substance abuse research papers

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• v.5(9); 2019 Sep

Advances in the science and treatment of alcohol use disorder

K. witkiewitz.

1 Department of Psychology and Center on Alcoholism, Substance Abuse, and Addictions, University of New Mexico, 2650 Yale Blvd. SE, Albuquerque, NM 87106, USA.

R. Z. Litten

2 Division of Medications Development and Division of Treatment and Recovery Research, National Institute on Alcohol Abuse and Alcoholism, 6700B Rockledge Drive, Bethesda, MD 20892-6902, USA.

3 Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, National Institute on Alcohol Abuse and Alcoholism Division of Intramural Clinical and Biological Research, and National Institute on Drug Abuse Intramural Research Program, National Institutes of Health, 10 Center Drive (10CRC/15330), Bethesda, MD 21224, USA.

4 Medication Development Program, National Institute on Drug Abuse Intramural Research Program, 251 Bayview Blvd., Baltimore, MD 21224, USA.

5 Center for Alcohol and Addiction Studies, Brown University, Providence, RI 02912, USA.

Pharmacological and behavioral treatments exist for alcohol use disorder, but more are needed, and several are under development.

Alcohol is a major contributor to global disease and a leading cause of preventable death, causing approximately 88,000 deaths annually in the United States alone. Alcohol use disorder is one of the most common psychiatric disorders, with nearly one-third of U.S. adults experiencing alcohol use disorder at some point during their lives. Alcohol use disorder also has economic consequences, costing the United States at least $249 billion annually. Current pharmaceutical and behavioral treatments may assist patients in reducing alcohol use or facilitating alcohol abstinence. Although recent research has expanded understanding of alcohol use disorder, more research is needed to identify the neurobiological, genetic and epigenetic, psychological, social, and environmental factors most critical in the etiology and treatment of this disease. Implementation of this knowledge in clinical practice and training of health care providers is also needed to ensure appropriate diagnosis and treatment of individuals suffering from alcohol use disorder.

INTRODUCTION

In most regions of the world, most adults consume alcohol at least occasionally ( 1 ). Alcohol is among the leading causes of preventable death worldwide, with 3 million deaths per year attributable to alcohol. In the United States, more than 55% of those aged 26 and older consumed alcohol in a given month, and one in four adults in this age group engaged in binge drinking (defined as more than four drinks for women and five drinks for men on a single drinking occasion) ( 2 ). Excessive alcohol use costs U.S. society more than $249 billion annually and is the fifth leading risk factor for premature death and disability ( 3 ).

The morbidity and mortality associated with alcohol are largely due to the high rates of alcohol use disorder in the population. Alcohol use disorder is defined in the Diagnostic and Statistical Manual for Mental Disorders , 5th edition (DSM-5) ( 4 ) as a pattern of alcohol consumption, leading to problems associated with 2 or more of 11 potential symptoms of alcohol use disorder (see Table 1 for criteria). In the United States, approximately one-third of all adults will meet criteria for alcohol use disorder at some point during their lives ( 5 ), and approximately 15.1 million of U.S. adults meet criteria for alcohol use disorder in the previous 12 months ( 6 ). The public health impacts of alcohol use extend far beyond those individuals who drink alcohol, engage in heavy alcohol use, and/or meet criteria for an alcohol use disorder. Alcohol use is associated with increased risk of accidents, workplace productivity losses, increased medical and mental health costs, and greater rates of crime and violence ( 1 ). Analyses that take into account the overall harm due to drugs (harm to both users and others) show that alcohol is the most harmful drug ( 7 ).

Only a small percent of individuals with alcohol use disorder contribute to the greatest societal and economic costs ( 8 ). For example, in the 2015 National Survey on Drug Use and Health survey (total n = 43,561), a household survey conducted across the United States, 11.8% met criteria for an alcohol use disorder ( n = 5124) ( 6 ). Of these 5124 individuals, 67.4% ( n = 3455) met criteria for a mild disorder (two or three symptoms, based on DSM-5), 18.8% ( n = 964) met criteria for a moderate disorder (four or five symptoms, based on DSM-5), and only 13.8% ( n = 705) met criteria for a severe disorder (six or more symptoms) ( 6 ). There is a large treatment gap for alcohol use disorder, arising from the fact that many individuals with alcohol use disorder do not seek treatment. Those with a mild or moderate alcohol use disorder may be able to reduce their drinking in the absence of treatment ( 9 ) and have a favorable course; but it is those with more severe alcohol use disorder who most often seek treatment and who may experience a chronic relapsing course ( 10 ).

HISTORY OF TREATMENT FOR ALCOHOL USE DISORDER

Near the end of the 18th century, the Pennsylvania physician Benjamin Rush described the loss of control of alcohol and its potential treatments ( 11 ). His recommendations for remedies and case examples included practicing the Christian religion, experiencing guilt and shame, pairing alcohol with aversive stimuli, developing other passions in life, following a vegetarian diet, taking an oath to not drink alcohol, and sudden and absolute abstinence from alcohol. Through the 1800s and early 1900s, the temperance movement laid the groundwork for mutual help organizations, and the notion of excessive alcohol use as a moral failing. During the same period, inebriate asylums emerged as a residential treatment option for excessive alcohol use, although the only treatment offered was forced abstinence from alcohol ( 12 ). The founding of Alcoholics Anonymous (A.A.) in the 1930s ( 13 ) and the introduction of the modern disease concept of alcohol use disorder (previously called “alcoholism”) in the 1940s ( 14 ) laid the groundwork for many of the existing treatment programs that remain widely available today. Over the past 80 years, empirical studies have provided support for both mutual support [A.A. and other support groups, such as SMART (Self-Management and Recovery Training)] and medical models of treatment for alcohol use disorder, as well as the development of new pharmacological and behavioral treatment options. In addition, there are several public health policy initiatives (e.g., taxation, restrictions on advertising, and outlet density) and brief intervention programs (e.g., social norms interventions) that can be effective in reducing prevalence of alcohol use disorder and alcohol-related harms ( 1 ).

NEUROBIOLOGY OF ALCOHOL USE DISORDER

Alcohol use disorder is characterized by loss of control over alcohol drinking that is accompanied by changes in brain regions related to the execution of motivated behaviors and to the control of stress and emotionality (e.g., the midbrain, the limbic system, the prefrontal cortex, and the amygdala). Mechanisms of positive and negative reinforcement both play important roles with individual drinking behavior being maintained by positive reinforcement (rewarding and desirable effects of alcohol) and/or negative reinforcement mechanisms (negative affective and physiological states that are relieved by alcohol consumption) ( 15 , 16 ). At the neurotransmitter level, the positive reinforcing effects of alcohol are primarily mediated by dopamine, opioid peptides, serotonin, γ-aminobutyric acid (GABA), and endocannabinoids, while negative reinforcement involves increased recruitment of corticotropin-releasing factor and glutamatergic systems and down-regulation of GABA transmission ( 16 ). Long-term exposure to alcohol causes adaptive changes in several neurotransmitters, including GABA, glutamate, and norepinephrine, among many others. Discontinuation of alcohol ingestion results in the nervous system hyperactivity and dysfunction that characterizes alcohol withdrawal ( 15 , 16 ). Acting on several types of brain receptors, glutamate represents one of the most common excitatory neurotransmitters. As one of the major inhibitory neurotransmitters, GABA plays a key role in the neurochemical mechanisms involved in intoxication, tolerance, and withdrawal. This brief review can offer only a very simplified overview of the complex neurobiological basis of alcohol use disorder. For deeper, more detailed analysis of this specific topic, the reader is encouraged to consult other reviews ( 15 , 16 ).

CLINICAL MANAGEMENT OF ALCOHOL WITHDRAWAL SYNDROME

Alcohol withdrawal symptoms may include anxiety, tremors, nausea, insomnia, and, in severe cases, seizures and delirium tremens. Although up to 50% of individuals with alcohol use disorder present with some withdrawal symptoms after stopping drinking, only a small percentage requires medical treatment for detoxification, and some individuals may be able to reduce their drinking spontaneously. Medical treatment may take place either in an outpatient or, when clinically indicated, inpatient setting. In some cases, clinical monitoring may suffice, typically accompanied by supportive care for hydration and electrolytes and thiamine supplementation. For those patients in need of pharmacological treatment, benzodiazepines (e.g., diazepam, chlordiazepoxide, lorazepam, oxazepam, and midazolam) are the most commonly used medications to treat alcohol withdrawal syndrome. Benzodiazepines work by enhancing the effect of the GABA neurotransmitter at the GABA A receptor. Notably, benzodiazepines represent the gold standard treatment, as they are the only class of medications that not only reduces the severity of the alcohol withdrawal syndrome but also reduces the risk of withdrawal seizures and/or delirium tremens. Because of the potential for benzodiazepine abuse and the risk of overdose, if benzodiazepine treatment for alcohol withdrawal syndrome is managed in an outpatient setting, careful monitoring is required, particularly when combined with alcohol and/or opioid medications ( 17 ).

a-2 agonists (e.g., clonidine) and β-blockers (atenolol) are sometimes used as an adjunct treatment to benzodiazepines to control neuro-autonomic manifestations of alcohol withdrawal not fully controlled by benzodiazepine administration ( 18 ). However, because of the lack of efficacy of a-2 agonists and β-blockers in preventing severe alcohol withdrawal syndrome and the risk of masking withdrawal symptoms, these drugs are recommended not as monotherapy, but only as a possible adjunctive treatment.

