Early Medication Treatment and Retention in Care Among Youths With Opioid Use Disorder | Adolescent Medicine | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Receipt of Timely Addiction Treatment and Association of Early Medication Treatment With Retention in Care Among Youths With Opioid Use Disorder

Educational Objective
To understand the relationship between the timing of initiation of opioid addiction therapy and retention in treatment programs.
1 Credit CME
Key Points

Question  What percentage of youths receive medications for opioid use disorder shortly after diagnosis, and are those who receive medications early after diagnosis more likely to remain in care compared with those who receive behavioral treatment only?

Findings  In this multistate cohort of 4837 youths with opioid use disorder, 1 of 21 adolescents younger than 18 years and 1 of 4 young adults aged 18 to 22 years received medication for opioid use disorder within 3 months of diagnosis. Youths who received buprenorphine were 42% less likely to discontinue treatment, those who received naltrexone were 46% less likely to discontinue treatment, and those who received methadone were 68% less likely to discontinue treatment compared with youths who received behavioral treatment only.

Meaning  Pharmacotherapy, a critical evidence-based intervention to address opioid use disorder, may be underused in youths with this disorder; those who receive medications shortly after diagnosis may be more likely to remain in care than youths who receive behavioral health services only.


Importance  Retention in addiction treatment is associated with reduced mortality for individuals with opioid use disorder (OUD). Although clinical trials support use of OUD medications among youths (adolescents and young adults), data on timely receipt of buprenorphine hydrochloride, naltrexone hydrochloride, and methadone hydrochloride and its association with retention in care in real-world treatment settings are lacking.

Objectives  To identify the proportion of youths who received treatment for addiction after diagnosis and to determine whether timely receipt of OUD medications is associated with retention in care.

Design, Setting, and Participants  This retrospective cohort study used enrollment data and complete health insurance claims of 2.4 million youths aged 13 to 22 years from 11 states enrolled in Medicaid from January 1, 2014, to December 31, 2015. Data analysis was performed from August 1, 2017, to March 15, 2018.

Exposures  Receipt of OUD medication (buprenorphine, naltrexone, or methadone) within 3 months of diagnosis of OUD compared with receipt of behavioral health services alone.

Main Outcomes and Measures  Retention in care, with attrition defined as 60 days or more without any treatment-related claims.

Results  Among 4837 youths diagnosed with OUD, 2752 (56.9%) were female and 3677 (76.0%) were non-Hispanic white. Median age was 20 years (interquartile range [IQR], 19-21 years). Overall, 3654 youths (75.5%) received any treatment within 3 months of diagnosis of OUD. Most youths received only behavioral health services (2515 [52.0%]), with fewer receiving OUD medications (1139 [23.5%]). Only 34 of 728 adolescents younger than 18 years (4.7%; 95% CI, 3.1%-6.2%) and 1105 of 4109 young adults age 18 years or older (26.9%; 95% CI, 25.5%-28.2%) received timely OUD medications. Median retention in care among youths who received timely buprenorphine was 123 days (IQR, 33-434 days); naltrexone, 150 days (IQR, 50-670 days); and methadone, 324 days (IQR, 115-670 days) compared with 67 days (IQR, 14-206 days) among youths who received only behavioral health services. Timely receipt of buprenorphine (adjusted hazard ratio, 0.58; 95% CI, 0.52-0.64), naltrexone (adjusted hazard ratio, 0.54; 95% CI, 0.43-0.69), and methadone (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.47) were each independently associated with lower attrition from treatment compared with receipt of behavioral health services alone.

Conclusions and Relevance  Timely receipt of buprenorphine, naltrexone, or methadone was associated with greater retention in care among youths with OUD compared with behavioral treatment only. Strategies to address the underuse of evidence-based medications for youths with OUD are urgently needed.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Accepted for Publication: May 30, 2018.

Corresponding Author: Scott E. Hadland, MD, MPH, MS, Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, 88 E Newton St, Vose Hall, Room 322, Boston, MA 02118 (scott.hadland@bmc.org).

