Receiving addiction treatment in the US: Do patient demographics, drug of choice, or substance use disorder severity matter?

Engagement, initiation, and retention in medication treatment for opioid use disorder among young adults: A narrative review of challenges and opportunities

INTRODUCTION

Opioid Use Disorder (OUD) is a catastrophic public health problem for young adults (YAs) and their families. While medication for OUD (MOUD) is safe, effective, and recognized as the standard of care, its' uptake and success have been limited in YAs compared to older adults.

METHODS

This narrative review summarizes the existing literature and highlights select studies regarding barriers to YA MOUD, potential explanations for those barriers, and strategies to overcome them.

RESULTS

Barriers are prominent along the entire cascade of care, including: treatment engagement and entry, MOUD initiation, and MOUD retention. Hypothesized explanations for barriers include: developmental vulnerability, inadequate treatment system capacity, stigma against MOUD, among others. Interventions to address barriers include: promotion of family involvement, increasing provider capacity, integration of MOUD into primary care, assertive outreach, and others.

CONCLUSIONS

Integrating an adapted version of family coaching from the Community Reinforcement Approach and Family Training (CRAFT) and other models into YA MOUD treatment serves as an example of an emerging novel practice that holds promise for broadening the funnel of engagement in treatment and initiation of MOUD, and enhancing treatment outcomes. This and other developmentally-informed approaches should be evaluated as part of a high-priority clinical and research agenda for improving OUD treatment for YAs.

Association of copayments with healthcare utilization and expenditures among Medicaid enrollees with a substance use disorder

BACKGROUND

The purpose of this study was to examine the association between copayments and healthcare utilization and expenditures among Medicaid enrollees with substance use disorders.

METHODS

This study used claims data (2020-2021) from a private insurer participating in Arkansas's Medicaid expansion. We compared service utilization and expenditures for enrollees in different Medicaid program structures with varying copayments. Enrollees with incomes above 100 % FPL (N = 10,240) had copayments for substance use treatment services while enrollees below 100 % FPL (N = 2478) did not. Demographic, diagnostic, utilization, and cost information came from claims and enrollment information. The study identified substance use and clinical comorbidities using claims from July through December 2020 and evaluated utilization and costs in 2021. Generalized linear models (GLM) estimated outcomes using single equation and two-part modeling. A gamma distribution and log link were used to model expenditures, and negative binomial models were used to model utilization. A falsification test comparing behavioral health telemedicine utilization, which had no cost sharing in either group, assessed whether differences in the groups may be responsible for observed findings.

RESULTS

Substance use enrollees with copayments were less likely to have a substance use or behavioral health outpatient (-0.04 PP adjusted; p = 0.001) or inpatient visit (-0.04 PP; p = 0.001) relative to their counterparts without copayments, equal to a 17 % reduction in substance use or behavioral health outpatient services and a nearly 50 % reduction in inpatient visits. The reduced utilization among enrollees with a copayment was associated with a significant reduction in total expenses ($954; p = 0.001) and expenses related to substance use or behavioral health services ($532; p = 0.001). For enrollees with at least one behavioral health visit, there were no differences in outpatient or inpatient utilization or expenditures between enrollees with and without copayments. Copayments had no association with non-behavioral health or telemedicine services where neither group had cost sharing.

CONCLUSION

Copayments serve as an initial barrier to substance use treatment, but are not associated with the amount of healthcare utilization conditional on using services. Policy makers and insurers should consider the role of copayments for treatment services among enrollees with substance use disorders in Medicaid programs.

The criminal justice system in alcohol use treatment: a nationwide analysis of racial disparities in treatment referral and completion

BACKGROUND

Alcohol use and the criminal justice (CJ) system have long been integrally connected in the United States and have both disproportionally impacted Communities of Color. Despite this connection, scholarly literature has largely focused on substance use as a whole, and little literature has examined the influence of race on CJ referral to alcohol treatment and treatment outcomes.

METHODS

A total of 749,349 cases from the treatment episodes dataset discharge were used in the current study. A series of ANOVA and logistic regression analyses were conducted to examine the impact of race on (i) likelihood of referral to alcohol treatment by the CJ system and (ii) the association between CJ referral and treatment completion.

