North America is in the midst of an overdose emergency that is having devastating effects, including among youth under 30 years of age. In Canada, youth represent the fastest growing age demographic for hospitalizations due to opioid poisoning, and in British Columbia, more than 1000 youth ages 10 to 29 have lost their lives to overdose since an official public health emergency was declared in 2016. Youth who are street involved (i.e., those experiencing homelessness or unstable housing) are particularly vulnerable to overdose, and many other health and social harms.
In BC and other settings, opioid agonist therapy (OAT) can be a powerful tool to reduce young people’s risk of overdose. And yet, OAT adherence among youth is still low in many contexts, and a number of challenges exist in providing OAT to youth who are street involved in particular.
A new qualitative study by our research team at the BC Centre on Substance Use (BCCSU) sheds light on what can help when talking to vulnerable youth about OAT as a part of their treatment plan. Our research involved 3 years of in-depth interviews with youth who were street involved, as well as with their health care providers. We found that youth were more likely to adhere to OAT when they were actively involved in decision making about their care at regular intervals, and worked collaboratively with their health care providers to pursue their health and other goals in the short, medium, and longer terms.
Many youth equated stopping opioid use with a sense of “getting back to normal” and the ability to pursue “normal” kinds of “drug free” futures that included living in desirable housing; having stable romantic relationships; and opportunities for work, leisure, and travel. These imagined futures did not sit well with the idea that their substance use disorder constituted a life-long illness.
Many youth viewed longer-term adherence to OAT as incompatible with the “normal” futures they imagined for themselves, whether because of the idea that OAT constituted just another form of drug use, potential negative side effects of OAT, or the need to go to the pharmacy for daily witnessed doses. While most youth in this study were willing to access OAT on a short-term basis to mediate painful withdrawal symptoms, the majority did not see themselves continuing to take OAT for longer than a few weeks.
These findings have important implications for clinical practice. In addiction medicine, substance use disorder is now widely recognized as a chronic and relapsing disease. While this addiction model can be destigmatizing, our results suggest that—at least for some youth in our setting—talking about OAT as something that needs to occur over a longer time period may actually prevent uptake because it undermines youth’s hopes for particular kinds of futures. Starting conversations with youth about OAT that reference shorter trial periods, at least initially, might improve their longer-term engagement with care.
Our findings also highlight the need to introduce conversations about mental and physical health challenges when discussing OAT with youth. While many care providers recognize that vulnerable youth use drugs to manage mental and physical health issues, we found that a number of youth initiated OAT—methadone in particular—for this same purpose. When talking with youth, providers need to understand the strategies that youth are currently employing to manage mental and physical health challenges, and involve youth in decision making about whether OAT might fit with these existing strategies.
Our research found that youth who spoke positively about OAT highlighted instances of regularly working together with clinicians to make treatment decisions. In the absence of this kind of provider-patient collaboration, many youth decided to manage their substance use and treatment on their own, which often resulted in abruptly stopping OAT, relapse, and heightened overdose risk.
The harms faced by youth who use drugs in the context of street involvement have been exacerbated by the social isolation and lockdown measures imposed by COVID-19. Our research demonstrates that there are ways of discussing OAT with youth that may improve their ongoing engagement with care. Providers should open up conversations with youth about OAT by actively eliciting their current understandings and experiences of addiction, recovery, and mental and physical health, and then work collaboratively with them to pursue goals in the short-, medium-, and longer-terms. Having these conversations with youth and regularly involving them in decision making about their treatment is more likely to translate into longer-term success.
—Danya Fast, PhD
—Madison Thulien, MPH
—Sandra Smiley, MSc
—Valerie Giang, MD, CCFP
Dr Danya Fast is a research scientist at the BC Centre on Substance Use (BCCSU) and an assistant professor in the Department of Medicine at the University of British Columbia. Ms Madison Thulien coordinates the qualitative and ethnographic research program at the BCCSU’s At-Risk Youth Study (ARYS). Ms Sandra Smiley is the knowledge translation coordinator at the BCCSU and an MPH candidate and Sommer Scholar at the Johns Hopkins Bloomberg School of Public Health. Dr Valerie Giang is an addiction medicine physician working in Vancouver.
This post has not been peer reviewed by the BCMJ Editorial Board.