The burden of substance use disorders, including abuse and dependence, among young people in the United States greatly affects local communities. Research shows that substance abuse among young people is related to diminished quality of life and lower life expectancy given that it is linked to higher rates of mental, medical, and behavioral risks, including psychological dysfunction, suicide, HIV and other STDs, vehicle accidents, overdose, violence, crime, and homicide (Eaton et al., 2012). As such, there has been increasing attention given to the treatment of substance use disorders among young people.
As supported by decades of research, the treatment of substance use disorders among young populations is complex. Studies show that despite significant strides in the development of effective treatments for substance use disorders, the information and skills acquired during treatment do not always endure during the initial posttreatment period as relapse remains a concern, averaging 65 to 80 percent. Major risk factors that have contributed to such relapse risk are the brevity of treatment and the lack of participation in treatment aftercare. Research supports that a protective factor of relapse is the engagement and retention in aftercare posttreatment (Burleson, Kaminer, & Burke, 2012).
However, to date, engagement and compliance in aftercare programs is largely inconsistent among substance abusing youth populations. Research shows that few young people attend traditional type aftercare programs like Twelve Step meetings because of the following reasons (Alcoholics Anonymous World Services, 2007; Sussman, 2010; Gonzales, Anglin, Beattie, Ong, & Glik, 2012a):
- Developmental disconnect (i.e., not many age-appropriate programs)
- Stigmatizing nature of addiction from attending such programs
- Inability to connect with the program focus (i.e., disease notions of substance use, total abstinence, and life-long recovery motto)
Increasingly, alternative aftercare approaches have been pursued, including structured home visits; family reunification combined with relapse prevention; recovery behavioral counseling combined with proactive facilitation of age-appropriate Twelve Step programs; community reintegration programs (i.e., behavioral action oriented modeling, role-playing, and shaping); and recovery monitoring or coaching using both in-person and telephone methods (Winters, Botzet, & Fahnhorst, 2011). Collectively, reviews from studies examining the impact of these alternative aftercare approaches with youth are favorable in terms of reducing substance use relapse outcomes after treatment (Kaminer & Godley, 2010). However, despite promise, research indicates that such benefits are largely seen among those who stay in the aftercare programs, as well as those who successfully adhere to aftercare plans.
Given that engagement and participation in aftercare programs among young people remains a challenge, the following practical questions should be considered: What are feasible and engaging aftercare approaches for this segment of the population and how can we effectively deliver aftercare to young people?
The current National Drug Control Strategy represents a comprehensive approach to address substance use disorders among young populations and calls for expanding support for recovery by integrating treatment for substance use disorders into health care (ONDCP, 2014). Increasingly, mobile-based communication technologies (mobile apps and text messaging), have been identified as promising tools within the health care context for delivering aftercare programs promoting the self-management of mental and behavioral health disorders (Cole-Lewis & Kershaw, 2010). The use of text-messaging in particular is an appealing aftercare intervention platform for youth, as US-based market sources show texting to be the primary way youth communicate, exceeding face-to-face contact, email, and voice-phone calls (Banks, 2008).
Market data reveal that the median number of texts sent on a typical day by young people rose from fifty in 2009 to seventy in 2011, identifying them as perpetual texters who send and receive 3,339 texts a month, averaging six texts per waking hour (Nielsen Reports, 2010). To date, studies support that texting serves as a useful approach to help young people self-manage complex health behaviors—diabetes, obesity, HIV-risk, smoking cessation, depression—by reminding, monitoring, educating about positive behavior change, and promoting engagement in social support and recovery-related behaviors (Fjeldsoe, Marshall, & Miller, 2009). The current study sought to address these questions and national call by pilot-testing the utility of a mobile-based aftercare intervention called Project Educating and Supporting Inquisitive Youth in Recovery (ESQYIR) with young people who completed substance abuse treatment.
Project ESQYIR is a twelve-week text messaging aftercare pilot intervention based on health care disease management principles (shown in Figure 1) that aim to help youth self-regulate key areas associated with relapse and engage in recovery related behaviors during the initial three months after specialty treatment.