Published Online: September 10, 2018. doi:10.1001/jamapediatrics.2018.2143

Author Contributions: Dr Hadland and Mr Rodean had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Hadland, Bagley, Rodean, Larochelle, Zima.

Acquisition, analysis, or interpretation of data: Hadland, Bagley, Rodean, Silverstein, Levy, Samet, Zima.

Drafting of the manuscript: Hadland, Zima.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Hadland, Rodean, Zima.

Obtained funding: Hadland.

Administrative, technical, or material support: Rodean, Silverstein, Larochelle, Zima.

Supervision: Hadland, Levy, Zima.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Hadland was supported by the Thrasher Research Fund Early Career Award, the Academic Pediatric Association Young Investigator Award, and grant L40 DA042434 from the National Institutes of Health/National Institute on Drug Abuse (NIH/NIDA). Dr Bagley was supported by grant K23 DA044324 from the NIH/NIDA. Dr Silverstein was supported by grant K24 HD081057 from the NIH/Eunice Kennedy Shriver National Institute of Child Health and Human Development. Dr Larochelle was supported by grant K23 DA042168 from the NIH/NIDA. Dr Samet was supported by grant R25 DA13582 from the NIH/NIDA.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Jason Vassy, MD, MPH, SM, Veterans Affairs Boston Healthcare System and Harvard Medical School, reviewed the manuscript. He was not compensated for his contribution.

