ABSTRACT
Emerging adults (EAs; ages 18-25) have higher rates of substance use disorders than any other age
group and have been hit particularly hard by the opioid crisis. EAs also demonstrate poor adherence to
healthcare regimens associated with substance use services, with higher dropout rates and lower service
utilization than any other age group. This poor adherence leads to devastating outcomes, including continued
substance use, incarceration, and overdose. In addition, high dropout rates contribute to skyrocketing costs to
treatment systems as a result of more acute service needs, expensive service utilization, and long waitlists. Cost-
effective strategies that are aimed at improving treatment adherence to substance use services and tailored to
meet the unique developmental needs of EAs are an imminent need. Further, little is known about risk factors
for dropout specific to this age group, hindering effective system responses to this significant problem.
At the same time, substance use service systems are increasingly using peer recovery supports (PRS;
i.e., paraprofessionals who have “lived experience” with substance use problems) to bolster treatment outcomes
without incurring considerable additional costs. However, services delivered by PRS have not been tailored
specifically to reduce EA dropout, and few have been rigorously tested at all. The current study will evaluate an
innovative EA-specific dropout prevention enhancement to usual treatment services, delivered by PRS in
community-based substance use treatment clinics (Aim 1). We will employ a stepped-wedge cluster randomized
design, resulting in each clinic having a longitudinal usual services phase and a longitudinal dropout prevention
phase. The two phases will be compared on rates of EA dropout and service utilization using objective data from
clinical charts. We will also evaluate cost-effectiveness and employ a qualitative approach to understanding the
varied financial factors that influence potential sustainability of such a dropout prevention enhancement (Aim 2).
In addition, we will leverage the stepped-wedge design to investigate factors purported to predict EA dropout
from substance use services and preliminarily investigate whether factors moderate dropout prevention (Aim 3).
These key variables include executive functioning, identity formation, motivation, substance use severity,
comorbid mental health symptoms, social support, and treatment-related cognitions. In particular, this study will
be the first to use a comprehensive assessment of executive functioning, including event-related potential and
behavioral data collected during computerized tasks, as a predictor of dropout from substance use services.
Results will greatly advance our knowledge of EA dropout and a potential enhancement specifically aimed at
reducing EA dropout, which has high potential to be cost-effective and easily disseminated. Answering these
key questions is a crucial next step in improving patient adherence for EAs in substance use services and,
ultimately, promoting positive outcomes for this high-risk group.
