Receipt of Recommended Medications and Retention in Care Among Youth with Opioid Use Disorder: A Multistate Study

Abstract

Importance:

Retention in care for individuals with opioid use disorder (OUD) is one of the single greatest predictors of reduced mortality. Although clinical trials support use of OUD medications among adolescents and young adults (“youth”), data on timely receipt of buprenorphine, naltrexone, and methadone and its association with retention in care in real-world treatment settings are lacking.

Objective:

To identify the proportion of youth who receive timely addiction treatment, and to determine whether timely receipt of OUD medications is associated with retention in care.

Design:

Retrospective cohort.

Setting:

Enrollment and complete health insurance claims of 2.4 million Medicaid-enrolled youth from 11 states, January 1, 2014 to December 31, 2015.

Participants:

Youth of age 13–22 years diagnosed with OUD.

Exposures:

Receipt of OUD medication (buprenorphine, naltrexone, or methadone) within three months of diagnosis, compared to receipt of behavioral health services alone.

Main Outcome and Measures:

Retention in care, with attrition defined as ≥60 days without any treatment-related claims.

Results:

Among 4,837 youth diagnosed with OUD, 56.9% were female and 76.0% were non-Hispanic white. Median age was 20 years (interquartile range [IQR], 19–22). Overall, 3,654 (75.5%) youth received any treatment within three months. Most received only behavioral health services (n=2,515; 52.0%), with fewer receiving OUD medications (n=1,139; 23.5%). Only 4.7% (95% confidence interval [CI], 3.1–6.2%) of adolescents <18 years and 24.7% (95% CI, 23.4–26.0%) of young adults ≥18 years received timely OUD medications. Median retention in care among youth who received timely buprenorphine, naltrexone, or methadone was 123 days (IQR, 33–434), 150 days (IQR, 50–670), and 324 days (IQR, 115–670), respectively, compared to 67 days (IQR, 14–206) among youth who received only behavioral health services. Timely receipt of buprenorphine (adjusted hazard ratio [aHR], 0.58; 95% CI, 0.52–0.64), naltrexone (aHR, 0.54; 95% CI, 0.43–0.69), and methadone (aHR, 0.32; 95% CI, 0.22–0.47) were each independently associated with lower attrition from treatment compared to receiving behavioral health services alone.

Conclusions and Relevance:

Timely receipt of buprenorphine, naltrexone, or methadone is associated with greater retention in care among youth with OUD. Strategies to address the underutilization of evidence-based medications for youth are urgently needed.

INTRODUCTION

As the US confronts the opioid crisis, morbidity and mortality for adolescents and young adults (collectively, “youth”) continues to rise. Overdose deaths, hospitalizations for nonfatal overdose, and diagnoses of opioid use disorder (OUD) among youth have increased sharply since the early 2000s.^1–4 Multiple major professional organizations and government bodies recommend providing youth of any age effective treatment as early as possible, including use of OUD medications buprenorphine, naltrexone, or methadone.^5–8 Despite these evidence-based recommendations, youth are only one-tenth as likely as adults to receive medication,^1,9 likely owing to poor availability of pediatric prescribers, provider discomfort with medications, and stigma surrounding medication treatment.^10,11 Even when youth receive medications, it is often only after providers have first exhausted other non-pharmacologic treatment options, such as behavioral health services.^1,9,11

Ensuring timely treatment with OUD medications may be especially important in light of data showing that adults who receive medications are more likely to be retained in addiction treatment.^12–14 Since living with addiction can be a lifelong process that involves cycles of relapse and recovery, maximizing retention in care is a central strategy in the pursuit of decreased mortality among individuals with OUD,.^15,16 In longitudinal cohort studies of adults who have initiated OUD treatment, all-cause mortality when an individual is in treatment is less than half that observed after discontinuing treatment.¹⁵ Since attrition from OUD treatment is greater for youth than it is for adults, strategies to prevent youth from leaving care are urgently needed.^17–20 Small randomized controlled trials (RCTs) show that, under experimental conditions, youth who receive medication treatment are more likely to be retained in treatment up to 12 weeks.^20–22 However, we know of no large studies with follow-up beyond this timeframe, or studies that have used data from real-world treatment settings.