Of critical importance to a successful outcome is the fact that alcohol withdrawal treatment provides an opportunity for the patient and the health care provider to engage the patient in a treatment program aimed at achieving and maintaining long-term abstinence from alcohol or reductions in drinking. Such a treatment may include pharmacological and/or psychosocial tools, as summarized in the next sections.

PHARMACOLOGICAL APPROACHES TO THE TREATMENT OF ALCOHOL USE DISORDER

U.s. food and drug administration–approved pharmacological treatments.

Development of novel pharmaceutical reagents is a lengthy, costly, and expensive process. Once a new compound is ready to be tested for human research use, it is typically tested for safety first via phase 0 and phase 1 clinical studies in a very limited number of individuals. Efficacy and side effects may then be further tested in larger phase 2 clinical studies, which may be followed by larger phase 3 clinical studies, typically conducted in several centers and are focused on efficacy, effectiveness, and safety. If approved for use in clinical practice, this medication is still monitored from a safety standpoint, via phase 4 postmarketing surveillance.

Only three drugs are currently approved by the U.S. Food and Drug Administration (FDA) for use in alcohol use disorder. The acetaldehyde dehydrogenase inhibitor disulfiram was the first medication approved for the treatment of alcohol use disorder by the FDA, in 1951. The most common pathway in alcohol metabolism is the oxidation of alcohol via alcohol dehydrogenase, which metabolizes alcohol to acetaldehyde, and aldehyde dehydrogenase, which converts acetaldehyde into acetate. Disulfiram leads to an irreversible inhibition of aldehyde dehydrogenase and accumulation of acetaldehyde, a highly toxic substance. Although additional mechanisms (e.g., inhibition of dopamine β-hydroxylase) may also play a role in disulfiram’s actions, the blockade of aldehyde dehydrogenase activity represents its main mechanism of action. Therefore, alcohol ingestion in the presence of disulfiram leads to the accumulation of acetaldehyde, resulting in numerous related unpleasant symptoms, including tachycardia, headache, nausea, and vomiting. In this way, disulfiram administration paired with alcohol causes the aversive reaction, initially proposed as a remedy for alcohol use disorder by Rush ( 11 ) in 1784. One challenge in conducting a double-blind, placebo-controlled alcohol trial of disulfiram is that it is easy to break the blind unless the “placebo” medication also creates an aversive reaction when consumed with alcohol, which would then provide the same mechanism of action as the medication (e.g., the placebo and disulfiram would both have the threat of an aversive reaction). Open-label studies of disulfiram do provide support for its efficacy, as compared to controls, with a medium effect size ( 19 ), as defined by Cohen’s d effect size ranges of small d = 0.2, medium d = 0.5, and large d = 0.8 ( 20 ). The efficacy of disulfiram largely depends on patient motivation to take the medication and/or supervised administration, given that the medication is primarily effective by the potential threat of an aversive reaction when paired with alcohol ( 21 ).

The next drug approved for treatment of alcohol use disorder was acamprosate; first approved as a treatment for alcohol dependence in Europe in 1989, acamprosate has subsequently been approved for use in the United States, Canada, and Japan. Although the exact mechanisms of acamprosate action are still not fully understood, there is evidence that it targets the glutamate system by modulating hyperactive glutamatergic states, possibly acting as an N -methyl- d -aspartate receptor agonist ( 22 ). The efficacy of acamprosate has been evaluated in numerous double-blind, randomized controlled trials and meta-analyses, with somewhat mixed conclusions ( 23 – 26 ). Although a meta-analysis conducted in 2013 ( 25 ) indicated small to medium effect sizes in favor of acamprosate over placebo in supporting abstinence, recent large-scale trials conducted in the United States ( 27 ) and Germany ( 28 ) failed to find effects of acamprosate distinguishable from those of a placebo. Overall, there is evidence that acamprosate may be more effective in promoting abstinence and preventing relapse in already detoxified patients than in helping individuals reduce drinking ( 25 ), therefore suggesting its use as an important pharmacological aid in treatment of abstinent patients with alcohol use disorder. The most common side effect with acamprosate is diarrhea. Other less common side effects may include nausea, vomiting, stomachache, headache, and dizziness, although the causal role of acamprosate in giving these side effects is unclear.

A third drug, the opioid receptor antagonist naltrexone, was approved for the treatment of alcohol dependence by the FDA in 1994. Later, a monthly extended-release injectable formulation of naltrexone, developed with the goal of improving patient adherence, was also approved by the FDA in 2006. Naltrexone reduces craving for alcohol and has been found to be most effective in reducing heavy drinking ( 25 ). The efficacy of naltrexone in reducing relapse to heavy drinking, in comparison to placebo, has been supported in numerous meta-analyses ( 23 – 25 ), although there is less evidence for its efficacy in supporting abstinence ( 25 ). Fewer studies have been conducted with the extended-release formulation, but its effects on heavy drinking, craving, and quality of life are promising ( 29 , 30 ). Common side effects of naltrexone may include nausea, headache, dizziness, and sleep problems. Historically, naltrexone’s package insert has been accompanied by a risk of hepatotoxicity, a precaution primarily due to observed liver toxicity in an early clinical trial with administrating a naltrexone dosage of 300 mg per day to obese men ( 31 ). However, there is no published evidence of severe liver toxicity at the lower FDA-approved dosage of naltrexone for alcohol use disorder (50 mg per day). Nonetheless, transient, asymptomatic hepatic transaminase elevations have also been observed in some clinical trials and in the postmarketing period; therefore, naltrexone should be used with caution in patients with active liver disease and should not be used in patients with acute hepatitis or liver failure.

Additional pharmacological treatments approved for alcohol use disorder in Europe

Disulfiram, acamprosate, and naltrexone have been approved for use in Europe and in the United States. Pharmacologically similar to naltrexone, nalmefene was also approved for the treatment of alcohol dependence in Europe in 2013. Nalmefene is a m- and d-opioid receptor antagonist and a partial agonist of the k-opioid receptor ( 32 ). Side effects of nalmefene are similar to naltrexone; compared to naltrexone, nalmefene has a longer half-life. Meta-analyses have indicated that nalmefene is effective in reducing heavy drinking days ( 32 ). An indirect meta-analysis of these two drugs concluded that nalmefene may be more effective than naltrexone ( 33 ), although whether a clinically relevant difference between the two medications really exists is still an open question ( 34 ). Network meta-analysis and microsimulation studies suggest that nalmefene may have some benefits over placebo for reducing total alcohol consumption ( 35 , 36 ). The approval of nalmefene in Europe was accompanied by some controversy ( 37 ); a prospective head-to-head trial of nalmefene and naltrexone could help clarify whether nalmefene has added benefits to the existing medications available for alcohol use disorder. Last, nalmefene was approved in Europe as a medication that can be taken “as needed” (i.e., on days when drinking was going to occur). Prior work has also demonstrated the efficacy of taking naltrexone only on days that drinking was potentially going to occur ( 38 ).

In addition to these drugs, a GABA B receptor agonist used to treat muscle spasms, baclofen, was approved for treatment of alcohol use disorder in France in 2018 and has been used off label for alcohol use disorder for over a decade in other countries, especially in other European countries and in Australia ( 39 , 40 ). Recent human laboratory work suggests that baclofen may disrupt the effects of an initial priming dose of alcohol on subsequent craving and heavy drinking ( 41 ). Meta-analyses and systematic reviews examining the efficacy of baclofen have yielded mixed results ( 35 , 39 , 42 ); however, there is some evidence that baclofen might be useful in treatment of alcohol use disorder among individuals with liver disease ( 43 , 44 ). Evidence of substantial heterogeneity in baclofen pharmacokinetics among different individuals with alcohol use disorder ( 41 ) could explain the variability in the efficacy of baclofen across studies. The appropriate dose of baclofen for use in treatment of alcohol use disorder remains a controversial topic, and a recent international consensus statement highlighted the importance of tailoring doses based on safety, tolerability, and efficacy ( 40 ).