RESULTS

Results revealed significant disparities in both who is referred to alcohol treatment by the CJ system and the association of that referral to treatment completion. Notably, American Indian/Alaska Native people were significantly more likely than people of all other races to be referred by the CJ system. However, American Indian/Alaska Native people showed the smallest association between CJ referral and treatment completion.

CONCLUSIONS

Contrary to previous literature, findings showed that referral of and positive association between CJ referral and treatment completion are not equal across people of different races. Taken together, these results highlight continued racial inequities in the role of the CJ system in alcohol treatment and the unique potential for non-CJ-related treatment to best serve people combatting alcohol use disorder.

Cultural considerations for substance use and substance use disorders among Black men

There are complex cultural considerations for understanding, assessing, and treating substance use disorders (SUD) among Black men, from the initiation of substance use through SUD-related outcomes. This narrative review provides insight into some of these factors, including the individual, interpersonal, and community-level risk and protective factors (e.g., family and social roles, religiosity, racism and discrimination, exposure to trauma and adversity) underlying relative risk for substance use and disparities in SUD-related outcomes. This article also highlights the ways that public attitudes and policies related to substance use have contributed to ongoing inequities in SUD treatment access for Black men. Recommendations for clinical research and practice include increasing focus on measurement equivalence, creating pathways for access to community-based and specialty treatment, and providing services that are culturally affirming, relevant, and appropriate. Comprehensive efforts are needed to reduce SUD-related inequities and promote positive well-being among Black men and their communities.

Overall and Telehealth Addiction Treatment Utilization by Age, Race, Ethnicity, and Socioeconomic Status in California After COVID-19 Policy Changes

Importance

Addiction treatment rapidly transitioned to a primarily telehealth modality (telephone and video) during the COVID-19 pandemic, raising concerns about disparities in utilization.

Objective

To examine whether there were differences in overall and telehealth addiction treatment utilization after telehealth policy changes during the COVID-19 pandemic by age, race, ethnicity, and socioeconomic status.

Design, Setting, and Participants

This cohort study examined electronic health record and claims data from Kaiser Permanente Northern California for adults (age ≥18 years) with drug use problems before the COVID-19 pandemic (from March 1, 2019, to December 31, 2019) and during the early phase of the COVID-19 pandemic (March 1, 2020, to December 31, 2020; hereafter referred to as COVID-19 onset). Analyses were conducted between March 2021 and March 2023.

Exposure

The expansion of telehealth services during COVID-19 onset.

Main Outcomes and Measures

Generalized estimating equation models were fit to compare addiction treatment utilization during COVID-19 onset with that before the COVID-19 pandemic. Utilization measures included the Healthcare Effectiveness Data and Information Set of treatment initiation and engagement (including inpatient, outpatient, and telehealth encounters or receipt of medication for opioid use disorder [OUD]), 12-week retention (days in treatment), and OUD pharmacotherapy retention. Telehealth treatment initiation and engagement were also examined. Differences in changes in utilization by age group, race, ethnicity, and socioeconomic status (SES) were examined.

Results

Among the 19 648 participants in the pre-COVID-19 cohort (58.5% male; mean [SD] age, 41.0 [17.5] years), 1.6% were American Indian or Alaska Native; 7.5%, Asian or Pacific Islander; 14.3%, Black; 20.8%, Latino or Hispanic; 53.4%, White; and 2.5%, unknown race. Among the 16 959 participants in the COVID-19 onset cohort (56.5% male; mean [SD] age, 38.9 [16.3] years), 1.6% were American Indian or Alaska Native; 7.4%, Asian or Pacific Islander; 14.6%, Black; 22.2%, Latino or Hispanic; 51.0%, White; and 3.2%, unknown race. Odds of overall treatment initiation increased from before the COVID-19 pandemic to COVID-19 onset for all age, race, ethnicity, and SES subgroups except for patients aged 50 years or older; patients aged 18 to 34 years had the greatest increases (adjusted odds ratio [aOR], 1.31; 95% CI, 1.22-1.40). Odds of telehealth treatment initiation increased for all patient subgroups without variation by race, ethnicity, or SES, although increases were greater for patients aged 18 to 34 years (aOR, 7.17; 95% CI, 6.24-8.24). Odds of overall treatment engagement increased (aOR, 1.13; 95% CI, 1.03-1.24) without variation by patient subgroups. Retention increased by 1.4 days (95% CI, 0.6-2.2 days), and OUD pharmacotherapy retention did not change (adjusted mean difference, -5.2 days; 95% CI, -12.7 to 2.4 days).