Using an 11-state sample of Medicaid-enrolled youth with OUD, we sought to identify: (1) the frequency with which youth who present to care for OUD receive timely addiction treatment, including behavioral health services and/or OUD medications; and (2) the association between timely receipt of OUD medications and subsequent retention in care. We hypothesized that timely receipt of buprenorphine, naltrexone, or methadone would predict longer retention in addiction treatment.

METHODS

Study Design and Sample

A retrospective cohort study was conducted using the 2014–2015 Truven-IBM Watson Health MarketScan Medicaid Database. These data included 2,490,114 youth of age 13 to 22 years with at least six months of continuous enrollment and all associated inpatient, outpatient, emergency department, behavioral health, and retail prescription drug claims between January 1, 2014 and December 31, 2015. Data were collected from 11 de-identified states representing all census regions of the US. The study was not considered human subjects research by the Boston University School of Medicine Institutional Review Board.

To generate the study sample, the following eligibility criteria were applied to identify all youth initiating a new episode of care for OUD: (i) primary or secondary diagnosis of OUD using International Classification of Diseases, Ninth Revision (ICD-9) codes 304.0x (“Opioid type dependence”) and 304.7x (“Combinations of opioid type drug with any other drug dependence”) in at least one inpatient or emergency department claim or two outpatient claims;^1,23 (ii) prior to diagnosis, a 60-day period without another OUD diagnosis or receipt of buprenorphine, methadone, or naltrexone;^1,23,24 and (iii) at least three months of enrollment data after diagnosis (eFigure 1).^1,23 We defined the date of the first observed OUD diagnosis as the start of the episode of care. Data from the first observed episode of care for OUD were included in analyses; any subsequent episodes of care were excluded.

Variables

Timely addiction treatment was defined as receipt of (i) behavioral health services and/or (ii) OUD medication (buprenorphine, naltrexone, or methadone) within three months of diagnosis. The three-month window was selected based on prior research;^1,23 sensitivity analyses also examined receipt of addiction treatment within one, two, six, nine, and 12 months of diagnosis. Behavioral health services were identified using claims for individual outpatient, group outpatient, intensive outpatient, partial hospitalization, residential, and inpatient treatment based on Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes (eTable 1).^25,26 Receipt of each of the three OUD medications was identified as follows: buprenorphine, using pharmacy claims that included a National Drug Code (NDC) for sublingual buprenorphine or buprenorphine/naloxone;^1,23 methadone, using HCPCS code H0020 (“Methadone administration and/or service”);^27,28 and naltrexone, using pharmacy claims that included an NDC for oral or long-acting injectable naltrexone and using HCPCS code J2315 (“Naltrexone, depot form”) (eTable 2).¹

Retention in care was defined as time from receipt of first addiction treatment (either behavioral health services or OUD medication) to time of treatment discontinuation. An individual was considered to have discontinued treatment if at least 60 days passed without a claim for behavioral health services or OUD medication. The date of treatment discontinuation was defined as the last date of any qualifying claim. Youth were censored if they disenrolled from their insurance plan.

Sociodemographic covariates included: age of diagnosis, sex, race/ethnicity, and Medicaid eligibility (disability or income). Clinical covariates included (at the time of diagnosis or during the preceding three months): pregnancy, depression, anxiety disorder, attention deficit hyperactivity disorder (ADHD), alcohol use disorder, other substance use disorder, acute pain condition, or chronic pain condition based on ICD-9 diagnosis codes (eTable 3).^29–32 Covariates were selected based on their established association with OUD and potential influences on treatment and retention in care.^1,5,6,9,33

Statistical Analysis

Sociodemographic and clinical characteristics associated with receipt of any timely addiction treatment were identified using multivariable logistic regression. Among youth who received timely addiction treatment, a subsequent model examined characteristics associated with receipt of OUD medication (with or without behavioral health services) compared to receipt of behavioral health services alone. Multivariable models included all sociodemographic and clinical covariates. Characteristics of youth receiving each of the three OUD medications were compared using chi-square tests or Fisher’s exact test.

