Denial and self-management: how adolescents and young adults initiate, escalate, problematize, and contemplate disclosure and treatment of opioid use

Adolescents and young adults (AYA) currently bear a significant burden of the opioid-related overdose epidemic in the United States. We aimed to develop a framework of how AYA in Indiana progress through initiation, escalation, and problematization of opioid use and contemplation of use disclosure/treatment initiation. We recruited AYA in Indiana with past-12-month non-prescribed opioid use (n=6, mean age 17.6) through a university-based behavioral research registry, community referrals, and respondent-driven sampling. We recruited Indiana community clinical (n=3) and non-clinical (n=11) key informants (including diverse backgrounds including homeless outreach workers, child protective services, police, and peer recovery coaches) with professional exposure to AYA with non-prescribed opioid use through community referrals, networking, and site visits. We conducted video-recorded in-depth semi-structured interviews of participants using Zoom. The AYA and key informant interview guides included open-ended questions asking participants to describe experiences of AYA using opioids, disclosing use, and learning about, imagining, and contemplating/seeking treatment. We created a framework of AYA opioid trajectories from interview transcripts using constructivist grounded theory methods utilizing NVivo (1.6.2). AYA experience common sequential 6-point trajectories around opioid use: 1) Opioid initiation. AYA initiate use secondary to peer influence in situations of curiosity and impulsivity, generally after other polysubstance use. 2) Use escalation. Intermittent use becomes more frequent and in increasing doses, exacerbated by unstructured time, denial of use as a problem, and invincibility. 3) Problematic use coupled with inertia. AYA begin to acknowledge their use is a problem in the setting of withdrawal symptoms, cravings, and excessive spending but continue to experience inertia and a lack of motivation to change, sometimes even after an overdose. 4) Doing it on my own. Exposure to crisis turning points and/or external consequences motivate AYA to desire change. They then turn to self-management because of the perception of treatment for opioid use as inpatient, restrictive, disruptive, and isolating, described as unnecessary/stigmatizing for their minimized use. AYA maintain secrecy during self-management, avoiding disclosure due to fears of stigma, disappointing adults, and school/legal consequences. 5) Decision to disclose use. AYA disclose use when there is an available trustworthy, non-judgmental listener, often when self-management fails or as a confession to a relationship partner. Trust to disclose is facilitated by authenticity and the caring nature of the listener, as well as normalization, self-disclosure, and vulnerability. 6) Movement toward treatment initiation. Treatment is initiated only after overcoming numerous barriers like lack of insurance, material resources, and available care. Progress toward treatment initiation is curtailed by caregivers’ and other adults’ lack of knowledge of available treatment paradigms and pathways to care. Further public awareness and AYA-directed educational campaigns around evidence-based opioid use treatment paradigms, coupled with provider education and training, may enhance uptake of and access to successful treatment among AYA with opioid use. Clinicians, educators, and community agency workers can utilize this framework to establish themselves as trustworthy listeners, facilitating productive discussions with AYA even at early stages of opioid use.