Buprenorphine and Naltrexone Underprescribed for Youth With Opioid Use Disorder

Early pharmacologic intervention for opioid use disorder (OUD) after diagnosis is crucial to prevent relapse and overdose in adolescents and young adults, yet this population often remains undertreated, according to a retrospective cohort study recently published in JAMA Pediatrics.¹ The study identified time trends and sociodemographic characteristics affecting receipt of buprenorphine and naltrexone among commercially insured American youth (ages 13-25 years) who received an OUD diagnosis between 2001 and 2014.

“Understanding which youth receive medications, which medication (buprenorphine or naltrexone) they receive, and how medication dispensing varies by sociodemographic characteristics is critical to inform the expansion of addiction treatment services, which is a national priority in the United States,” the study authors wrote, noting that the youth opioid epidemic in the United States continues to worsen despite increasing recognition of the issue.

Using de-identified information from the OptumInsight database, which includes enrollment records and all medical and pharmacy claims from a large US commercial health insurer, the study authors identified 20,822 OUD diagnoses (0.2%) among the ~9.7 million youth records analyzed. Of the individuals with an OUD diagnosis, 65.8% were male, 82.2% came from a predominantly non-Hispanic white neighborhood, and the mean age at diagnosis was 21.0 years. Diagnosis rates increased throughout the study period, from 0.26 per 100,000 person-years in 2001 to 1.51 per 100,000 person-years in 2014, with young adults aged ≥18 years seeing the greatest increase in diagnosis rates.

Among the patients with OUD, 26.8% (n=5580) received buprenorphine or naltrexone within 6 months of their diagnosis, considered to represent a timely treatment. Rates of medication prescribing increased 10-fold between 2002 and 2009, from 3.0% to 31.8%, but subsequently declined to 27.5% in 2014, despite escalating OUD diagnosis rates.

Factors significantly associated with decreased odds of medication receipt included younger age (<16 years), female sex, nonwhite race (ie, non-Hispanic black race or Hispanic ethnicity), and place of residence in a neighborhood with a low-middle poverty level. When medication was prescribed, buprenorphine was dispensed 8 times more frequently than naltrexone, despite the fact that naltrexone does not require a special prescriber certification. Naltrexone was most likely to be prescribed if patients were younger, female, living in metropolitan areas, or from neighborhoods with higher education levels and lower poverty levels.

Summary and Clinical Applicability

“In the face of a worsening opioid crisis in the United States, strategies to expand the use of pharmacotherapy for adolescents and young adults are greatly needed, and special care is warranted to ensure equitable access for all affected youth to avoid exacerbating health disparities,” the study authors concluded. They urged clinicians and policymakers to carefully consider racial/ethnic and sex disparities when crafting such strategies.

Four study limitations were reported:

An inability to account for the severity of patients’ addiction, which might affect OUD medication prescribing.
A reliance on billing codes, which could underestimate the prevalence of OUD.
An inability to account for youth receiving methadone, although the authors suspect the prevalence to be low.
The inclusion of only commercially insured youth, which could skew OUD diagnosis and medication prescribing rates by not accounting for uninsured patients and those with private health insurance.