’s r correlation indicated no significant correlation between the number of clinically elevated scales and number of medications prescribed (r = .175, p > .05).

Discussion

Our evaluation of youth in state licensed and funded SUD residential programs in Massachusetts found most youth had clinically elevated behavioral health symptoms including symptoms associated with conduct disorder and/or problems with opioid misuse. Not surprisingly, most youth were prescribed psychotropic and/or SUD medication. These findings highlight the behavioral health complexity of these youth, and the need for support for both their SUD and psychiatric disorders in this setting.

The high prevalence of clinically significant symptoms of psychopathology found in our study was similar to the prevalence of current co-occurring psychiatric disorders reported in adolescent SUD residential treatment (63.7%; Wise et al., 2001), and higher than reported for young adult SUD residential treatment (46.9%; Bergman et al., 2014). The young adult study did not assess for lifetime history of conduct disorder, current antisocial personality disorder, or ADHD which may have influenced the lower rate of co-occurring psychiatric disorders since symptoms/diagnosis of conduct disorder as well as symptoms/diagnosis of ADHD were common in our study and the adolescent sample (Wise et al., 2001). Disruptive disorders are important to include when assessing the presence and impact of co-occurring psychopathology among youth in SUD residential treatment since they commonly co-occur with SUDs (Couwenbergh et al., 2006), and are associated with increased morbidity (Fairchild et al., 2019; Uchida et al., 2018).

Our finding that most youth in SUD residential treatment were on psychotropic and/or SUD medication is higher than what has previously been reported for adolescent and young adult SUD residential treatment (26.4%–46.2%; Schuman-Olivier et al., 2014; Wise et al., 2001). The difference in the observed use of medication treatment between studies could be related to the timing of this study. There has been 10 to 20 years of research on the appropriateness and FDA approved use of psychotropics for youth with psychiatric disorders since these other studies were published. Furthermore, there has been increased emphasis on treating youth with an OUD with medication over the past 10 years (Committee on Substance Use and Prevention, 2016; Society for Adolescent Health and Medicine, 2021), including mandates from the Department of Public Health to not restrict admission to residential treatment when an individual is on agonist medication for OUD.

Regarding specific psychotropic medication, anti-depressant medication was the most commonly prescribed class of medication for youth in our study. Our data are similar to the prevalence of antidepressants in adults in short-term SUD residential treatment in New Zealand (58.6%; Foulds et al., 2016). Of interest, rates of prescription stimulant use were not reported in this study (Foulds et al., 2016). The rate of prescription stimulant treatment for youth with clinically significant symptoms of ADHD in our study was lower than the 62% of adolescents in the United States diagnosed with ADHD who received medication (prescription stimulants and non-stimulants; Danielson et al., 2018) in 2016, and lower than the 52% of individuals with ADHD and OUD who received ADHD treatment in the United States in 2017 (primarily prescription stimulants; Park et al., 2023). Differences in the rates of stimulant ADHD treatment observed in our study could be influenced by the fact that we only identified youth with clinically significant symptoms of ADHD instead of youth diagnosed ADHD. Differences may also be related to the setting as the other studies (Danielson et al., 2018; Park et al., 2023) relied upon insurance claims largely in the outpatient setting, while many SUD treatment programs, especially residential, prohibit the use of medication such as stimulants with abuse liability. Future research is needed on program medication policies as well as details of psychotropic medications prescribed.

We found that one-half of patients who identified a primary problem with opioid misuse were receiving buprenorphine/naloxone. Our findings are reassuring since underutilization of buprenorphine in residential treatment settings continues to be problematic. For example, recent work by King et al. (2023) found that although 87.5% of the 160 adolescent residential treatment programs could provide psychotropic medication, only 24.4% offered buprenorphine to treat OUD. This is of special note given the decline in buprenorphine prescriptions for youth between 2007 and 2017 (Terranella et al., 2023), with only 23.5% to 27.5% of youth with OUD receiving medication for OUD in 2014 to 2015 (Hadland et al., 2017, 2018). The higher rates of medication for OUD in our sample may reflect more severe illness given these youth were in residential treatment, coupled with local state regulations prohibiting the restriction of type of prescribed medication. Additional research is needed to understand the prevalence of medication treatment for SUD in youth SUD residential treatment programs, as well as barriers and facilitators to the use of SUD medication in this setting.