Conclusions

In this cohort study of insured adults with drug use problems, there were increases in overall and telehealth addiction treatment utilization after telehealth policies changed during the COVID-19 pandemic. There was no evidence that disparities were exacerbated, and younger adults may have particularly benefited from the transition to telehealth.

Increasing Attendance in Addiction Treatment With Limited Resources: A Narrative Review

Treatment nonattendance frequently compromises client outcomes in psychosocial addiction treatment services. However, there is limited literature on strategies that increase attendance and retention without a significant resource burden on clinician or organization. This review of 13 studies describes strategies that do not financially reward clients for attendance or require more than 1 day of training/supervision to implement. These strategies are as follows: role induction; pretreatment written or verbal contact; short message service and telephone reminders; and contracting, prompting, and reinforcement. There is some evidence that role induction strategies can increase attendance in early treatment, with stronger evidence for a more intensive approach. Short message service and telephone reminders show a consistent positive impact on early attendance, although the relationship may weaken over time and for individuals with more complex needs (ie, high impulsivity). The strategy: contracting, prompting, and reinforcement shows promising findings, particularly in the first 3 months of treatment. There is considerable variability in study designs, interventions, and sample sizes-future research should more precisely identify relationships between outcomes and the "active ingredients" in each strategy. However, preliminary evidence suggests that some low clinician/organization-burden strategies increase treatment attendance and retention. The mechanisms underpinning these strategies may overlap with therapeutic engagement theories (eg, outcome expectations, common-factors model). Although these interventions have small to moderate effect sizes, their relative simplicity and low cost increase the likelihood of being implemented at a broad scale, amplifying their benefits.

COVID-19 pandemic-related changes in utilization of telehealth and treatment overall for alcohol use problems

BACKGROUND

During the COVID-19 pandemic, specialty alcohol treatment transitioned rapidly to telehealth, which may have created barriers for some patients but increased access for others. This study evaluated the impact of the COVID-19 pandemic on alcohol treatment utilization and potential disparities.

METHODS

We analyzed electronic health record and claims data from Kaiser Permanente Northern California for adults with alcohol use problems (alcohol use disorder or unhealthy alcohol use diagnoses) during pre-COVID-19 (March to December 2019, n = 32,806) and COVID-19 onset (March to December 2020, n = 26,763). Generalized estimating equation models were fit to examine pre-COVID-19 to COVID-19 onset changes in alcohol treatment initiation, engagement, and retention (days in treatment). Heterogeneity in pre-COVID-19 to COVID-19 onset changes in treatment utilization by age, race, and ethnicity; neighborhood deprivation index (NDI); and comorbid medical and psychiatric disorders were also examined.

RESULTS

Treatment initiation increased during the COVID-19 onset period (adjusted odds ratio [aOR] = 1.46; 95% CI = 1.41-1.52). The increases in odds of treatment initiation during the COVID-19 onset period compared with the pre-COVID period were largest among patients aged 18-34 years (aOR = 1.59; 95% CI = 1.48-1.71), those without medical conditions (aOR = 1.56; 95% CI = 1.49-1.65), and those without psychiatric disorders (aOR = 1.60; 95% CI = 1.51-1.69). Patients aged 18-34 years (aOR = 5.21; 95% CI = 4.67-5.81), those with the second highest NDIs (aOR = 4.63; 95% CI = 4.12-5.19), and those without medical (aOR = 4.34; 95% CI = 4.06-4.65) or psychiatric comorbidities (aOR = 4.48; 95% CI = 4.11-4.89) had the greatest increases in telehealth treatment initiation from pre-COVID-19 to COVID-19 onset. Treatment engagement and retention also increased during COVID-19 onset, with the greatest increase among patients aged 35-49 years who initiated treatment via telehealth (engagement: aOR = 2.33; 95% CI = 1.91-2.83; retention: adjusted mean difference [aMD] = 3.3 days; 95% CI = 2.6-4.1). We found no significant variation of changes in treatment utilization by race and ethnicity.

CONCLUSIONS

The transition to telehealth in this healthcare system may have attracted subgroups of individuals who have historically underutilized care for alcohol use problems, particularly younger and healthier adults, without exacerbating pre-pandemic racial and ethnic disparities in treatment utilization.