The Kaplan-Meier method was then used to measure retention in care among youth who received timely OUD medications as compared to youth who received only behavioral health services. Since the exposure of interest (timely receipt of OUD medication) was a subset of the outcome (ongoing receipt of behavioral health services and/or OUD medication), a separate Kaplan-Meier curve examined the outcome of retention in behavioral health services alone. Multivariable Cox proportional hazards regression was then used to identify the association of receiving timely OUD medications with retention in care. Some youth had an initial claim for addiction treatment but did not receive any subsequent services, which resulted in violation of the proportional hazards assumption of Cox regression.³⁴ The analysis was therefore limited to youth who had at least one subsequent claim after their initial claim; potential differences in sociodemographic and clinical characteristics between youth with and without subsequent claims were identified using multivariable logistic regression. Models examined retention in care in relation to the initial OUD medication used (buprenorphine, naltrexone, methadone, or none), and were adjusted for receipt of higher levels of behavioral health care (intensive outpatient treatment, partial hospitalization, residential care, or inpatient care),²⁵ as well as all sociodemographic and clinical characteristics.

Analyses were conducted using SAS Version 9.4 (SAS Institute Inc., Cary, NC). All statistical tests were two-sided and considered significant at p<0.05.

RESULTS

Sample

The data included 2,483,250 Medicaid-enrolled youth of age 13–22 years, among whom 4,837 (0.2%) initiated a new episode of care for OUD and thus met sample inclusion criteria. Median age of diagnosis was 20 (interquartile range [IQR], 19–21) years. Youth were 56.9% female and 76.0% non-Hispanic white. Females comprised 40.6% (n=67) of 13- to 15-year-olds with OUD, 41.4% (n=233) of 16- and 17-year-olds with OUD, 55.8% (n=1,030) of 18- to 20-year-olds with OUD; and 62.8% (n=1,422) of 21- and 22-year-olds with OUD. Overall, 28.0% (n=773) of all females were pregnant at the time of OUD diagnosis or in the preceding three months.

Timely Addiction Treatment

Overall, 3,654 (75.5%) youth received any timely addiction treatment (Table 1). The percentage receiving any treatment did not differ significantly between adolescents <18 years (76.1%; 95% confidence interval [CI], 73.0%−79.2%) and young adults ≥18 years (73.7%; 95% CI, 72.4%−75.1%). The majority of the 3,654 youth receiving timely addiction treatment received behavioral health services (n=3,238; 88.6%), either alone or in combination with OUD medications. Of youth receiving any behavioral health services, 872 (26.9%) received intensive outpatient treatment or partial hospitalization, and 1,664 (51.4%) received residential or inpatient care. The remaining 702 (21.7%) received outpatient care only.

Table 1.

Receipt of addiction treatment^a within 3 months of diagnosis among 4,837 Medicaid-enrolled youth with OUD.