Promising pharmacological treatments

Numerous other medications have been used off label in the treatment of alcohol use disorder, and many of these have been shown to be modestly effective in meta-analyses and systematic reviews ( 23 , 24 , 26 , 35 ). Systematic studies of these medications suggest promising findings for topiramate, ondansetron, gabapentin, and varenicline. The anticonvulsant drug topiramate represents one of the most promising medications in terms of efficacy, based on its medium effect size from several clinical trials [for a review, see ( 45 )], including a multisite clinical study ( 46 ). One strength of topiramate is the possibility of starting treatment while people are still drinking alcohol, therefore serving as a potentially effective treatment to initiate abstinence (or to reduce harm) rather than to prevent relapse in already detoxified patients ( 45 ). Although not approved by the FDA, it is worth noticing that topiramate is a recommended treatment for alcohol use disorder in the U.S. Department of Veterans Affairs ( 47 ). A concern with topiramate is the potential for significant side effects, especially those affecting cognition and memory, warranting a slow titration of its dose and monitoring for side effects. Furthermore, recent attention has been paid on zonisamide, another anticonvulsant medication, whose pharmacological mechanisms of actions are similar to topiramate but with a better tolerability and safety profile ( 48 ). Recently published and ongoing research focuses on a potential pharmacogenetic approach to treatment in the use of topiramate to treat alcohol use disorder, based on the possibility that both efficacy and tolerability and safety of topiramate may be moderated by a functional single-nucleotide polymorphism (rs2832407) in GRIK1, encoding the kainate GluK1 receptor subunit ( 49 ). Human laboratory studies ( 50 ) and treatment clinical trials ( 51 ) have also used a primarily pharmacogenetic approach to testing the efficacy of the antinausea drug ondansetron, a 5HT 3 antagonist, in alcohol use disorder. Overall, these studies suggest a potential role for ondansetron in alcohol use disorder, but only in those individuals with certain variants of the genes encoding the serotonin transporter 5-HTT and the 5-HT 3 receptor. The anticonvulsant gabapentin has shown promising results in human laboratory studies and clinical trials ( 52 – 54 ), although a more recent multisite trial with an extended-release formulation of the medication did not have an effect of gabapentin superior to that of a placebo ( 55 ). Although the latter findings might be related to potential pharmacokinetic issues secondary to the specific formulation used, it is nonetheless possible that gabapentin may be more effective in patients with more clinically relevant alcohol withdrawal symptoms ( 52 ). Several human laboratory studies support a role for varenicline, a nicotinic acetylcholine receptor partial agonist approved for smoking cessation, in alcohol use disorder [for a review, see ( 56 )], and two of three clinical trials also support its efficacy on alcohol outcomes ( 57 – 59 ), especially in heavy drinkers who are males ( 59 ) and in male and female alcohol-dependent individuals who are also smokers ( 60 ). Additional details on the FDA-approved medications and other medications tested in clinical research settings for the treatment of alcohol use disorder are summarized in Table 2 .

FDA, U.S. Food and Drug Administration; AMPA, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid; NMDA, N -methyl- d -aspartate; PO, per os (oral); IM, intramuscular; HT, serotonin.

The medications and targets described above have shown promising results in phase 2 or phase 3 medication trials. However, owing to the development of novel neuroscience techniques, a growing and exciting body of data is expanding the armamentarium of targets currently under investigation in animal models and/or in early-phase clinical studies. Pharmacological approaches with particular promise for future drug development include, but are not limited to the following [for recent reviews, see, e.g., ( 56 , 61 – 68 )]: the antipsychotic drug aripiprazole, which has multiple pharmacological actions (mainly on dopamine and serotonin receptors), the antihypertensive alpha-1 blocker drugs prazosin and doxazosin, neurokinin-1 antagonism, the glucocorticoid receptor blocker mifepristone, vasopressin receptor 1b antagonism, oxytocin, ghrelin receptor antagonism, glucagon-like peptide-1 agonism, and pharmacological manipulations of the nociception receptor (We are intentionally using a general pharmacological terminology for the nociceptin receptor, given that it is unclear whether agonism, antagonism, or both may represent the best approach.). New medications development is particularly important for the treatment of comorbid disorders that commonly co-occur among individuals with alcohol use disorder, particularly affective disorders, anxiety disorders, suicidality, and other substance use disorders. This aspect of alcohol use disorder is relevant to the fact that addictive disorders often present with significantly more severe symptoms when they coexist with other mental health disorders ( 69 ). Likewise, there is evidence that pharmacotherapy is most effective when implemented in conjunction with behavioral interventions ( 70 ), and all phase 2 and phase 3 medication trials, mentioned above, have included a brief psychosocial behavioral treatment in combination with medication.

BEHAVIORAL/PSYCHOLOGICAL TREATMENTS FOR ALCOHOL USE DISORDER

Evidence-based treatments.

A wide range of behavioral and psychological treatments are available for alcohol use disorder, and many treatments are equally effective in supporting abstinence or drinking reduction goals ( 71 – 74 ). Treatments with the greatest evidence of efficacy range from brief interventions, including motivational interviewing approaches, to operant conditioning approaches, including contingency management and the community reinforcement approach, to cognitive behavioral treatments, including coping skills training and relapse prevention, and to acceptance- and mindfulness-based approaches. Twelve-step facilitation, which was designed specifically to connect individuals with mutual support groups, has also been shown to be effective ( 75 ). In addition, harm reduction treatments, including guided self-control training and controlled drinking interventions, have been successful in supporting drinking reduction goals ( 70 ).

Meta-analyses and systematic reviews have found that brief interventions, especially those based on the principles of motivational interviewing, are effective in the treatment of alcohol use disorder. These interventions can include self-monitoring of alcohol use, increasing awareness of high-risk situations, and training in cognitive and behavioral techniques to help clients cope with potential drinking situations, as well as life skills training, communication training, and coping skills training. Cognitive behavioral treatments can be delivered in individual or group settings and can also be extended to the treatment of families and couples ( 72 , 73 ).

Acceptance- and mindfulness-based interventions are increasingly being used to target alcohol use disorder and show evidence of efficacy in a variety of settings and formats, including brief intervention formats ( 76 ). Active ingredients include raising present moment awareness, developing a nonjudgmental approach to self and others, and increasing acceptance of present moment experiences. Acceptance- and mindfulness-based interventions are commonly delivered in group settings and can also be delivered in individual therapy contexts.

Computerized, web-based, and mobile interventions have also been developed, incorporating the principles of brief interventions, behavioral and cognitive behavioral approaches, as well as mindfulness and mutual support group engagement; many of these approaches have demonstrated efficacy in initial trials ( 77 – 79 ). For example, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has developed the Take Control computerized intervention that includes aspects of motivational interviewing and coping skills training and was designed to provide psychosocial support (particularly among those assigned to the placebo medication) and also to increase adherence and retention among individuals enrolled in pharmacotherapy trials ( 80 ).

Mutual support group (e.g., A.A. and SMART) attendance and engagement have been shown to be associated with recovery from alcohol use disorder, even in the absence of formal treatment ( 81 ). However, selection biases (e.g., people selecting to attend these groups) raise difficulties in assessing whether other factors that are associated with treatment effectiveness may be the active ingredients for improving outcomes among those who attend mutual support groups. For example, individuals who are highly motivated to change might be more likely to attend mutual support groups. Likewise, mutual support groups often provide individuals with increased social network support for abstinence ( 82 ). Motivation to change and having a social network that supports abstinence (or reductions in drinking) are both factors that are associated with greater treatment effectiveness ( 83 ).

As noted above, most behavioral and psychological treatments are equally effective with small effect size differences [Cohen’s d = 2.0 to 0.3 ( 20 )] between active treatments ( 84 – 88 ). Behavioral interventions have also been shown to be as effective as pharmacotherapy options, with a 16-week cognitive behavioral intervention shown to be statistically equivalent to naltrexone in reducing heavy drinking days in a large randomized trial ( 27 ). One of the challenges of examining behavioral interventions in randomized trials is that intervention blinding and placebo controls cannot be implemented in most contexts, other than in computerized interventions. Furthermore, the general therapeutic factors common to most behavioral interventions (e.g., therapist empathy and supportive therapeutic relationship) in treatment of alcohol use disorder are as powerful as the specific therapeutic targets of specific behavioral interventions (e.g., teaching skills in a cognitive behavioral treatment) in facilitating behavioral change ( 89 ).

Promising future behavioral treatments and neuromodulation treatments

With respect to behavioral treatments, there are numerous opportunities for the development of novel mobile interventions that could provide treatment and recovery support in near real time. This mobile technology may also extend the reach of treatments to individuals with alcohol use disorder, particularly in rural areas. On the basis of a contextual self-regulation model of alcohol use ( 90 ), it is critical to address the immediate situational context alongside the broader social, environmental, and familial context in which an individual experiences the world and engages in momentary decision-making. Ambulatory assessment, particularly tools that require only passive monitoring (e.g., GPS, heart rate, and skin conductance) and real-time support via mobile health, could provide immediate environmental supports and could extend the reach of medications and behavioral treatments for alcohol use disorder. For example, a mobile device could potentially signal a high-risk situation by indicating the geographic location (near a favorite drinking establishment) and the heart rate (increased heart rate when approaching the establishment). The device could provide a warning either to the individual under treatment and/or to a person supporting that individual’s recovery. In addition, developments in alcohol sensing technology (e.g., transdermal alcohol sensors) could greatly increase rigor of research on alcohol use disorder and also provide real-time feedback on alcohol consumption levels to individuals who are attempting to moderate and/or reduce their alcohol use.