Trends in Alcohol Use Disorder Treatment Utilization and Setting From 2008 to 2017

OBJECTIVE

Little is known about recent trends in treatment for alcohol use disorder. The authors used national data to examine treatment trends among individuals with alcohol use disorder.

METHODS

A sample of nonelderly adults (ages 18-64 years, N=36,707) with alcohol use disorder was identified from the National Survey on Drug Use and Health. Multinomial logistic regression analysis was conducted to examine trends in treatment for alcohol use disorder in 2008-2010, 2011-2013, and 2014-2017 in any medical setting (hospitals, rehabilitation centers, mental health centers, emergency departments, and private doctors' offices), self-help groups only (no medical setting), and no setting (i.e., no treatment). Additional analyses investigated trends in mental health treatment. Regression models adjusted for predisposing, enabling, and need-related characteristics.

RESULTS

Among those with an alcohol use disorder, the percentage who received any treatment was significantly lower in 2011-2013 (5.6%) than in 2008-2010 (6.9%) (p<0.05). In adjusted analyses, the probability of receiving no treatment increased by 1.5 percentage points in 2014-2017 (95% CI=0.5-2.5) compared with the 2008-2010 baseline. Significant declines were observed in the receipt of any treatment in a medical setting (marginal effect [ME]=-1.0%, 95% CI=-2.0 to -0.0) and self-help treatment only (ME=-0.5%, 95% CI=-0.8 to -0.1) in 2014-2017 compared with the baseline period. The probability of receiving any mental health treatment did not change during the study period.

CONCLUSIONS

Among persons with an alcohol use disorder, treatment declined from 2008 to 2017. Future studies should examine the mechanisms that may be responsible for this decline.

Substance use disorder approaches in US primary care clinics with national reputations as workforce innovators

BACKGROUND

Over the last decade, primary care clinics in the United States have responded both to national policies encouraging clinics to support substance use disorders (SUD) service expansion and to regulations aiming to curb the opioid epidemic.

OBJECTIVE

To characterize approaches to SUD service expansion in primary care clinics with national reputations as workforce innovators.

METHODS

Comparative case studies were conducted to characterize different approaches among 12 primary care clinics purposively and iteratively recruited from a national registry of workforce innovators. Observational field notes and qualitative interviews from site visits were coded and analysed to identify and characterize clinic attributes.

RESULTS

Codes describing clinic SUD expansion approaches emerged from our analysis. Clinics were characterized as: avoidant (n = 3), contemplative (n = 5) and responsive (n = 4). Avoidant clinics were resistant to planning SUD service expansion; had no or few on-site behavioural health staff; and lacked on-site medication treatment (previously termed medication-assisted therapy) waivered providers. Contemplative clinics were planning or had partially implemented SUD services; members expressed uncertainties about expansion; had co-located behavioural healthcare providers, but no on-site medication treatment waivered and prescribing providers. Responsive clinics had fully implemented SUD; members used non-judgmental language about SUD services; had both co-located SUD behavioural health staff trained in SUD service provision and waivered medication treatment physicians and/or a coordinated referral pathway.

CONCLUSIONS

Efforts to support SUD service expansion should tailor implementation supports based on specific clinic training and capacity building needs. Future work should inform the adaption of evidence-based practices that are responsive to resource constraints to optimize SUD treatment access.

Contextual challenges in police-assisted substance use referral programs: Impact of COVID-19 and Black Lives Matter movement

Background: Police assisted referral (PAR) programs provide people with substance use disorders (SUD) with a non-arrest treatment pathway, yet systemic barriers, including stigma and access to treatment services, may limit engagement. We sought to understand how the dual contextual challenges of COVID-19 and the Black Lives Matter movement have impacted PAR programs. Methods: Participants completed semi-structured interviews between July and September 2020. Transcribed interviews were analyzed qualitatively to extract emergent codes and themes. Results: Key themes included: adoption and reach of adapted remote services, and barriers to access; and questions on the role of police as health service providers, including police embeddedness in the community. COVID-related social distancing demands undermined police engagement with people with SUD. Treatment providers and advocates reported moderate success in utilizing remote interventions as workarounds. While participants acknowledged the Black Lives Matter movement's criticism of police, many saw continued value in police involvement in substance use interventions, due to their accessibility in communities and capacity for rapid response. Conclusions: PAR programs quickly adapted to a largely remote format, increasing longer-term accessibility. While Black Lives Matter had little direct impact on PAR programs, concerns about police-community relations were acknowledged. Recommendations include further police training to enhance trust and reduce stigma, and wider integration of digitally-based substance use referral options.