		Received Any Timely Treatmenta (N = 3,654)
Characteristic	Total, N	N (%)	Adjustedb OR (95% CI)
Age of diagnosis
21–22 years	2,263	1,550 (68.5)	Reference
18–20 years	1,846	1,479 (80.1)	1.09 (0.94 − 1.26)
16–17 years	563	432 (76.7)	1.24 (0.97 − 1.58)
13–15 years	165	122 (74.0)	0.68 (0.47 − 0.98)
Sex
Male	2,085	1,590 (76.3)	Reference
Female	2,752	2,064 (75.0)	1.02 (0.87 − 1.18)
Race/ethnicity
White non-Hispanic	3,677	2,876 (78.2)	Reference
Black non-Hispanic	388	242 (62.4)	0.51 (0.41 − 0.65)
Hispanic	55	41 (74.5)	0.83 (0.44 − 1.54)
Other	717	495 (69.0)	0.64 (0.54 − 0.77)
Medicaid-eligible due to disability
No	4,571	3,510 (76.8)	Reference
Yes	266	144 (54.1)	0.41 (0.32 − 0.54)
Pregnancyc
No	4,064	3,109 (76.5)	Reference
Yes	773	545 (70.5)	0.73 (0.60 − 0.88)
Depressionc
No	3,227	2,415 (74.8)	Reference
Yes	1,610	1,239 (77.0)	1.28 (1.08 − 1.51)
Anxiety disorderc
No	3,439	2,616 (76.1)	Reference
Yes	1,398	1,038 (74.2)	0.84 (0.71 − 1.00)
Attention deficit hyperactivity disorderc
No	4,244	3,191 (75.2)	Reference
Yes	593	463 (78.1)	1.21 (0.97 − 1.53)
Alcohol use disorderc
No	4,138	3,082 (74.5)	Reference
Yes	699	572 (81.8)	1.43 (1.15 − 1.78)
Other substance use disorderc
No	2,307	1,740 (75.4)	Reference
Yes	2,530	1,914 (75.7)	0.94 (0.82 − 1.08)
Acute pain conditionc
No	3,282	2,505 (76.3)	Reference
Yes	1,555	1,149 (73.9)	1.16 (0.98 − 1.38)
Chronic pain conditionc
No	3,253	2,555 (78.5)	Reference
Yes	1,584	1,099 (69.4)	0.59 (0.50 − 0.69)

^a.Had a claim for either behavioral health services or medication treatment within 3 months of diagnosis

^b.Adjusted for all other covariates listed in the table

^c.At or during the three months prior to receiving OUD diagnosis

Only a minority of youth received timely buprenorphine, naltrexone, or methadone (n=1,139; 23.5%) (Table 2). Overall, 4.7% (95% CI, 3.1–6.2%) of adolescents received OUD medications as compared to 24.7% (95% CI, 23.4–26.0%) of young adults. Most of the 1,139 youth who received medication also received concurrent behavioral health services (n=723; 63.5%). Most youth who received an OUD medication received it within one month of diagnosis (eTable 4).

Table 2.

Type of addiction care received within 3 months of diagnosis among 3,654 Medicaid-enrolled youth who received any treatment for OUD.

Characteristic	Behavioral Health Services Only (N = 2,515), N (%)	Received OUD Medicationa (N = 1,139), N (%)	Adjustedb OR for Receipt of OUD Medication (95% CI)
Age of diagnosis
21–22 years	889 (57.3)	661 (42.7)	Reference
18–20 years	1,035 (70.0)	444 (30.0)	0.78 (0.67 − 0.91)
16–17 years	402 (93.1)	30 (6.9)	0.16 (0.11 − 0.24)
13–15 years	118 (96.7)	4 (3.3)	0.08 (0.03 − 0.23)
Sex
Male	1,175 (73.9)	415 (26.1)	Reference
Female	1,340 (64.9)	724 (35.1)	1.06 (0.90 − 1.26)
Race/ethnicity
White non-Hispanic	1,948 (67.7)	928 (32.3)	Reference
Black non-Hispanic	206 (85.1)	36 (14.9)	0.48 (0.33 − 0.70)
Hispanic	31 (75.6)	10 (24.4)	0.68 (0.32 − 1.45)
Other	330 (66.7)	165 (33.3)	1.01 (0.82 − 1.26)
Medicaid-eligible due to disability
No	2,391 (68.1)	1,119 (31.9)	Reference
Yes	124 (86.1)	20 (13.9)	0.47 (0.28 − 0.77)
Pregnancyc
No	2,219 (71.4)	890 (28.6)	Reference
Yes	296 (54.3)	249 (45.7)	1.62 (1.31 − 2.00)
Depressionc
No	1,562 (64.7)	853 (35.3)	Reference
Yes	953 (76.9)	286 (23.1)	0.81 (0.67 − 0.98)
Anxiety disorderc
No	1,733 (66.2)	883 (33.8)	Reference
Yes	782 (75.3)	256 (24.7)	0.89 (0.72 − 1.09)
Attention deficit hyperactivity disorderc
No	2,135 (66.9)	1,056 (33.1)	Reference
Yes	380 (82.1)	83 (17.9)	0.91 (0.69 − 1.21)
Alcohol use disorderc
No	2,020 (65.5)	1,062 (34.5)	Reference
Yes	495 (86.5)	77 (13.5)	0.43 (0.33 − 0.56)
Other substance use disorderc
No	1,045 (60.1)	695 (39.9)	Reference
Yes	1,470 (76.8)	444 (23.2)	0.60 (0.52 − 0.70)
Acute pain conditionc
No	1,685 (67.3)	820 (32.7)	Reference
Yes	830 (72.2)	319 (27.8)	0.91 (0.74 − 1.10)
Chronic pain conditionc
No	1,755 (68.7)	800 (31.3)	Reference
Yes	760 (69.2)	339 (30.8)	1.30 (1.07 − 1.59)