Recent advances in neuromodulation techniques may also hold promise for the development of novel treatments for alcohol use disorder. Deep brain stimulation, transcranial magnetic stimulation, transcranial electrical stimulation (including transcranial direct current stimulation and transcranial alternating current stimulation), and real-time neurofeedback have recently been tested as potential treatments for addiction, although evidence in favor of these treatments is currently uncertain and focused mostly on intermediate targets (e.g., alcohol craving) ( 91 ). These techniques attempt to directly target specific brain regions and addiction-related cognitive processes via surgically implanted electrodes (deep brain stimulation), electrical currents or magnetic fields applied to the scalp (transcranial electrical and magnetic stimulation, respectively), or individual self-generated modulation via feedback (neurofeedback). Although robust large scale trials with double-blind, sham controls, and long-term follow-ups of alcohol behavior change and relapse have not been conducted ( 91 ), the heterogeneity of alcohol use disorder suggests that targeting one specific neural region may be insufficient to treat such a complex disorder, with its multiple etiologies and diverse clinical courses ( 92 ).

Factors contributing to the effectiveness of treatments

Numerous models have examined factors that predict treatment readiness, treatment engagement, and treatment outcomes for alcohol use disorder. The transtheoretical model of change proposes that an individual’s own readiness to change his or her drinking behavior may have an impact on treatment engagement and effectiveness ( 93 ). The dynamic model of relapse proposes the involvement of multiple interacting biological, psychological, cognitive, emotional, social, and situational risk factors that are static and dynamic in their association with treatment outcomes ( 83 ). Neurobiological models of addiction focus on the brain reward and stress system dysfunction that contributes to the development and maintenance of alcohol use disorder, that is, the “addiction cycle” ( 15 , 16 ). The alcohol and addiction research domain criteria (AARDoC) ( 92 ), which have been operationalized in the addictions neuroclinical assessment ( 94 ), focus on the following three domains that correspond to particular phases in the addiction cycle: incentive salience in the binge/intoxication phase, negative emotionality in the withdrawal/negative affect phase, and executive function in the preoccupation/anticipation phase. Within each domain of the AARDoC, the addictions neuroclinical assessment proposes constructs that can be measured at multiple levels of analysis, such as craving in the incentive salience domain, negative affect and emotion dysregulation in the negative emotionality domain, and cognitive impairment and impulsivity in the executive function domain. The AARDoC acknowledge that environmental and contextual factors play a role in alcohol use disorder and treatment outcomes. Moreover, because of the heterogeneity of alcohol use disorder, the significance of these domains in causing alcohol use disorder and alcohol-related problems will vary among individuals.

Each of the abovementioned theoretical models proposes factors that may affect treatment effectiveness; however, many of the constructs proposed in each of these models are overlapping and likely contribute to the effectiveness of alcohol use disorder treatment across a range of populations and settings. A heuristic model combining components from each of these models is shown in Fig. 1 . Specifically, this model highlights the precipitants of alcohol use that are influenced by the neurobiological adaptations proposed in the addiction cycle (indicated by bold font) and additional contextual factors (regular font) that decrease or increase the likelihood of drinking in context, depending on whether an individual uses effective coping regulation in the moment. The domains supporting alcohol use/coping regulation (negative emotionality, executive function, incentive salience, and social environment) may interact to predict alcohol use or coping regulation in the moment. For example, network support for abstinence could improve decision-making and decrease likelihood of drinking. Conversely, experiences of physical pain are associated with increases in negative affect and poorer executive function, which could both increase likelihood of drinking. Both of these examples require environmental access to alcohol and a desire to drink alcohol. Treatment effectiveness will depend on the extent to which a particular treatment targets those risk factors that are most likely to increase or decrease the likelihood of drinking for each individual, as well as the personal resources that each individual brings to treatment and/or that could be enhanced in treatment. A functional analysis of contextual risk and protective factors can be critically important in guiding treatment.

Risk factors proposed in the AARDoC, including incentive salience, negative emotionality, executive function, and social environmental factors, are shown in black bold font encircling alcohol use. Contextual risk factors, including decision-making, self-efficacy, pain, craving, etc., are shown in black font in colored boxes. Risk and protective factors overlap with alcohol use and interact in predicting coping regulation and alcohol use among individual patients.

For example, there is considerable heterogeneity in treatment response to naltrexone, which may vary in efficacy in some individuals. Recent studies conducted to determine whether certain patients may benefit more from naltrexone have yielded mixed findings ( 95 ). Promising evidence suggests that individuals with the OPRM1 A118G G (Asp40) allele may have a better response to naltrexone ( 96 – 98 ); however, a prospective study of medication response among individuals stratified by presence of the Asp40 allele did not provide support for the genotype by treatment interaction ( 99 ), and recent human laboratory studies have not confirmed the hypothesized mechanisms underlying the pharmacogenomic effect ( 100 ). Initial evidence suggests that naltrexone may be more effective in reducing heavy drinking among smokers ( 101 ) and among those with a larger number of heavy drinkers in their social networks ( 102 ). With respect to reinforcement typologies, recent work has found that naltrexone may be more effective among those who tend to drink alcohol for rewarding effects ( 103 ), and acamprosate may also be more effective for individuals who drink to relieve negative affect ( 104 ).

GAPS IN SCIENTIFIC KNOWLEDGE AND NEW RESEARCH DIRECTIONS

Heterogeneity of individuals with alcohol use disorder.

This review has briefly summarized the treatments currently available for alcohol use disorder that are relatively effective, at least in some patients. Many new treatments are also being developed, and some of them seem promising. Nevertheless, numerous gaps in scientific knowledge remain. Notably, most people who drink alcohol do not develop an alcohol use disorder, most people with alcohol use disorder do not seek treatment, and most of those who do not seek treatment “recover” from alcohol use disorder without treatment ( 2 ). Very little is known about factors, particularly neurobiological, genetic, and epigenetic factors, that predict the transition from alcohol use to alcohol use disorder, although basic science models suggest that a cycle of neuroadaptations could be at play ( 15 , 16 ). We also lack a basic understanding of how individuals recover from alcohol use disorder in the absence of treatment and what neurobiological, psychological, social, and environmental factors are most important for supporting recovery from alcohol use disorder. Gaining a better understanding of recovery in the absence of treatment, particularly modifiable psychological, neurobiological, and epigenetic factors, could provide novel insights for medications and behavioral treatment development. Among many other factors, special attention is needed in future studies to shed light on the role of sex and gender in the development and maintenance of alcohol use disorder and on the response to pharmacological, behavioral, and other treatments.

The heterogeneity of alcohol use disorder presents a major challenge to scientific understanding and to the development of effective treatments for prevention and intervention ( 92 ). For example, a DSM-5 diagnosis of alcohol use disorder requires 2 or more symptoms, out of 11, over the past year. That requirement equates to exactly 2048 potential symptom combinations that would meet the criteria of alcohol use disorder. An individual who only meets criteria for tolerance and withdrawal (i.e., physiological dependence) likely requires a very different course of treatment from an individual who only meets the criteria for failure to fulfill role obligations and use of alcohol in hazardous situations. Gaining a better understanding of the etiology and course of alcohol use disorder, as well as identifying whether different subtypes of drinkers may respond better to certain treatments ( 103 , 104 ), is critical for advancing the science of alcohol use disorder prevention and treatment. Alternative conceptualizations of alcohol use disorder may also aid in improving our understanding of the disorder and reducing heterogeneity. For example, the pending International Classification of Diseases , 11th edition, will simplify the diagnosis of alcohol dependence to requiring only two of three criteria in the past 12 months: (i) impaired control over alcohol use; (ii) alcohol use that dominates over other life activities; and (iii) persistence of alcohol use despite consequences. The diagnosis will be made with or without physiological dependence, as characterized by tolerance, withdrawal, or repeated use to prevent or alleviate withdrawal ( 105 ). It remains to be seen whether simplification of the criteria set will narrow our conceptualization or potentially increase heterogeneity of this disorder among those diagnosed with alcohol dependence.

Placebo effect

An additional challenge to development of pharmacological treatments for alcohol use disorder is the high placebo response rates seen in drug trials ( 106 ). The tendency for individuals to have a good treatment response when assigned to placebo medication reflects both the high probability of recovery without treatment and the heterogeneity in the disorder itself. Many people who enter treatment are already motivated to change behavior, and receiving a placebo medication can help these individuals continue the process of change. Gaining a better understanding of which kinds of individuals respond to placebo and of the overall physiological and behavioral complexities in the placebo response is critical to identifying those individuals who will benefit the most from active medication. More generally, very little is understood about how motivation to change drinking behavior may influence the efficacy of active medications, particularly via adherence mechanisms. Additional research on targeted (i.e., as needed) dosing of medications, such as nalmefene and naltrexone ( 32 , 38 ), would be promising from the perspective of increasing adherence to medications and also raising awareness of potentially heavy drinking occasions.