A cascade of care for alcohol use disorder: Using 2015-2019 National Survey on Drug Use and Health data to identify gaps in past 12-month care

BACKGROUND

Although effective treatments exist, alcohol use disorder (AUD) is undertreated. We used a cascade of care framework to understand gaps in care for persons with AUD.

METHODS

Using 2015-2019 National Survey on Drug Use and Health data, we evaluated the following steps in the cascade of care: (1) adult prevalence of AUD; (2) proportion of adults with AUD who utilized health care in the past 12 months; (3) proportion with AUD screened about their alcohol use; (4) proportion with AUD who received a brief intervention about their alcohol misuse; (5) proportion with AUD who received information about treatment for alcohol misuse; and (6) proportion with AUD who received treatment. Analyses were stratified by AUD severity.

RESULTS

Of the 214,505 persons included in the sample, the weighted prevalence of AUD was 7.8% (95% CI 7.6-8.0%). Cascades of care showed the majority of individuals with AUD utilized health care in the past 12 months [81.4% (95% CI 80.7-82.1%)] and were screened about alcohol use [69.9% (95% CI 68.9-70.8%)]. However, only a minority of individuals received subsequent steps of care, including 11.6% (95% CI 11.0-12.2%) who reported receiving a brief intervention, 5.1% (95% CI 4.6-5.6%) who were referred to treatment, and 5.8% (95% CI 5.4-6.3%) who received treatment. Similar patterns were observed when cascades of care were stratified by AUD severity.

CONCLUSIONS

Persons with AUD commonly utilize health care and are often screened about alcohol use, but few receive treatment. Healthcare settings-particularly primary care settings-represent a prime opportunity to implement AUD treatment to improve outcomes in this high-risk population.

A Global Pandemic and Substance Use Disorder: Healthcare Professionals' Viewpoints on the Merging of Two Crises

COVID-19 has resulted in extraordinary adversities. Mandates such as distancing and variations to treatment services were implemented to slow transmission of the virus, but created new challenges for persons with Substance Use Disorder (SUD). To better understand this phenomenon, we surveyed healthcare professionals on how they believe COVID-19 has impacted persons with SUD and what needs to occur to effectively treat this vulnerable population. Methods: Attending physicians, residents, nurses, medical and nursing students, and other healthcare professionals were asked to respond to three open-ended questions related to the impact of COVID-19 on persons with SUD. Two independent coders reviewed the comments utilizing constant comparative analysis to develop themes. Results: Common themes of concern were found from the respective participants (n = 205) including: lack of access to treatment, feelings of isolation, negative impacts on mental health, and the possibility of relapse. Healthcare strategies to effectively treat and help persons with SUD included increasing access to treatment including telehealth, development of peer support groups, availability of mental health resources, development of enhanced communication channels between providers and patients, and systematic changes. Conclusion: During the COVID-19 pandemic, overdose deaths have dramatically increased. As the short-term and long-term effects of the pandemic become more apparent, swift and comprehensive responses and policies must be enacted. This study provides insight from healthcare providers on the effects of the pandemic for persons with SUD. Many preexisting issues remain unresolved (e.g. stigma and healthcare disparities), and now the pandemic has presented new obstacles as noted by the providers. The findings from this study provide implications for important discussion regarding the development of strategies for substance use treatment and harm reduction.

Opioid-Induced Hearing Loss and Neonatal Abstinence Syndrome: Clinical Considerations for Audiologists and Recommendations for Future Research

Purpose Over the last two decades, the number of Americans misusing opioids has reached epidemic levels. With such drastic increases in opioid misuse, audiologists are more likely to have patients with opioid-induced hearing loss or neonatal abstinence syndrome (NAS) than in previous years. More attention is needed on how these increases might influence clinical practice and such a discussion could be useful for audiologists. The goal of this article, therefore, is to summarize what is currently known regarding the relationship between opioid misuse and audiology to help guide hearing health care providers (with a particular focus on opioid-induced hearing loss and NAS). This article (a) summarizes the overlap in opioid misuse and hearing loss populations, (b) describes the evidence linking opioid misuse to hearing loss, (c) discusses clinical implications that opioid-induced hearing loss and NAS have for practicing audiologists, and (d) recommends directions for future audiological research on opioid-induced hearing loss and NAS. Conclusions There is considerable overlap between populations at-risk for hearing loss and opioid misuse. Additionally, compelling evidence exists linking opioid misuse to hearing loss, but the specific causal mechanisms remain unclear, indicating a need for additional research. This article attempts to fill a gap in the audiological literature and has the potential to serve as a guide for hearing health care providers to make more informed clinical decisions regarding patients with opioid-induced hearing loss and NAS. Clinicians may wish to consider the concerns raised in this article before intervening with such concerns, especially in the absence of best practice protocols.