Hadland  SE, Wharam  JF, Schuster  MA, Zhang  F, Samet  JH, Larochelle  MR.  Trends in receipt of buprenorphine and naltrexone for opioid use disorder among adolescents and young adults, 2001-2014.  JAMA Pediatr. 2017;171(8):747-755. doi:10.1001/jamapediatrics.2017.0745PubMedGoogle ScholarCrossref
Gaither  JR, Leventhal  JM, Ryan  SA, Camenga  DR.  National trends in hospitalizations for opioid poisonings among children and adolescents, 1997 to 2012.  JAMA Pediatr. 2016;170(12):1195-1201. doi:10.1001/jamapediatrics.2016.2154PubMedGoogle ScholarCrossref
Curtin  SC, Tejada-Vera  B, Warner  M. Drug overdose deaths among adolescents aged 15–19 in the United States: 1999-2015. NCHS data brief no 282. Hyattsville, MD: Centers for Disease Control and Prevention; 2017.
Zibbell  JE, Iqbal  K, Patel  RC,  et al; Centers for Disease Control and Prevention (CDC).  Increases in hepatitis C virus infection related to injection drug use among persons aged ≤30 years—Kentucky, Tennessee, Virginia, and West Virginia, 2006-2012.  MMWR Morb Mortal Wkly Rep. 2015;64(17):453-458.PubMedGoogle Scholar
Committee on Substance Use and Prevention.  Medication-assisted treatment of adolescents with opioid use disorders.  Pediatrics. 2016;138(3):e20161893. doi:10.1542/peds.2016-1893PubMedGoogle ScholarCrossref
US Dept of Health and Human Services (HHS) Office of the Surgeon General.  Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: US Department of Health and Human Services; 2016.
Center for Substance Abuse Treatment.  Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction: Treatment Improvement Protocol (TIP) Series, No. 40. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2004.
Kampman  K, Jarvis  M.  American Society of Addiction Medicine (ASAM) national practice guideline for the use of medications in the treatment of addiction involving opioid use.  J Addict Med. 2015;9(5):358-367. doi:10.1097/ADM.0000000000000166PubMedGoogle ScholarCrossref
Feder  KA, Krawczyk  N, Saloner  B.  Medication-assisted treatment for adolescents in specialty treatment for opioid use disorder.  J Adolesc Health. 2017;60(6):747-750. doi:10.1016/j.jadohealth.2016.12.023PubMedGoogle ScholarCrossref
Rosenblatt  RA, Andrilla  CHA, Catlin  M, Larson  EH.  Geographic and specialty distribution of US physicians trained to treat opioid use disorder.  Ann Fam Med. 2015;13(1):23-26. doi:10.1370/afm.1735PubMedGoogle ScholarCrossref
Bagley  SM, Hadland  SE, Carney  BL, Saitz  R.  Addressing stigma in medication treatment of adolescents with opioid use disorder.  J Addict Med. 2017;11(6):415-416. doi:10.1097/ADM.0000000000000348PubMedGoogle ScholarCrossref
Thomas  CP, Fullerton  CA, Kim  M,  et al.  Medication-assisted treatment with buprenorphine: assessing the evidence.  Psychiatr Serv. 2014;65(2):158-170. doi:10.1176/appi.ps.201300256PubMedGoogle ScholarCrossref
Krupitsky  E, Nunes  EV, Ling  W, Illeperuma  A, Gastfriend  DR, Silverman  BL.  Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial.  Lancet. 2011;377(9776):1506-1513. doi:10.1016/S0140-6736(11)60358-9PubMedGoogle ScholarCrossref
Bell  J, Trinh  L, Butler  B, Randall  D, Rubin  G.  Comparing retention in treatment and mortality in people after initial entry to methadone and buprenorphine treatment.  Addiction. 2009;104(7):1193-1200. doi:10.1111/j.1360-0443.2009.02627.xPubMedGoogle ScholarCrossref
Sordo  L, Barrio  G, Bravo  MJ,  et al.  Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies.  BMJ. 2017;357:j1550. doi:10.1136/bmj.j1550PubMedGoogle ScholarCrossref
Dupouy  J, Palmaro  A, Fatséas  M,  et al.  Mortality associated with time in and out of buprenorphine treatment in French office-based general practice: a 7-year cohort study.  Ann Fam Med. 2017;15(4):355-358. doi:10.1370/afm.2098PubMedGoogle ScholarCrossref
Schuman-Olivier  Z, Weiss  RD, Hoeppner  BB, Borodovsky  J, Albanese  MJ.  Emerging adult age status predicts poor buprenorphine treatment retention.  J Subst Abuse Treat. 2014;47(3):202-212. doi:10.1016/j.jsat.2014.04.006PubMedGoogle ScholarCrossref
Weinstein  ZM, Kim  HW, Cheng  DM,  et al.  Long-term retention in office based opioid treatment with buprenorphine.  J Subst Abuse Treat. 2017;74:65-70. doi:10.1016/j.jsat.2016.12.010PubMedGoogle ScholarCrossref