Our findings need to be considered in light of substantial methodologic limitations. Although we were able to collect information on the type and dose of medication prescribed to youth in these programs, we did not have information regarding the indication for the medication. Likewise, we were able to collect information on psychiatric symptoms and the primary substance of use, but we did not have information regarding specific clinical diagnosis(es). We were therefore limited in our ability to match medication regimens to indicated diagnoses, and could only explore associations between medications with a clear indication for one disorder, such as medications for clinically significant symptoms of ADHD, opioid misuse, and alcohol misuse. The current study was also conducted during COVID-19 pandemic quarantine in which programs reported a lower census when compared to pre-pandemic, and this may have influenced the acuity of the youth in these programs since youth with less acuity may have chosen to stay at home. Lastly, the services provided in residential SUD treatment, and the intensity of the services provided can vary substantially (Miles et al., 2022) and our findings may not generalize to other residential settings.

Despite these limitations, our findings documented that the youth in SUD residential treatment had a high prevalence of clinically elevated psychiatric symptoms across several symptom domains. Psychotropic medication was commonly prescribed to youth in the SUD residential treatment setting to treat co-occurring psychiatric disorders and SUD. With limited research and resources for clinicians in youth SUD residential programs, medication management in the context of complicated behavioral presentations and high-risk co-occurring SUD, such as OUD, is likely very challenging. Since residential treatment is a common treatment setting for youth with high-severity SUD it is important to evaluate youth treatment needs that incorporates youth, caregiver, and staff feedback, appropriateness of medications, current practices in this setting including medication management and behavioral therapies, and other treatment outcomes.

Footnotes

Acknowledgements

The authors appreciated feedback on the design of the project from Brian Jenney, support with data entry from Maria Estevez, and feedback from Nat Mulkey on the initial literature review on youth residential treatment.

Author Note

Tribute to Dr. Biederman: Dr. Biederman led by example in all areas of his career. His commitment to patient care and focus on clinical research that was clearly centered on improving clinical care left a lasting impression on me. While he encouraged me to pursue funding, he was also realistic and very pragmatic. He taught me how to approach clinical care and innovation in a systematic way that would allow me to disseminate findings when there was new information to share with the field. He was an exceptional mentor, and it was a tremendous privilege to learn from him about data analysis and interpretation as well as how to be clear and precise when disseminating findings. I am grateful for the time he spent with me editing manuscripts line by line, and reviewing presentations slide by slide. I have also benefitted from this same type of mentorship from his mentees. I approached this project in the spirit of Dr. Biederman. His clinical and research lessons will always remain with me.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Amy Yule has received funding from the National Institutes of Health (4UH3DA050252-02 and 7R01HD092456-03), the Doris Duke Charitable Foundation’s COVID-19 Fund to Retain Clinical Scientists collaborative grant program (2021261) through support from the John Templeton Foundation (62288), and the National Center for Advancing Translational Sciences, National Institute of Health, through the Boston University Clinical and Translational Science Institute (1UL1TR001430). She also has received funding for clinical program development from the Jack Satter Foundation. She has been a consultant to the Gavin House and BayCove Human Services (clinical services), as well as the American Psychiatric Association’s Providers Clinical Support System Sub-Award. Dr. Timothy Wilens has received research funding from the National Institutes of Health through the HEAL Initiative under award number 1UG3DA050252-01 and 4UH3DA050252-02. Dr. Wilens works as a consultant for Ironshore, the Gavin Foundation, Bay Cove Human Services, the US National Football League, the US Minor and Major League for Baseball, and White Rhino/3D Therapy LLC. Dr. Wilens also serves as a co-editor for the journal Elsevier Psychiatric Clinics of North America (ADHD). In addition, he has published the book Straight Talk About Psychiatric Medications for Kids with the Guilford Press and co-edited the textbook ADHD in Adults and Children with the Cambridge University Press. Victoria Mail and Rebecca Butler have nothing to disclose.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded through the Massachusetts Department of Public Health Office of Youth and Young Adult Services, the Doris Duke Charitable Foundation’s COVID-19 Fund to Retain Clinical Scientists collaborative grant program (2021261) through support from the John Templeton Foundation (62288), and the National Center for Advancing Translational Sciences, National Institute of Health, through the Boston University Clinical and Translational Science Institute (1UL1TR001430).

ORCID iD

Amy M. Yule

Author Biographies

Amy M. Yule is an Adult, Child, and Addiction Psychiatrist. She is an Associate Professor of Psychiatry at the Chobanian and Avedisian School of Medicine at Boston University. She is also the Vice Chair of Addiction Psychiatry at Boston Medical Center.

Victoria Mail completed her Masters in Mental Health Counseling at Boston University. She is a therapist in a community mental health center.

Rebecca Butler is a Licensed Clinical Social Worker. She was the Assistant Director of The Massachusetts Department of Public Health Office of Youth and Young Adult Services when this study was completed.

Timothy E. Wilens is an Adult, Child, and Addiction Psychiatrist. He is a Professor of Psychiatry at Harvard Medical School. He is the Chief of the Division of Child and Adolescent Psychiatry and Co-Director of the Center for Addiction Medicine at Massachusetts General Hospital.

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