A Cascade of Care for Alcohol Use Disorder: Using 2015-2018 National Survey on Drug Use and Health Data to Identify Gaps in Care

BACKGROUND

Although effective treatments exist, alcohol use disorder (AUD) is undertreated. We used a cascade of care framework to understand gaps in care between diagnosis and treatment for persons with AUD.

METHODS

Using 2015-2018 National Survey on Drug Use and Health data, we evaluated the following steps in the cascade of care: 1) prevalence of adults with AUD; 2) proportion of adults who utilized health care in the past 12 months; 3) were screened about alcohol use; 4) received a brief intervention about alcohol misuse; 5) received information about treatment for alcohol misuse; and 6) proportion of persons with AUD who received treatment. Analyses were stratified by AUD severity.

RESULTS

Of the 171,766 persons included in the sample, weighted prevalence of AUD was 7.9% (95% CI 7.7-8.0%). Persons with AUD utilized health care settings at similar rates as those without AUD. Cascades of care showed the majority of individuals with AUD utilized health care and were screened about alcohol use, but the percent who received the subsequent steps of care decreased substantially. For those with severe AUD, 83.5% (CI: 78.3%-88.7%) utilized health care in the past 12 months, 73.5% (CI: 68.1%-78.9%) were screened for alcohol use, 22.7% (CI: 19.4%-26.0%) received a brief intervention, 12.4% (CI: 10%-14.7%) received information about treatment, and 20.5% (CI: 18%-23.1%) were treated for AUD. The greatest decrease in the care continuum occurred from screening to brief intervention and referral to treatment. More persons with severe AUD received treatment than were referred, indicating other pathways to treatment outside of the healthcare system.

CONCLUSIONS

Persons with AUD utilize health care at high rates and are frequently screened about alcohol use, but few receive treatment. Health care settings-particularly primary care settings-represent a prime opportunity to implement pharmacologic treatment for AUD to improve outcomes in this high-risk population.

Individualized approach to primary prevention of substance use disorder: age-related risks

Background

The misuse of legal and illegal substances has led to an increase in substance use disorder (SUD) in the United States. Although primary prevention strategies have been successfully used to target chronic physical diseases, these strategies have been less effective with SUD, given misconceptions of SUD, shortages in behavioral health professionals, and the population-based focus on specific substances. A developmental approach to the identification and primary prevention of SUD that does not fully rely upon behavioral health workers is needed. The purpose of this paper was to examine age related risk factors for developing SUD and present a novel individualized approach to SUD prevention.

Methods

A literature search was conducted to identify risk factors for SUD among children, young adults, adults, and older adults. We searched CINAHL, PsycINFO, and PubMed between the years 1989–2019, and extracted data, analyzing similarities and differences in risk factors across life stages. Broader categories emerged that were used to group the risk factors.

Results

More than 370 articles were found. Across all age groups, risk factors included adverse childhood experiences, trauma, chronic health diseases, environmental factors, family history, social determinants, and grief and loss. Despite the similarities, the contextual factors and life challenges associated with these risks varied according to the various life stages. We proposed an approach to primary prevention of SUD based on risk factors for developing the disease according to different age groups. This approach emphasizes screening, education, and empowerment (SEE), wherein individuals are screened for risk factors according to their age group, and screening results are used to customize interventions in the form of education and empowerment. Given that trained persons, including non-healthcare providers, close to the at-risk individual could conduct the screening and then educate and mentor the individual according to the risk level, the number of people who develop SUD could decrease.

Conclusions

The risk factors for developing SUD vary across the various life stages, which suggests that individualized approaches that do not overtax behavioral healthcare workers are needed. Using SEE may foster early identification and individualized prevention of SUD.