Recent developments in pharmacological and behavioral approaches

In addition to gaining a better understanding of the disorder and who benefits from existing treatments, the examination of molecular targets for alcohol use disorder could open up multiple innovative directions for future translational research on the treatment of alcohol use disorder. Recent research has identified many targets that might be important for future medication trials ( 67 ). For example, most of the medication development efforts in past decades have focused on pathways and targets typically related to reward processing and positive reinforcement. While important, this approach ignores the important role of stress-related pathways (e.g., corticotropin release factor and other related pathways) in negative reinforcement and in the later stages of alcohol use disorder, which is often characterized by physical dependence, anxiety, and relief drinking [for reviews, see ( 15 , 16 )]. Furthermore, it is also becoming more and more apparent that other promising targets may be identified by looking at the brain not as an isolated system but rather as an organ with bidirectional interactions with peripheral systems. Examples of the latter approach include the growing evidence suggesting a potential role of inflammation and neuroinflammation and of the gut-liver-brain axis in the neurobiological mechanisms that regulate the development and/or maintenance of alcohol use disorder ( 107 – 109 ). Moving medications development from phase 1 to phase 2 and 3 trials has also been a difficulty in the field. Future directions that might improve translation of basic science into clinical practice include the broader use of human laboratory models and pilot clinical trials ( 110 ), as well as expanding the outcomes that might be targeted in phase 2 and phase 3 trials to include drinking reduction outcomes ( 111 , 112 ).

New directions for behavioral treatment development include a greater focus on identifying effective elements of behavioral treatments and on the components of treatment that are most critical for successful behavior change ( 89 , 113 ). Studies investigating the effects of specific treatment components are critical for refining treatment protocols to more efficiently target the symptoms of alcohol use disorder. Continued development of mobile health interventions will also help with disseminating treatment to a wider range of individuals struggling with alcohol use disorder.

Translation of addiction science to clinical practice

Last, but not the least, there is also a critical need for more research on dissemination and implementation, given the fact that many treatment programs still do not incorporate evidence-based practices, such as cognitive behavioral skills training, mindfulness-based interventions, and medications. Both pharmacological and behavioral treatments for alcohol use disorder are markedly underused; the recent Surgeon General’s report Facing Addiction in America ( 114 ) highlights the fact that only about 1 in 10 people with a substance use disorder receives any type of specialty treatment. Therefore, basic science and human research efforts will need to be accompanied by translational approaches, where effective novel medications and precision medicine strategies are effectively translated from research settings to clinical practice. Greater integration of alcohol screening and medication in primary care and other clinical settings, as well as research on best methods for implementation, has great potential for expanding access to effective treatment options ( 115 ). Because the heterogeneity of alcohol use disorder makes it highly unlikely that one single treatment will work for all individuals, it is important to provide a menu of options for pharmacological and behavioral therapies to both clinicians and patients. Reducing the stigma of alcohol use disorder and moving toward a public health approach to addressing this problem may further increase the range of acceptable treatment options.

Acknowledgment

Funding: This research was supported by a grant from NIAAA (R01 AA022328) awarded to K.W. (principal investigator). R.Z.L. is funded by NIAAA. L.L. is jointly funded by NIAAA and the National Institute on Drug Abuse (NIDA) (ZIA-AA000218). The content of this review does not necessarily represent the official views of the funders. Author contributions: K.W. wrote the first draft of the manuscript. K.W., R.Z.L., and L.L. provided additional text and edits. All authors approved the final draft. Competing interests: The authors declare that they have no competing interests. Data and materials availability: All data needed to evaluate the conclusions in the paper are present in the paper and/or in the materials cited herein. Additional data related to this paper may be requested from the authors.

REFERENCES AND NOTES

• Open access
• Published: 28 May 2022

A qualitative study exploring how young people perceive and experience substance use services in British Columbia, Canada

• Roxanne Turuba 1 , 2 ,
• Anurada Amarasekera 1 , 2 ,
• Amanda Madeleine Howard 1 , 2 ,
• Violet Brockmann 1 , 2 ,
• Corinne Tallon 1 , 2 ,
• Sarah Irving 1 , 2 ,
• Steve Mathias 1 , 2 , 3 , 4 , 5 ,
• Joanna Henderson 6 , 7 ,
• Kirsten Marchand 1 , 4 , 5 , 8 &
• Skye Barbic 1 , 2 , 3 , 4 , 5 , 8  

Substance Abuse Treatment, Prevention, and Policy volume  17 , Article number:  43 ( 2022 ) Cite this article

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Substance use among youth (ages 12–24) is troublesome given the increasing risk of harms associated. Even more so, substance use services are largely underutilized among youth, most only accessing support when in crisis. Few studies have explored young people’s help-seeking behaviours to address substance use concerns. To address this gap, this study explored how youth perceive and experience substance use services in British Columbia (BC), Canada.

Participatory action research methods were used by partnering with BC youth (under the age of 30) from across the province who have lived and/or living experience of substance use to co-design the research protocol and materials. An initial focus group and interviews were held with 30 youth (ages 12–24) with lived and/or living experience of substance use, including alcohol, cannabis, and illicit substances. The discussions were audio-recorded, transcribed verbatim, and analyzed thematically using a data-driven approach.

Three main themes were identified and separated by phase of service interaction, starting with: Prevention/Early intervention , where youth described feeling unworthy of support; Service accessibility , where youth encountered many barriers finding relevant substance use services and information; and Service delivery , where youth highlighted the importance of meeting them where they are at, including supporting those who have milder treatment needs and/or do not meet the diagnosis criteria of a substance use disorder.

Conclusions

Our results suggest a clear need to prioritize substance use prevention and early interventions specifically targeting youth and young adults. Youth and peers with lived and/or living experience should be involved in co-designing and co-delivering such programs to ensure their relevance and credibility among youth. The current disease model of care leaves many of the needs of this population unmet, calling for a more integrated youth-centred approach to address the multifarious concerns linked to young people’s substance use and service outcomes and experiences.

Substance use initiation is common during adolescence and young adulthood [ 1 ]. In North America, youth (defined here as aged 12–24) report the highest prevalence of substance use compared to older age groups [ 2 , 3 ], alcohol being the most common (youth 15–19: 57%; youth 20–24: 83%), followed by cannabis (youth 15–19: 19%; youth 20–24: 33%), and illicit substances (youth 15–19: 4%; youth 20–24: 10%) [ 2 ]. High rates of substance use among youth are worrisome given the ample evidence linking early onset to an increased risk of developing a substance use disorder (SUD) and further mental health and psychosocial problems [ 4 , 5 , 6 ]. Youth are also more likely to use more heavily and in riskier ways than adults, making them especially vulnerable to substance use related harms [ 2 , 7 ]. For example, polysubstance use is more common and increasing among youth [ 8 , 9 , 10 ], which has been associated with an increase in youth overdose hospitalizations [ 11 ]. Substance use is also associated with several leading causes of death among youth (e.g., suicide, unintentional injury, violence) [ 12 , 13 ], demonstrating an urgent need to provide effective substance use services to this population.

Current evidence-based recommendations to address substance use issues among youth include a range of comprehensive services, including family-oriented treatments, behavioural therapy, harm reduction services, pharmacological treatments, and long-term recovery services [ 14 , 15 , 16 , 17 ]. Like with adults, these services should be tailored based on young people’s individual needs and circumstances and should consider concurrent mental health disorders which are common among youth who use substances [ 3 , 15 , 18 ]. Merikangas et al. [ 18 ] reported rates of co-occurring mental health disorders as high as 77% among a community sample of youth with a SUD diagnosis. Regardless of precedence, both mental health and SUD can have exacerbating effects on each other if not treated, highlighting the importance of early diagnosis and early access to care [ 19 ]. However, current practices utilizing an integrative approach to diagnose and treat SUD and concurrent mental health disorders have yet to be widely implemented [ 20 , 21 , 22 ]. Further, the current substance use service landscape has been largely designed to treat SUD in adult populations [ 17 ], who often require more intensive treatment compared to youth [ 15 ].

Literature suggests that there are differences between how youth and adults perceive and present substance use issues, suggesting different approaches may be needed to address substance use concerns [ 15 ]. For example, youth have shorter substance use histories and therefore often express fewer negative consequences related to their substance use, which may reduce their perceived need for services [ 15 ]. Further, the normalization of substance use among younger populations and the influence of peers and family members may also play a factor in reducing young people’s ability to recognize problems that arise due to their substance use [ 9 , 23 ]. Confidentiality concerns may also prevent youth from accessing services when needed [ 23 ]. Youth are therefore unlikely to access substance use services before they are in crisis. The 2019 National Survey on Drug Use and Health [ 24 ] reported that only 7.2% of youth ages 12–25 who were identified as needing specialized substance use treatment (defined as substance use treatment received at a hospital (inpatient), rehabilitation facility (inpatient or outpatient), or a mental health centre) accessed appropriate services and that 92% of youth did not feel they needed to access specialized services for substance use. In 2020, the percentage of youth who received specialized treatment dropped to 3.6 and 98% of youth did not perceive the need for it [ 3 ], demonstrating the exacerbating effects the pandemic has had on young people’s service trajectory and experiences.