The focus and content of the mobile components were developed from qualitative input from youth in treatment. Specifically, the self-monitoring texts were developed to question youth about weekly troubles they experienced with regards to core areas associated with relapse after treatment—confidence, stress, negative mood, recovery behaviors, and substance use—that were identified from previous research that explored relapse barriers with substance-abusing youth (Gonzales, Anglin, Beattie, Ong, & Glik, 2012b). Self-monitoring texts were sent daily in the late afternoon, which was supported from formative work that explored the feasibility of using text messaging as a method of continuing care with treatment-involved youth (Gonzales, Anglin, & Glik, 2014). Specifically, we found that youth suggested sending texts during the late afternoon as it would be the most useful time to reach them. Feedback texts were designed as automated messages based on a system of predetermined rules linked to user numeric responses that were grouped into the following message banks: positive appraisal, assertive, motivational, inspirational, coping, and recovery reminders. These feedback areas, and the content for these banks, were identified from formative work that focused on exploring recovery needs and barriers among substance-abusing youth in treatment (Gonzales, Anglin, Glik, & Zavalza, 2013). Reminder texts were sent the same evening and the following morning if monitoring text responses were missed.
At the end of each week, youth received a feedback report displaying their relapse risk based on the monitoring areas with recovery tips focused on drug avoidance activities. Wellness texts were sent daily in the early afternoon to provide a recovery tip of the day focused on social, personal, physical, and emotional areas of wellness. This focus of the aftercare intervention was essential as research with youth in treatment recommended that recovery programs focus on promoting lifestyle change through wellness (Gonzales et al., 2012a). Content for recovery wellness areas was derived from the Centers for Disease Control’s Getting Healthy program and Kaiser’s wellness program specific to youth populations. Educational and social support texts were sent on weekends. The substance abuse education texts were adapted using information from the National Institute on Drug Abuse’s (NIDA’s) educational information and tailored to the youth’s primary substance(s) of abuse which they reported receiving treatment for. Text information specific to social support services and resources were tailored geographically to the youths’ zip-code residence location.
The pilot aftercare Project ESQYIR study recruited a total of eighty youth who were enrolled in a youth treatment program upon completion during January 2012 and July 2013. After following necessary Institutional Review Board protocols of consent and ensuring that youth agreed to study criteria and participation in a twelve-week study, as well as follow-up data collection interviews at three, six, and nine months after discharge from the study. For completion of baseline and follow-up data, youth received $10 in giftcards to Target or Starbucks. Youth were randomized (using an online research randomizer) to receive either a mobile texting aftercare intervention or aftercare as a usual standard control. As such, the control group in this pilot study served as a natural standard of care, consisting of standard aftercare practice used by typical community-based treatment programs.
Youth participants from this pilot study were mainly recruited from outpatient programs, with about a quarter from residential settings. Most youth reported marijuana (55.1 percent) or methamphetamine (29.7 percent) as their primary drugs of choice, followed by cocaine (14.9 percent), heroin (10.8 percent), prescription drugs (5.9 percent), and others including alcohol (4.1 percent). Most of the youth participants were male (73 percent), with the majority indicating either Caucasian (43.2 percent) or Hispanic (37.8 percent) ethnic backgrounds. Other ethnicities reported included: African American (9.5 percent), Asian/Pacific Islanders (8.1 percent), and American Indian (1.4 percent). The average age of the youth was 20.4 years old (SD = 3.5), ranging from fourteen to twenty-six years old. In terms of SES characteristics, the average education completed among the youth was 12.8 years (SD = 2.9), 63.0 percent were not currently enrolled in school, and 62.2 percent were not employed.
