Half of Young People With Opioid Use Disorder Never Start Treatment

Nearly 230,000 Americans between 13 and 25 were diagnosed with opioid use disorder between 2016 and 2023 while enrolled in Medicaid, a population that had insurance coverage for the two medications known to keep people alive. When researchers at Mass General Brigham went looking for how many of them were still taking those medications six months later, the number came back at roughly one in 32.

The study, led by Scott Hadland, chief of adolescent and young adult medicine at Mass General for Children, was published Friday in JAMA Network Open. It is the largest national portrait yet of what happens to young people after an opioid use disorder diagnosis, drawn from eight years of Medicaid enrollment files and insurance claims covering 229,847 patients. What it describes is a care system that can get a teenager to a first appointment and then cannot keep her there.

"A little over half of young people initiate treatment at all," Hadland said. "About a third have at least two visits in the first month. About a sixth of those in care receive medication. And only about one in 32 receive medication for 180 days."

A Decade of Claims, and a Widening Gap

Numbers like these are hard to feel. The clinical reality behind them is not. During the years the study covers, poisonings including overdose climbed to the third-leading cause of death for Americans 19 and under, a rise that began around 2019 and accelerated into the early 2020s. Hadland has watched it up close.

"I have had patients die as recently as this past month here in Massachusetts, from overdose," he said. "And so the stakes here are really, really high."

The backdrop is a 2016 policy statement from the American Academy of Pediatrics, which urged doctors to offer medication-assisted treatment — buprenorphine and methadone — to adolescent and young adult patients who needed it. Both drugs are the standard of care for adults, and decades of evidence show they reduce overdose death and improve retention. The pediatric guidance asked clinicians to treat young people the same way.

The follow-through has been partial. More young people receive medication today than in 2016; the study's encouraging headline is that initiation improved, if only modestly. But the share who stayed on medication for six months, already low, appears to have slipped.

Access Improved. Continuity Didn't.

That split is the study's central finding, and it is the part usually lost in coverage of youth addiction. Getting a young person into care and keeping a young person in care are different problems with different obstacles. The first is about screening, referral and workforce. The second is about the structure of a treatment system built for adults, and about the willingness of families and patients to commit to a medication that may be needed for years.

Very few studies focus specifically on young people taking these medications, which means doctors have no definitive answer when a parent asks how long a child will need to stay on buprenorphine or what the long-term effects are. The evidence that does exist points one way: the longer someone stays on medication, the better they do.

That is an awkward message for teenagers, who tend to want a short course and a clean exit. Sivabalaji Kaliamurthy, a child and adolescent psychiatrist who treats addiction, told STAT that kids often do not want to hear it, and that families can be apprehensive about an open-ended commitment.

The Methadone Barrier for Minors

The study's most striking single number concerns methadone. Over the entire eight-year period, fewer than 10 minors in the sample received it. The figure was so small that the researchers suppressed the exact count, reporting it as "not defined" to protect patient privacy.

Two Documented 'Failed' Attempts First

The reason is statutory. Federal law requires minors to have two documented "failed" attempts at recovery without medication before they can begin methadone, and even then many of the specialized clinics that dispense it will not accept patients under 18. Buprenorphine is easier for physicians to prescribe, but recent research has found that few residential treatment facilities for adolescents actually offer it.

"Once you turn 18, a whole bigger field of people are open to helping you," Kaliamurthy said. "And it's just a number if you think about it."

That number, the birthday, determines whether a young person in crisis has access to the medication with the deepest evidence base. For adolescents with opioid use disorder, the country's regulatory framework treats methadone less as a treatment than as a last resort, available only after non-pharmacologic options have been tried and failed.

Who Falls Out of Care

Attrition was not evenly distributed. The study found that Black young people and other racially minoritized groups had worse attrition at every stage of care than their white peers. The authors treat that pattern as a signal about where the system's friction concentrates rather than as anything about patient motivation, and it mirrors what adult treatment data have shown for years.

Geography and insurance type compound it. Because Medicaid covers a large share of young people with opioid use disorder, the study captures a population that in principle has the least to lose financially from seeking care. Even so, only about half ever saw a clinician for the diagnosis, and only about a third had two visits in the first month.

The Pediatric Workforce Problem

Where the study ends, the workforce question begins. Primary care pediatricians and family physicians who already have long relationships with patients and families need to feel comfortable prescribing buprenorphine. That was the AAP's bet in 2016, and it remains the most plausible route to scale.

A Cultural Shift, Slowly

There are signs it is happening. Sarah Bagley, an internist and pediatrician at Boston Medical Center who treats adolescents, told STAT that interest from generalists in understanding and treating opioid use disorder has grown. Hadland said he now fields active demand for the knowledge where he once had to pitch it, and he spent the day the study published traveling to the AAP's annual conference to give a plenary talk on addiction and the potency of the drug supply. The pediatric workforce, he said, is still not keeping up.

Bagley framed the engagement problem plainly. "It doesn't matter how good the treatment we have actually is if we haven't created a clinical environment that is appealing, safe, compassionate, and nonjudgmental," she said.

What the Numbers Don't Say

Claims data can measure who was diagnosed, who filled a prescription and who kept showing up. They cannot say why a 17-year-old stopped, whether a parent talked her out of it, or whether a clinic quietly declined to take her case. The study also cannot speak to quality: buprenorphine prescribed at a dose too low to control cravings looks identical to adequate treatment in a billing record.

The 180-day threshold is a research convention, not a clinical finish line. It is used because retention at six months predicts retention at a year, which in turn predicts the outcomes that matter — survival, employment, stable housing, keeping custody of a child. The study's authors note the limits directly: this is a description of the care that exists, not a test of what would work better.

What This Means for Treatment

Retention is a system property, not a patient defect. A young person who stops coming after two visits has usually hit one of a short list of predictable obstacles: a clinic that will not take minors, a school schedule that conflicts with dosing hours, a parent uneasy about medication, a prescription that has to be renewed in another town, a counselor who is not sure buprenorphine is appropriate for a 16-year-old.

The country has begun to solve the first step, getting a diagnosis into a chart, without building the continuity behind it. That the findings arrive from Medicaid claims rather than a clinical trial matters. This is what ordinary care looks like for the young people with the most coverage and the fewest resources.

Hadland's conclusion is structural. The infrastructure to deliver buprenorphine and methadone is inexpensive to run and already exists; what is missing is the clinical environment and the workforce confidence to keep young patients engaged past the first appointment. Families looking for care can start by asking a program three direct questions: Does it prescribe medication? Does it treat adolescents? How does it handle the handoff to adult services? Those answers separate programs equipped for dual diagnosis care from those that are not.

The alternative is the trajectory the study documents: a diagnosis, a visit or two, and then nothing.