Although help-seeking behaviours to address mental health concerns among youth have been explored [ 25 , 26 ], few studies have been specifically designed to explore young people’s experiences with substance use services. Existing evidence has largely focused on the experiences of street entrenched youth and youth who specifically use illicit substances (e.g., opioids, heroin, fentanyl) ([ 1 , 27 , 28 , 29 , 30 ], (Marchand K, Fogarty O, Pellat KM, Vig K, Melnychuk J, Katan C, et al: “We need to build a better bridge”: findings from a multi-site qualitative analysis of opportunities for improving opioid treatment services for youth, Under review)), which remains an important research focus, but may not be representative of those who have milder treatment needs. As such, this qualitative study aims to understand how youth perceive and experience substance use services in British Columbia (BC) more broadly. This study also explored young people’s recommendations to improving current models of care to address substance use concerns.

Study design & setting

This study is part of the Building capacity for early intervention: Increasing access to youth-centered, evidence-based substance use and addictions services in BC and Ontario project, which aims to create youth-informed substance use training for peer support workers and other service providers working within an integrated care model. The project is being led by Foundry Central Office and the Youth Wellness Hubs Ontario (YWHO), two youth integrated health service hubs in BC and Ontario respectively. As part of this project, the BC project team conducted a qualitative research study, entitled The Experience Project , to support the development of substance use training. This paper focuses on this BC study, which follows standards for reporting qualitative research (SRQR) [ 31 ].

In May 2020, we applied participatory action research (PAR) methods [ 32 , 33 ], by partnering with 14 youth (under the age of 30) throughout the course of the project, who had lived and/or living experience of substance use and lived in BC. Youth advisors were recruited through social media and targeted outreach (i.e., advisory councils from Indigenous-led organizations and rural and remote communities) in order to engage a diverse group of young people. A full description of our youth engagement methods has been described elsewhere (Turuba R, Irving S, Turnbull H, Howard AM, Amarasekera A, Brockmann V, et al: Practical considerations for engaging youth with lived and/or living experience of substance use as youth advisors and co-researchers, Under review). British Columbia has a population of approximately 4.6 million people, 88% of which reside within a metropolitan area; only 12% live in rural and remote communities across a vast region of land. Nationally, BC has been disproportionately impacted by the opioid crisis, counting 1782 illicit drug overdose deaths in 2021 alone, 84% of which were due to fentanyl poisoning [ 34 ]. Although more than half of BC’s population reside in the Metro Vancouver area, rates of illicit drug overdose deaths are similar across all health regions [ 34 ].

The youth partners formed a project advisory which co-created and revised the research protocol and materials. The initial focus group questions were informed by Foundry’s Clinician Working Group, based on what Foundry clinicians wanted to know about youth who use substances and how best to support them. The subsequent interview guide was developed based on the focus group learnings and debriefing sessions with the project youth advisory (see Data Collection section below). Three advisory members were also hired as youth research assistants to support further research activities including data collection, transcription, and analysis.

Participants

Participants were defined as youth between the ages of 12–24 who had lived and/or living experience of substance use (including alcohol, cannabis, and/or illicit substance use) in their lifetime and lived in BC. Substance use service experience was not a requirement as we wanted to understand young people’s perception of services and barriers to accessing them. Youth were recruited through Foundry’s social media pages and targeted advertisements. Organizations serving youth across the province were contacted about the study and asked to share recruitment adverts with youth clients. Organizations were identified by our youth advisors and Foundry service teams from across the province in order to recruit a geographically diverse sample of youth. This included mental health services, child and family services, social services, crisis centres, youth shelters, harm reduction services, treatment centres, substance use research partners, community centres, friendship centres, schools, and youth advisories. Interested youth contacted the research coordinator (author RT) to confirm their eligibility. Youth under the age of 16 required consent from a parent or legal guardian and gave their assent in order to participate, while youth ages 16–24 consented on their own behalf. Verbal consent was obtained from participants/legal guardians over the phone or Zoom after being read the consent form, prior to the focus group/interview. A hard copy of their consent form was signed by the research coordinator and sent to the participant/legal guardian for their records.

Data collection

Data collection began in November 2020 until April 2021. An initial semi-structured 2-h focus group with 3 youth (ages 16–24) was facilitated by 2 trained research team members, including a youth research assistant with lived/living experience. A peer support worker was also available for further support. The focus group discussion highlighted youth participants’ multifarious experiences with substance use services and the variety of substances used, which led us to change our data collection methods to individual in-depth interviews. Two interview guides were developed based on the focus group learnings to reflect the different range of service experiences. Interviews questions were reviewed and modified with the project youth advisory. Semi-structured interviews were held with 27 youth participants, which were facilitated by 1–2 members of the research team and lasted 30-min to an hour. In an effort to promote a safe and inclusive space for youth to share their experiences, participants were given the option to request a focus group/interview facilitator who identified as a person of color if preferred. The focus group/interviews began with introductions and the development of a community agreement to ensure youth felt safe to share their experiences. Participants were also sent a demographic survey to fill out prior to the focus group/interview, which was voluntary and not a requirement for participating in the qualitative focus group/interview. Due to the COVID-19 pandemic, the discussions were conducted virtually over Zoom. Participants were provided with a $30 or $50 honoraria for taking part in an interview or focus group, respectively.

Data analysis

The focus group and interviews were audio-recorded, transcribed verbatim, and analyzed thematically using NVivo (version 12) following an inductive approach using Braun and Clarke’s six step method [ 35 ]. The research coordinator led the analysis and debriefed regularly with author KM, who has extensive experience with qualitative health research in substance use [ 36 , 37 ]. The transcripts were read multiple times and initial memos were taken. A data driven approach was used to generate verbatim codes and identify themes. Meetings were also held with the youth research assistants to discuss the data and review and refine the themes to strengthen the credibility and validity of the findings, given their role as facilitators and their lived/living experience with substance use. This included selecting supporting quotes to highlight in the manuscript and conference presentations.

We interviewed a total of 30 youth participants. Socio-demographics, substance use patterns and service experiences are listed in Table  1 . Participants’ median age was 21 and primarily identified as women (55.6%) and white/Caucasian (66.7%). Most youth had used multiple substances in their lifetime and over the past 12-months, with alcohol being the most common, followed by marijuana/cannabis, psychedelics, amphetamines (e.g., MDMA, ecstasy) and other stimulants, non-prescription or illicit opioids, depressants, and inhalants. More than half (55.6%) had some post-secondary education and almost all participants were either in school and/or employed (94.4%). Seventy-five percent of participants had experience accessing substance use services.

Three overarching themes of youths’ substance use service perceptions and experiences were identified (see Fig.  1 ). These themes were specific to the phase of service interaction youth described, given that they were all at different phases of their substance use journeys and had different levels of interaction with substance use services. For example, some youth had never accessed substance use services but described their perceptions of services based on the information available to them, while others described specific service interactions they had. The themes were therefore separated by phase of service interaction, starting with 1. Prevention/Early intervention, where youth describe feeling unworthy of support; 2. Service accessibility, where youth encounter many barriers finding relevant services and information; and 3. Service delivery, where youth highlight the importance of meeting them where they are at.

Overarching themes describing young people’s experiences with substance use services

Prevention/early intervention: youth feel unworthy of support

Many youth described feeling unworthy of health and social services, especially when they did not identify as having a SUD. Young people’s perception of SUD typically revolved around the use of “ harder substances”, which participants defined as heroin, crack cocaine, intravenous drugs, and being in crisis situations, such as being homeless or at risk of an overdose. Youth perceived that most services were geared towards this population and therefore not for them. Many described suffering from “ imposter syndrome ” fearing that they would be taking space away from others who needed it more or judged by services providers for accessing services they did not ‘need’:

“...that idea that you could go get help for your drug use without it – without you being some stereotype of an addict, right?... like there’s different severities of addiction, or you could not have an addiction but also still have some sort of issue related to substance use that should be dealt with. I think my biggest fear as a person with anxiety, through all aspects of accessing health care, is that...I am gonna go to the doctor and they’re going to say ‘Oh my god what an idiot, she doesn’t need to be here, I’m just going to give her something to shut her up’.”

Youth described feeling embarrassed or afraid of how people in the community (including friends, family, and service providers), would react to their substance use, not wanting to disappoint anyone or be stereotyped as an “ addict ”, a “ bad person ” or a “ criminal ”. Alternately, some youth were simply not ready to change their substance use behaviours and assumed this would be expected of them if they reached out for support. As one participant described: “A lot of people are under the idea that if they tell people about their problems, they’re just going to ship them off somewhere, and the only form of recovery is abstinence based, which is not at all helpful and way too intimidating.”

Youth also felt that substance use adverts were often irrelevant to their experiences, and that public health messaging was polarizing and unconvincing:

“I feel like maybe there could be a larger conversation about how drugs are fun, and we should stop – like that’s the thing, if everyone pretends that they’re not and that it’s all bad – that’s why people don’t believe you, they don’t believe what you’re saying, right? Drugs are really fun, that’s why they’re dangerous. That’s why people have addiction problems. They’re really fun until they’re not.”