^a.Includes youth who did and did not receive concurrent behavioral health services

^b.Adjusted for all other covariates listed in the table

^c.At or during the three months prior to receiving OUD diagnosis

Of the 1,139 youth who received timely OUD medications, 936 (82.1%) received buprenorphine, 135 (11.9%) received naltrexone, and 68 (6.0%) received methadone (eTable 5). Adolescents were more likely to receive naltrexone than young adults (35.3% vs. 11.1%; p<0.001 for group difference). No adolescents received methadone.

Retention in Care

The 3,654 youth who received any treatment contributed 13,185 person-months of follow-up. Overall, 2,575 (70.5%) youth discontinued treatment (crude incidence density, 19.5 discontinuing events per 100 person-months). Youth who received timely OUD medications were more likely to be retained in any addiction treatment and more likely to be retained in behavioral health services (Figure 1).

Figure 1:

Retention in care according to timely receipt of OUD medication (buprenorphine, naltrexone, or methadone) within 3 months of diagnosis among youth (A) receiving any addiction treatment, and (B) behavioral health services.

Median retention in care among youth who received only behavioral health services was shorter (67 days; IQR, 14–206) than among youth who received timely buprenorphine (123 days; IQR, 33–434), naltrexone (150 days; IQR, 50–670), or methadone (324 days; IQR, 115–670). Similarly, median duration of behavioral health services among youth who did not receive timely OUD medications was shorter (65 days; IQR, 13–204) than among youth who received timely buprenorphine (108 days; IQR, 34–290), naltrexone (152 days; IQR, 55–670), or methadone (217 days; IQR, 41–354).

Of the 3,654 youth who received any timely addiction treatment, 3,247 (88.9%) met criteria for inclusion in the Cox regression analysis of retention in care (i.e., had at least one subsequent claim for behavioral health services or an OUD medication); the remaining 407 (11.1%) youth were excluded to satisfy the proportional hazards assumption of Cox regression. Included youth were more likely than excluded youth to be pregnant (aOR, 1.55; 95% CI, 1.10–2.18); have received intensive outpatient treatment, partial hospitalization, residential, or inpatient behavioral health services (aOR, 2.39; 95% CI, 1.86–3.08); have received buprenorphine (aOR, 1.35; 95% CI, 1.04–1.74); or have received methadone (aOR, 5.22; 95% CI, 1.26–21.5). Of included youth, 97 (2.9%) youth had claims for detoxification services. Of the 3,238 youth who had an initial behavioral health claim, 2,885 (89.1%) had a subsequent claim.

Compared to youth who received only behavioral health services, youth who received timely buprenorphine, naltrexone, and methadone were 42% (95% CI, 36–48%), 46% (95% CI, 31–57%), and 68% (95% CI, 53–78%) less likely, respectively, to discontinue addiction treatment, and were 27% (95% CI, 18–36%), 43% (95% CI, 27–56%), and 53% (95% CI, 32–67%) less likely, respectively, to discontinue behavioral health services (Table 3).

Table 3.

Retention in care among youth with at least two claims for addiction treatment.