For purposes of this article, we examined differences in primary substance use relapse, substance use problem severity, and participation in recovery-related behaviors between the two study conditions from baseline to the three-month follow-up only using the following measures:
- Urine analysis via disposable testing cups with temperature strips
- Self-reported substance use using the Teen-Addiction Severity Index-T-ASI (Kaminer, Bukstein, & Tarter, 1991)
- Problem severity using the Global Appraisal Inventory of Needs-GAIN (Dennis, Titus, White, Unsicker, & Hodgkins, 2003)
- Recovery-directed goal behaviors including participation in Twelve Step social support groups and extracurricular activities using the Brief Addiction Monitor-BAM (Cacciola et al., 2013)
Analyses using longitudinal mixed effects repeated measures showed that youth participants who received the texting aftercare intervention were significantly less likely to relapse to their primary drug (OR = 0.52, p = 0.002) and report significantly less substance use problem severity (β = -0.46, p = .03) from baseline to the three-month follow-up compared to youth participants who were in a standard aftercare as usual group. The effect size for the reduced substance use over time ranged from .28 (one-month), .35 (two-month), .48 (discharge), and .42 (three-month follow-up). We found that youth who relapsed tended to be younger than those who did not relapse at pilot study discharge (19.3 + 3.3 vs. 21.7 + 3.2 years), which was also observed at the three-month follow-up (19.4 + 3.2 vs. 21.6 + 3.1 years). Qualitative results from this pilot study highlighted that the adolescents under eighteen in particular expressed more dislike with the texting program than the young adults who participated and expressed enthusiasm for the mobile program.
Results also showed that youth in the texting aftercare intervention reported higher participation rates in extracurricular recovery behaviors (β = 1.63, p = .03) than youth in the standard aftercare as usual control group, including Twelve Step meetings (mean = 9 days) than control participants (mean = three days) at discharge from the pilot study; however, this effect disappeared at the three-month follow-up. Similarly, we found that youth who were exposed to the texting aftercare intervention engaged in more recovery-related activities at study discharge (mean = eighteen days) compared to the standard aftercare control youth (mean = ten days), which was also the case at the three-month follow-up (mean = fifteen days versus twelve days, respectively).
Results from the twelve-week mobile aftercare pilot study, called Project ESQYIR, suggest that texting provides a feasible and effective way to reduce relapse risk and engage youth in recovery support after substance abuse treatment. Results highlight that without such aftercare exposure, youth continue to experience substance use problems after treatment discharge as highlighted by the increase in substance use problem severity.
Findings from this pilot study offer useful insight into the context of recovery for substance abusing youth. This pilot study raised some issues of feasibility for certain youth groups. Specifically, the adolescent population had some mobile phone access issues during the study which negatively affected recruitment and study retention. During recruitment, several adolescents did not have access to mobile phones; hence we were only able to recruit twenty adolescent participants into the study. We also ran into mobile phone access issues with adolescent participants throughout the study, as a total of four reported that their phone was taken away by parents or had a phone number change. We did not come across such issues with the young adult participants during recruitment to the study or during study implementation as only one had the phone turned off. In light of these issues, we believe there is still much need to address substance use issues among adolescents and young adult populations differently. For instance, given the feasibility of phone access issues, aftercare efforts with adolescents may need to be shifted to different settings (i.e., schools) where the audience is captive, with different efforts (i.e., risk reduction interventions) rather than standard continued aftercare.
For young adults, mobile texting serves as a promising tool that can be used in aftercare to address issues of relapse in a novel way. This pilot study highlights that mobile texting is useful for engaging and retaining young people in such extended care interventions and increasing aftercare compliance specific to the targeted recovery effort. This confirms what we have learned from the extant literature and the use of mHealth programs with youth (Fox & Duggan, 2012). Specifically, mobile behavior change intervention programs offers many opportunities to engage youth in aftercare including increased accessibility, convenience, tailored strategies to engage, real time monitoring and intervention personalization, and minimal resources to maintain (Patrick, Griswold, Raab, & Intille, 2008). Because this mobile-based aftercare program was automated, it required minimal time commitments and effort to maintain. This is a major advantage in the current environment of dwindling resources and competing provider time constraints.
Acknowledgments: This study was supported by grant K01 DA027754 from the National Institute on Drug Abuse (NIDA); however it should be noted that the opinions expressed in this paper are those of the authors and do not represent those of NIDA. The authors acknowledge the contributions of the research team, including Samantha Douglas, Kara Lee, and Christina Zavalza as well as the collaborating treatment program staff.
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Editor’s Note: This article was adapted from an article by the same authors previously published in the Journal of Substance Abuse Treatment (JSAT). This article has been adapted as part of Counselor’s memorandum of agreement with JSAT. The following citation provides the original source of the article:
Gonzales, R., Ang, A., Murphy, D., Glik, D. C., & Anglin, M. D. (2014). Substance use recovery outcomes among a cohort of youth participating in a mobile-based texting aftercare program. Journal of Substance Abuse Treatment, 47(1), 20–6.