“I think if they had signs that spoke more to the average college student who is maybe getting black out every weekend or popping zanies...instead I’m hearing about a 40-year old who’s been using hard drugs for like 20 years”.

Further, youth described how marijuana/cannabis and stimulant use were often disregarded, which are commonly used among youth and young adults [ 24 ]. For example, participants described the lack of recognition marijuana/cannabis has as being an addictive substance for some people, which invalidated their experiences. Hence, youth struggled to understand when their substance use “hit a threshold of bad enough to bother public health services” and therefore often only reached out for support when in crisis: “What stopped me from accessing services after this initial attempt was me just second-guessing that I actually had an issue ”.

Youth expressed wanting more information about the neuroscience of addiction, and how to differentiate between substance use, abuse, and disorder to reduce feelings of shame and increase their ability to identify when they should reach out for support. Youth also appreciated learning that substances affect people differently, which validated their experiences : “I learned that it’s very different for everyone....and I was like ‘Oh, I didn’t think there was anybody like me’. So it was this amazing thing, learning that I’m not the only high schooler struggling with this.”

Youth were more likely to reach out to friends for support; however, participants reported that the normalization of substance use among youth meant peers often did not take issues seriously and therefore could not be an effective source of support long-term. This also strengthened participants’ self-doubt about whether their issues warranted support from health and social services, often delaying accessing to care.

Service accessibility: youth encounter many barriers finding substance use services and information “zero to 100”

When youth were ready to access services and information for their substance use, they encountered many barriers. Youth expressed not knowing what services and supports were available, or which services they would benefit from: “It seems like through my searching, it’s either you can get counselling, or you can reach out for people – to health professionals to chat with on a hotline. Or it goes from zero to 100 where you have to get admitted to a rehab treatment program.”

Youth expressed a lack of available information about substance use and services and identified a need to reach those who were not already actively accessing services. This included advertising about different service options in schools, coffee shops, bars, and social media. “I would’ve never went up and asked somebody about it [information about substance use services] or looked it up on the internet. That just wasn’t an interest at all.... I feel like it’s got to be in schools where you can just plain and broad see it in the office or have school counsellors talk about it.” Youth also wanted more information provided in schools about the long-term effects of different substances, harm reduction, and how lifestyle choices and emotional regulation can play a role in substance use behaviours.

Having information more widely available was also identified to “ help break the stigma” by increasing people’s awareness about substance use and available supports. Youth often had to research information independently, which had its own barriers. This included not knowing what to look for or where to start, a lack of information about services listed on service websites, requiring further research through phone calls and emails, and a lack of service options available. As one youth described:

“When I saw people talking about their problems on social media...it just made me realize there’s so much other treatments out there that are just very simple. Like, you can honestly learn breathing techniques...or like cognitive behavioural therapy or all these other things...I guess for people to be able to talk about it – people don’t really see what is cognitive behavioural therapy online, you have to search it up yourself. But for some companies being able to express what it is, express what their services are, it would be able to give an idea to some people.”

When trying to access services, youth described encountering other challenges, including long wait times, challenges getting to appointments (e.g., lack of transportation), limited hours of operation, and a lack of services available, including a lack of affordable services, especially for specialized care (e.g., service providers specializing in substance use, LGBTQ2S+, etc.). A lack of referrals between services was also a barrier to receiving care, placing the responsibility on the youth to reconnect with care, which required them to continuously retell their story. Youth also felt like service providers tended to withhold information about service options based on their level of perceived need, which was often inaccurate, and thus, felt they needed to appear more in crisis to receive more options:

“They [service providers] will withhold certain information from you based on what your need is, because I feel like they try to assess people, and they place them on a sliding scale of like, “Who needs one more?” Which is why I didn’t really like that because … a lot of… supports only became available to me after I had been in the hospital, when I feel like I would’ve benefitted from the support even more, like beforehand.”

Service delivery: importance of meeting youth where they are at

For youth who accessed substance use services, their care experiences varied widely depending on their interactions with their service providers, with some who “ genuinely listened ” and “ took their time to make a connection ”, while others were described as “ uncompassionate ” and ‘ don’t really understand what I’m going through’ . Youth wanted to be “ treated with the same respect and dignity like anyone ” but described being treated like children, as though they were being “ lectured by a parent ” or treated as though incapable of making good decisions for themselves. Youth described “ not being taken seriously” and their issues often “ pushed aside” for not fitting a certain “ stereotype ”. For example, one participant expressed: “I was a really good student, I had a really good home life, and everything was, on the outside, literally perfect. And there was kind of that stigma around “You don’t have any problems, why would you have problems?”.” This strengthened youths’ perceptions that substance use services were not for them and prevented them from accessing further support. As one youth described their experience after an overdose:

“When they had asked me my age and I had told them my age, they were like, ‘Oh my goodness. What are you doing?’ And it was just a random nurse. It wasn’t actually anyone trained, but I just felt like, ‘Wow. Maybe I should go home’. Even though I really needed to be there, it was just hard to not get up and run.”

Youth recognized the importance of crisis-oriented services; however they expressed that “the goal should be preventing crisis rather than just helping people when they get there.” This implied taking youth’s concerns at face value, regardless of how service providers perceived their situation:

“Yeah, I guess assuming that people are asking for help because they really need it, and because... people that are good at holding it together, that have extreme privilege, that look like they’re healthy and making it work, they’re still accessing services for a reason and maybe to include more of a preventative mind frame in their model of care in the sense that, this person may be not be at their worst right now, and that’s actually wonderful that they’re here before that happens, so let’s take this seriously and try to work with them before, you know, they look like they need help.”

Having a service provider who took additional steps to support them, such as providing rides, meeting them in more casual settings, and checking in with them regularly, made youth feel genuinely cared for and increased their likelihood of returning. As one youth described:

“I found that they checked in a lot and it made me feel like they actually cared. You know what I mean? It’s not like just because I’m not there in that moment seeing them... Sometimes, I’d get a text or a phone call being like, “Hey, what are you doing? I haven’t you seen in a while.” You know what I mean? And I had a period of time with the counsellor that I was seeing that I literally ignored her calls for 2 months and [she] was still calling me and leaving voice mails. Even though I wasn’t answering and speaking to her, I still felt like, "Wow, she actually gives a shit. She's still trying to communicate and be there even though I’m not putting the same effort back.”

Being able to connect with someone of similar age, gender, and race/ethnicity generally made it easier for youth to relate to their service provider, however this varied and highlighted the importance of providing youth with options to choose from. Youth described being more comfortable talking to someone who could relate to them and had their own lived experiences. Hearing about similar experiences helped youth feel “ normal ” and validated. This came in the form of peer support, friends, support groups, and online forums such as Reddit and Facebook groups. However, some youth described hesitancy accessing peer support services given that peers may not have received any formal substance use training. Meanwhile, some youth assumed their problems would not compare to the lived experiences of peer support workers, and therefore did not see its value. As one youth described “Hearing [about] other people’s problems...[it] reminds me that other people have gone through wars and made it out of wars, which is like, would be comforting for some people, but for me, makes me feel like [I should] “get over it”.”

Youth desired a holistic approach to care, where all aspects of their life were considered rather than solely focusing on their substance use. As one participant describes: “It wasn’t just substance abuse going on for me, so programs kind of like CBT again, it kind of helps you deal with emotions no matter what way you choose to cope...I think just more effort to get to the root of the problem instead of just trying to stop the symptom.” Focusing on accomplishments rather than abstinence was important, as abstinence was not always young people’s objective for accessing services. Setting more attainable and flexible goals also reduced pressures associated with potential relapses, which were often a source of shame. Having providers who rejected the “ all or nothing approach ” made youth feel more confident and comfortable admitting setbacks.

Addressing mental health concerns was also a priority for most youth, many for whom it had been the primary reason for their service visit. “When I started talking about my mental health as a factor in substance abuse rather than two different things...once I figured out what works for me...and that [mental health] was more stable, everything fell into place after that.” Other factors youth wanted service providers to consider included traumatic experiences, parental substance use, school and work stress, social pressures, and relationship issues. Youth also found it helpful when service providers helped them build recovery capital, including helping them meet their basic needs, recommending school and employment programs, and finding activities and healthy habits. As one youth described “We talked about lots of different ways to cope and things that do not necessarily have anything to do with my substance use, such as eating habits and exercising and study habits when I’m in school. Those really impact me. When those are going well, then it is easier for me to heal from my substance use.”

Youth experience many challenges engaging with existing substance use services in BC as they are currently delivered. Participants in our study described their perceptions towards substance use and their experiences trying to navigate services, and they reflected on multi-level barriers associated with accessing information and support. Throughout these discussions, youth described how the crisis-oriented state of the current health care system leaves many of their needs unmet, calling for a more youth-centred and driven preventative and early intervention approach for diverse youth across BC.