Characteristic	Adjusteda HR (95% CI)
	Attrition from Any Addiction Treatmentb,c (n = 3,247)	Attrition from Behavioral Health Servicesb (n = 2,885)
Sociodemographic characteristics
Age ≥21 years	1.63 (1.45 – 1.83)	1.59 (1.41 – 1.80)
Male sex	1.13 (1.03 – 1.24)	1.13 (1.02 – 1.24)
Non-Hispanic white	1.03 (0.93 – 1.14)	1.05 (0.94 – 1.18)
Medicaid-eligible due to disability	0.63 (0.49 – 0.80)	0.60 (0.46 – 0.78)
Clinical characteristics
Pregnancyd	0.87 (0.75 – 0.99)	0.90 (0.77 – 1.04)
Comorbid behavioral health diagnosis (depression, anxiety, or attention deficit hyperactivity disorder)d	1.04 (0.95 – 1.14)	1.01 (0.92 – 1.11)
Comorbid alcohol or other substance use disorderd	1.02 (0.93 – 1.12)	1.00 (0.91 – 1.10)
Acute or chronic pain conditiond	0.92 (0.84 – 1.01)	0.92 (0.83 – 1.01)
Treatment received
Higher level of behavioral health servicese within 3 months of initiating episode of care	0.94 (0.85 – 1.02)	0.92 (0.83 – 1.01)
Received timely OUD medication within 3 months of diagnosis
No medication	Reference	Reference
Buprenorphine	0.58 (0.52 – 0.64)	0.73 (0.64 – 0.82)
Naltrexone	0.54 (0.43 – 0.69)	0.57 (0.44 – 0.73)
Methadone	0.32 (0.22 – 0.47)	0.47 (0.33 – 0.68)

^a.Multivariable models included all covariates listed in table

^b.Attrition defined as ≥60 days without any claims for services

^c.Includes receipt of any behavioral health services or OUD medications

^d.At or during the three months prior to receiving OUD diagnosis

^e.Includes intensive outpatient treatment, partial hospitalization, residential care, or inpatient care

DISCUSSION

In this multistate study of addiction treatment and retention in care, we found that three-quarters of youth diagnosed with OUD received timely treatment within three months. However, most treatment included behavioral health services only, and fewer than one in four received timely buprenorphine, naltrexone, or methadone. A marked difference was observed by age, with only 4.7% of adolescents receiving an OUD medication, compared to 24.7% of young adults. Receipt of each of the three OUD medications was independently associated with enhanced retention. Youth receiving buprenorphine, naltrexone, and methadone were 42%, 46%, and 68% less likely, respectively, to discontinue treatment during the follow-up period compared to youth who received only behavioral health services.

Retention in care is critical to successful addiction treatment and is increasingly being adopted as a quality measure.^26,35–40 In treatment protocols and clinical trials, eliminating or reducing substance use has traditionally been the primary endpoint.⁴¹ However, the rise in overdose mortality and the recognition that addiction is a chronic, relapsing condition have prompted clinicians, researchers, and policymakers to increasingly focus on retention in care.^6,41 Even when patients do not reduce their substance use, individuals engaged and retained in care can receive harm reduction services and treatment of comorbid medical and psychiatric conditions.^42–44 The advantage of this approach is supported by a recent large meta-analysis, which found that among adults, remaining in treatment is associated with substantially reduced all-cause and overdose mortality.¹⁵

Our findings reveal a critical gap in quality of care for youth, with only a minority who come to medical attention receiving the evidence-based OUD medications recommended by multiple national treatment guidelines.^5–8 Furthermore, this poor deployment of timely OUD medication may place youth at risk for early treatment discontinuation. Our results build on the findings of the only three RCTs of OUD medications among youth conducted to date. These RCTs showed improved treatment outcomes – including short-term enhanced retention in care – among youth who received buprenorphine under experimental conditions.^20–22 We found that not only buprenorphine, but also naltrexone and methadone, when provided in real-world treatment settings, are associated with enhanced retention in care compared to behavioral health services alone. Since clinical follow-up in youth RCTs to date has only ranged from 28 days to 12 weeks,^20,21 our results also suggest that OUD medications may contribute to enhanced retention in care persisting well beyond the timeframes previously studied.

