Why are teens not being treated for opioid use disorders?

As the prevalence of opioid use disorders among teenagers and young adults increases, the amount of medications dispensed to treat those disorders is dropping, according to a new report published in JAMA Pediatrics.

Only about a quarter of teenagers and young adults are treated with pharmacotherapy, and there are significant disparities across gender, age, and ethnicities in regard to trends in dispensing.

Deaths from drug overdoses tripled from 2000 to 2014, with the majority rooted in prescription opioid and heroin use. Opioid use disorder (OUD) often starts in adolescence and young adulthood, and early intervention is key to heading off a cascade into lifelong addiction. No previous studies have examined to what extent adolescents and young adults struggling with OUDs receive pharmacologic support including medications such as buprenorphine and naltrexone.

The study was conducted using data on 9.7 million teenagers and young adults aged 13 to 25 years collected from a national commercial insurance database from 2001 through 2014. Researchers identified which individuals in the study group received either buprenorphine or naltrexone in the first 6 months following diagnosis of an OUD.

Of the 20,882 teenagers and adolescents in the study identified with an OUD, 65.8% were male; 82.2% were non-Hispanic white; and the mean age was 21 years at first diagnosis.

Researchers found that the diagnosis rate of OUDs among adolescents and young adults increased 6-fold over the study period, and medication receipt increased 10-fold, from 3% in 2002 to 31.8% in 2009, then dropping to 27.5% by 2014. A little more than a quarter-26.8%-of the teenagers and young adults studied were dispensed a pharmacologic treatment within 6 months of diagnosis, according to the report. Most-89.2%-were prescribed buprenorphine, while 10.8% were given naltrexone. Age played a role, too, and researchers found that younger patients were less likely to receive medication to treat OUD, with just 1.4% of 13- to 15-year-olds receiving medication compared with 9.7% of 16- to 17-year-olds; 22% of 18- to 20-year-olds; and 30.5% of 21- to 25-year-olds.

The study found that teenagers aged younger than 16 years were the least likely to be prescribed medication to treat OUD, or receive treatment in general. Researchers note that fewer than 1 in 3 specialty drug treatment programs in the country enroll adolescents, and pediatricians who prescribe buprenorphine are rare.

Females were also less likely to receive medications, with 20.3% of females receiving medication compared with 24.4% of males. Racial disparities were identified as well, with 14.8% of non-Hispanic blacks receiving medication compared with 20% of Hispanic adolescents and young adults and 23.1% of non-Hispanic whites.

The treatment gap among Hispanic and black teenagers and young adults is significant. Researchers found that even with appropriate insurance coverage, Hispanic and black adolescents and young adults are less likely than their white counterparts to receive medications for OUDs, and treatment rates in general were significantly lower, with 6.9% of blacks and 8.5% of Hispanics receiving treatment compared with 10.7% of whites. When treatment is offered, these populations also have barriers to completion, with only half of black and Hispanic teenagers and young adults completing treatment programs.

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The report also brings attention to the disturbing trend of a decrease in pharmacotherapy to treat OUD at the same time that opioid use diagnoses and health insurance coverage under the Affordable Care Act (ACA) were increasing.

“Both of these forces likely resulted in an expansion in the number of youth in OUD care, which may not have been accompanied by improved access to medications,” the study notes. “National data preceding the ACA suggest that those with commercial insurance are less likely to receive addiction treatment (with or without pharmacotherapy) than are those with public insurance. In the face of changing national health insurance policies, further studies are needed to understand differences in diagnosis and treatment between commercially and publicly insured adolescents and young adults with OUD.”

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The key to increasing the number of pediatricians who can and will offer pharmacologic intervention for OUDs is understanding current dispensing trends. In terms of which medications were dispensed, researchers found that buprenorphine was dispensed 8 times more often than naltrexone, and naltrexone was used most often in younger and female patients; for those in metropolitan areas; and for patients in higher education or lower poverty level neighborhoods.

Buprenorphine was approved for use in teenagers in 2003, whereas naltrexone has been approved for use in patients aged 18 years and older since 1984. The medications are easier to use than methadone because they can be offered in the primary care setting, but there is a widespread shortage of physicians who have completed the waiver certification needed to prescribe buprenorphine-and only 1% of those who have the certification are pediatricians.

The American Academy of Pediatrics didn’t issue a statement in support of pharmacotherapy to treat OUDs in teenagers and young adults until August 2016, which may have contributed to the slow uptake of medication-driven treatment by pediatricians, according to the report.

Scott Hadland, MD, MPH, MS, pediatrician and addiction specialist at Boston Medical Center in Massachusetts, and lead author, says he hopes medical treatment of OUD will be very carefully discussed between patients, family members, and physicians.

“Medications have been shown to treat withdrawal and cravings, and reduce relapse, and are an extremely effective component of treatment for OUD. Offering medications early in the life course of addiction-particularly to patients with severe addiction-is critical to prevent downstream harm from addiction,” Hadland says. “We need to ensure that pediatricians, and other providers who care for adolescents and young adults, feel comfortable addressing addiction just as they do other pediatric problems, because as our data show, addiction is a pediatric onset condition.”

Hadland says he hopes the medical community will continue to work to ensure that as treatment is expanded for young people with OUD that it is done in a way that does not exacerbate the treatment inequities observed in the report.

“My concern is that although all the teenagers and young adults we studied had access to health insurance, they may not have had equal access to high-quality, evidence-based addiction treatment,” Hadland says. “Specifically, there may have been poorer access to providers who are proficient in addiction treatment. Denial of care or clinician bias may have also contributed.”

Hadland says he was particularly surprised at how few young people with OUDs received medications.

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“Only 1 in 4 received a medication, and the proportion was far lower among younger individuals-most notably the adolescents in our study. In the face of one of the nation’s most pressing public health problems, the opioid crisis, the treatment gap is vast,” Hadland says. “If the United States is to effectively address the opioid crisis, it needs to be addressing addiction upstream, early in the life course.”

The level of the disparities across populations affected by addiction also were unexpected, he says.

“We were surprised by gender, racial, and ethnic disparities in receipt of medications. Females were 21% less likely than males to receive a medication. Black adolescents and young adults were 42% less likely than their white counterparts to receive a medication, and Hispanic teenagers and young adults were 17% less likely than their non-Hispanic white counterparts to receive a medication,” Hadland says. “This again highlights the importance of ensuring that as we work to address the treatment gap, we do so in a way that improves, rather than worsens, the disparities we observed.” Hadland says he is hopeful his report will serve as a wakeup call to physicians as they come in contact with patients with OUDs.

“My hope is that the pediatric workforce will recognize how far short we have fallen in addressing one of this nation’s most pressing public health concerns,” Hadland says. “Since many adolescents and young adults with OUD may have no other contact with a health professional other than with their pediatrician, it is now incumbent on the pediatric workforce to become proficient in screening for OUD, and to gain basic skills in treating addiction, including through the use of medications such as buprenorphine and naltrexone.”