In accordance with the Canadian Drugs and Substances Strategy [ 38 ], all three themes demonstrate a clear need to prioritize substance use prevention and early intervention specifically targeting youth. Youth are in the early phase of substance use, which presents a critical opportunity to reduce potential related harms, including SUDs. However, many existing prevention programs and early interventions have shown limited effectiveness in reducing substance use and associated harms among youth [ 39 ], and very few youths receive evidence-based substance use prevention and education [ 40 , 41 ]. Hanley et al. [ 41 ] reported only 35% of schools in the United States used evidence-based programing, and that only 14% used evidence-based strategies as their primary source of programming. Programs like D.A.R.E. are still being used [ 42 ], which focus on the potential negative consequences associated with substance use to deter young people from using, rather than acknowledging their place in society [ 43 , 44 ]. This approach fails to acknowledge that youth often use substances for enjoyment and social benefits, rather than solely responding to distress [ 44 , 45 ], leading to unconvincing public health messages that fail to resonate with youth.

Following the principles of the Canadian Standards for Community-Based Youth Substance Abuse Prevention [ 46 ], substance use prevention and education should be informed by youth to ensure messaging is relevant to their experiences and is effective in providing youth with the tools needed to make informed decisions about substance use. Moffat et al. [ 47 ] reported that involving youth in prevention efforts helped develop public health recommendations about cannabis that were less ambiguous and stimulated productive conversations among youth about the associated risks. A systematic review on the involvement of youth in substance use prevention efforts also reported that these practices increased youths’ knowledge about substance use and supported the development of prevention interventions that were specifically tailored to the needs of the community [ 48 ].

Youth participants also highlighted the benefits of hearing from peer experiences and advocated for more opportunities for peers to talk in schools. Although there has been increasing evidence supporting the effectiveness of peer-led programs in reducing substance use and associated harms, peers remain largely underutilized in substance use prevention efforts [ 49 , 50 ]. These findings underline the importance of reducing stigma and discrimination against people who use substances, so that peers can be actively engaged in programs design and delivery. However, the findings from this study also indicates that youth may worry about peers invalidating their own experiences through self-disclosure, highlighting the different preferences among youth. This also suggests that the purpose of self-disclosure may need to be better conveyed to youth as a tool to help build common humanity and trust rather than the focus of peer roles.

The study also highlighted that preventative efforts are not only important in school settings but should also be applied in other healthcare settings. As youth from this study explained, services should address the motivations for using substances from a holistic perspective rather than trying to treat substance use alone, requiring an individualized approach. Concurrent mental health disorders, including internalizing (e.g., anxiety, depression) and externalizing disorders (e.g., attention deficit hyperactivity disorder, conduct disorder) are common among youth and are often linked to substance use issues, highlighting the importance of diagnosing and treating substance use and mental health concerns simultaneously [ 22 , 51 ]. However, our results emphasized that the current fragmented state of the healthcare system makes this approach challenging for young people and their families. As many youths access the healthcare system for reasons other than substance use concerns, substance use screening and brief interventions need to occur in a variety of health care settings, accompanied with proper staff training. This approach has been proven to be effective in reducing substance use and violence among youth by screening for substance use in schools, emergency departments, and primary care settings among high-risk youth [ 52 ]. However, this study suggests that substance use screening should be applied more broadly and intentionally integrated as youth may not present external signs of problematic substance use and may not feel comfortable bringing it up unless explicitly asked or in crisis. Providing service providers with training on how to provide culturally safe care to youth who use substances is imperative for this approach to be effective and maintain trusting relationships with youth, given young people’s fears of being stigmatized and judged when accessing services [ 53 , 54 ].

There has been increasing evidence supporting the benefits of an integrated approach to address substance use and mental health concerns among youth, which would facilitate the early identification of possible substance use issues [ 21 ]. Although several barriers can impede the implementation of such services (e.g., organizational-level barriers, distinct health financing systems, and having to train providers in multiple disciplines) [ 54 ], this model of care has been successfully implemented in Australia (Headspace) [ 55 ], Ireland (Jigsaw) [ 56 ], and Canada (Foundry, Youth Wellness Hubs Ontario, ACCESS Open Minds, and YouthCAN Impact) [ 21 , 57 ]. This framework has the potential to increase service provider awareness about the complexities associated with substance use and facilitate the delivery of a wide range of services to support recovery, such as primary care, financial assistance, supportive housing, employment, education, and family support. Given youths’ hesitancy to discuss substance use issues with health care providers, this framework should also integrate peer support services to provide youth with a relatable point of contact to discuss issues without fear of judgment or negative consequences [ 21 ]. Although peer support has been associated with positive treatment outcomes [ 58 ], this study suggests that these services need to be better integrated and conveyed to youth who may benefit.

The service accessibility barriers described by youth in this study reflect the undeniable need to increase the service system’s capacity to provide substance use services. These barriers are consistent with other Canadian studies [ 26 , 59 , 60 ], including a study conducted with youth in urban, rural, and remote Ontario [ 59 ] who described a general lack of substance use services available, low service awareness by youth, and a lack of coordination and collaboration between services. Family members in this study validated these challenges as they described trying to navigate the system for and/or with their young person, which was further substantiated by caregivers trying to navigate youth opioid treatment services in BC (Marchand KM, Turuba R, Katan C, Brasset C, Fogarty O, Tallon C, et al: Becoming our young people’s case managers:Caregivers’ experiences, needs, and ideas for improving opioid use treatments for young people using opioids, Under review). Given the increasing harms associated with the opioid crisis [ 7 ], coordinated efforts across all levels of government and multiple sectors are imperative to improving young people’s access to substance use services and create space, not only for youth in dire need of these services, but for those trying to address substance use concerns proactively.

This study had several limitations. Participants were recruited through Foundry social media channels and targeted advertisements, therefore youth who had access to a phone or a computer and followed mental health and/or substance use organizations were more likely to hear about the study. Consequently, our sample mainly included youth who were actively employed and in school and living in stable living environments. Yet, similar accessibility barriers are described by street-entrenched youth in Ontario [ 27 ] and British Columbia [ 30 ], including long wait times and difficulties seeking support due to stigma, as well as negative experiences with abstinent-based approaches, highlighting young people’s desire for holistic care regardless of substance use patterns. Although we tried to recruit through several health and social services across the province, the COVID-19 pandemic likely limited organizations’ capacity to support with local promotion. Further, we were only able to recruit 1 youth between the ages of 12–15, likely due to our inability to recruit through schools and need for parental consent, which hindered our ability to identify potential differences in substance use service perceptions and experiences between adolescents and young adults. Given the important life transitions that occur between adolescence and young adulthood, future studies exploring these differences are important as different prevention and early intervention approaches may be warranted. Exploring how perceptions and experiences differ across communities could also be an important consideration for future research to better understand how geographic location, including urban and rural differences, impacts young peoples’ access to services. Despite these limitations, the findings of this study have important implications in the way we co-design and deliver substance use services to youth. They also have important considerations for policy makers who are considering how to shape substance use services for diverse youth in their jurisdictions.

This study highlights the many challenges youth experience when engaging with substance use services and emphasizes a need for a more preventative approach. The lack of integration and capacity among service providers to provide substance use services implies that youth who have milder treatment needs and/or do not meet the diagnosis criteria of SUD often do not have access to adequate substance use service interventions. Research, health service, and policy efforts should focus on substance use prevention and early interventions to address young people’s concerns before they are in crisis and increase their ability to perceive the need to reach out for support. Moving forward, it is critical that diverse youth and peers with lived and/or living experience be involved in these efforts, including the co-design of new services and evaluation of impact of prevention and early intervention services, including quality improvement efforts. Intentional, sustained investment in youth substance use services will optimize the health outcomes and experiences of young people across BC, transformation that young people can no longer patiently wait for.

Availability of data and materials

The datasets generated and analysed during the current study are not publicly available due to the potential for identifying participants but are available from the corresponding author on reasonable requests.

Abbreviations

British Columbia

Drug Abuse Resistance Education

3,4-Methylenedioxymethamphetamine

• Participatory action research

Substance use disorder

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Acknowledgements

The Experience Project is grateful to have taken place on the ancestral lands of many different Indigenous Nations and Peoples across what we now call British Columbia. We are also very grateful to the Youth4Youth Advisory Committee who supported the research and the participants who shared their experiences and insights with us.

The Experience Project has been made possible through the financial contributions of Health Canada under their Substance Use and Addiction Program. The views herein do not necessarily represent the views of Health Canada. Author Kirsten Marchand is supported by a Michael Smith Foundation for Health Research/Centre for Health Evaluation & Outcome Sciences Research Trainee award and author Skye Barbic by a Scholar grant funded by the Michael Smith Foundation for Health Research.

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Turuba, R., Amarasekera, A., Howard, A.M. et al. A qualitative study exploring how young people perceive and experience substance use services in British Columbia, Canada. Subst Abuse Treat Prev Policy 17 , 43 (2022). https://doi.org/10.1186/s13011-022-00456-4

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• Substance use
• Adolescents
• Young adults
• Service experiences
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Substance Abuse Treatment, Prevention, and Policy

ISSN: 1747-597X

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