Strategies to enhance access to OUD medications for youth are urgently needed.^1,9,45 Our study sample included only youth who presented to medical attention, a group comprising only a minority of the true population of youth with OUD.⁶ Youth encounter substantial barriers to accessing OUD medications, including insufficient pediatric prescribers, poor familiarity with medications among providers, systemic barriers to accessing methadone, and stigma surrounding medication use.^1,9–11 At many treatment programs, youth may be denied OUD medications due to their younger age, or paradoxically if they are receiving an OUD medication prescribed elsewhere, use of medications may preclude entry into treatment.¹¹ As of January 2018, the Substance Abuse and Mental Health Services Administration Treatment Locator lists 1,765 addiction treatment programs for adolescents or young adults, among which only 37% prescribe OUD medications – and of the remaining programs, 43% deny admission to youth receiving medications prescribed elsewhere.⁴⁶ Our findings suggest that the practice of limiting access to OUD medications for youth may be detrimental for addiction treatment programs, since receipt of medication is associated with enhanced retention in care.

Critically, we observed differences by race in access to OUD medications. In one recent study of youth with private health insurance, black youth were 42% less likely to receive buprenorphine or naltrexone for OUD compared to white youth,¹ which is consistent with our finding that black youth were 59% less likely to receive OUD medications. Importantly, we did not observe any differences in retention in care according to race after controlling for receipt of medications. Therefore, amidst national efforts to expand access to evidence-based treatment, it is crucial that policymakers address the national treatment gap in a way that improves, rather than exacerbates, the disparities that we observed.

There are several limitations to this study. First, due to the observational nature of our study, we are unable to conclusively determine whether the enhanced retention in care we observed was due to the OUD medications themselves, or to the clinical systems in which they were provided. For example, methadone is typically administered in a setting with strict rules and regulations that may promote greater adherence for patients who receive such treatment.⁴⁷ Similarly, provision of evidence-based medications such as buprenorphine or naltrexone could be more common in treatment centers with higher quality standards.^38,39 Second, we found that behavioral health services alone were associated with poorer retention in care than OUD medication treatment, but the behavioral health services we included were diverse. Although we adjusted for level of care, we cannot exclude the possibility that some behavioral health services may have been highly effective but were categorized with less effective behavioral health services.

Third, although we adjusted for sociodemographic and clinical characteristics of youth, we cannot exclude the potential influence of unmeasured confounders. In particular, given the administrative nature of the data, we were unable to adjust for OUD disease severity, and youth with more severe OUD may have been more likely to receive medication as well as added resources to maximize retention. Fourth, we were unable to identify buprenorphine used in detoxification settings, which, when rapidly tapered, may be associated with poorer retention in care compared to longer term buprenorphine maintenance treatment.²⁰ Since only 2.9% of youth received detoxification services in the study sample, this potential limitation is unlikely to have had a substantial impact on the effect sizes we observed.

To our knowledge, this is the first large study to examine receipt of each of the three evidence-based OUD medications among youth. We are also unaware of other large studies that have examined retention in care in relation to timely OUD medication treatment for youth. The finding that medications were provided to only approximately one in four youth presenting for care overall – including only one in 21 adolescents – highlights a crucial potential opportunity to improve OUD care and enhance retention in treatment. As overdose deaths mount among US youth, it is vital that clinicians, researchers and policymakers ensure that access to evidence-based OUD medications for young people remains a national priority.

KEY POINTS.

Question: What percentage of youth receive timely medications for opioid use disorder (OUD), and are youth who receive timely medications more likely to remain in care?

Findings: In this multistate cohort of 4,837 youth with OUD, one in 21 adolescents <18 years and one in four young adults 18–22 years received medication within three months of diagnosis. Youth who received buprenorphine, naltrexone, or methadone were 42%, 46%, and 68% less likely, respectively, to discontinue treatment.

Meaning: Pharmacotherapy, a critical evidence-based intervention to address OUD, is underutilized in youth. Youth who receive timely medications are more likely to remain in care.