Dreifuss  JA, Griffin  ML, Frost  K,  et al.  Patient characteristics associated with buprenorphine/naloxone treatment outcome for prescription opioid dependence: results from a multisite study.  Drug Alcohol Depend. 2013;131(1-2):112-118. doi:10.1016/j.drugalcdep.2012.12.010PubMedGoogle ScholarCrossref
Marsch  LA, Moore  SK, Borodovsky  JT,  et al.  A randomized controlled trial of buprenorphine taper duration among opioid-dependent adolescents and young adults.  Addiction. 2016;111(8):1406-1415. doi:10.1111/add.13363PubMedGoogle ScholarCrossref
Woody  GE, Poole  SA, Subramaniam  G,  et al.  Extended vs short-term buprenorphine-naloxone for treatment of opioid-addicted youth: a randomized trial.  JAMA. 2008;300(17):2003-2011. doi:10.1001/jama.2008.574PubMedGoogle ScholarCrossref
Marsch  LA, Bickel  WK, Badger  GJ,  et al.  Comparison of pharmacological treatments for opioid-dependent adolescents: a randomized controlled trial.  Arch Gen Psychiatry. 2005;62(10):1157-1164. doi:10.1001/archpsyc.62.10.1157PubMedGoogle ScholarCrossref
Stein  BD, Gordon  AJ, Sorbero  M, Dick  AW, Schuster  J, Farmer  C.  The impact of buprenorphine on treatment of opioid dependence in a Medicaid population: recent service utilization trends in the use of buprenorphine and methadone.  Drug Alcohol Depend. 2012;123(1-3):72-78. doi:10.1016/j.drugalcdep.2011.10.016PubMedGoogle ScholarCrossref
Garnick  DW, Lee  MT, O’Brien  PL,  et al.  The Washington circle engagement performance measures’ association with adolescent treatment outcomes.  Drug Alcohol Depend. 2012;124(3):250-258. doi:10.1016/j.drugalcdep.2012.01.011PubMedGoogle ScholarCrossref
American Society of Addiction Medicine; Mee-Lee  D, ed.  The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. 3rd ed. Chevy Chase, MD: American Society of Addiction Medicine; 2013.
Harris  AHS, Ellerbe  L, Phelps  TE,  et al.  Examining the specification validity of the HEDIS quality measures for substance use disorders.  J Subst Abuse Treat. 2015;53:16-21. doi:10.1016/j.jsat.2015.01.002PubMedGoogle ScholarCrossref
Mohlman  MK, Tanzman  B, Finison  K, Pinette  M, Jones  C.  Impact of medication-assisted treatment for opioid addiction on Medicaid expenditures and health services utilization rates in Vermont.  J Subst Abuse Treat. 2016;67:9-14. doi:10.1016/j.jsat.2016.05.002PubMedGoogle ScholarCrossref
Frazier  W, Cochran  G, Lo-Ciganic  W-H,  et al.  Medication-assisted treatment and opioid use before and after overdose in Pennsylvania Medicaid.  JAMA. 2017;318(8):750-752. doi:10.1001/jama.2017.7818PubMedGoogle ScholarCrossref
Agency for Healthcare Research and Quality. Clinical Classifications Software (CCS) for ICD-9-CM. https://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp#overview. Published March 2017. Accessed August 17, 2017.
Bardach  NS, Coker  TR, Zima  BT,  et al.  Common and costly hospitalizations for pediatric mental health disorders.  Pediatrics. 2014;133(4):602-609. doi:10.1542/peds.2013-3165PubMedGoogle ScholarCrossref
Centers for Disease Control and Prevention. Prescription drug overdose data & statistics: guide to ICD-9-CM and ICD-10 codes related to poisoning and pain. https://www.cdc.gov/drugoverdose/pdf/pdo_guide_to_icd-9-cm_and_icd-10_codes-a.pdf. Revised August 12, 2013. Accessed August 17, 2017.
Pletcher  MJ, Kertesz  SG, Kohn  MA, Gonzales  R.  Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments.  JAMA. 2008;299(1):70-78. doi:10.1001/jama.2007.64PubMedGoogle ScholarCrossref
Grant  BF, Saha  TD, Ruan  WJ,  et al.  Epidemiology of DSM-5 drug use disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions–III.  JAMA Psychiatry. 2016;73(1):39-47. doi:10.1001/jamapsychiatry.2015.2132PubMedGoogle ScholarCrossref
Kleinbaum  DG, Klein  M. Evaluating the proportional hazards assumption. In: Kleinbaum DG, Klein M, eds.  Survival Analysis. New York, NY: Springer; 2012:161-200. doi:10.1007/978-1-4419-6646-9_4
Harris  AHS, Humphreys  K, Bowe  T, Tiet  Q, Finney  JW.  Does meeting the HEDIS substance abuse treatment engagement criterion predict patient outcomes?  J Behav Health Serv Res. 2010;37(1):25-39. doi:10.1007/s11414-008-9142-2PubMedGoogle ScholarCrossref
Watkins  KE, Ober  AJ, Lamp  K,  et al.  Collaborative care for opioid and alcohol use disorders in primary care: the SUMMIT randomized clinical trial.  JAMA Intern Med. 2017;177(10):1480-1488. doi:10.1001/jamainternmed.2017.3947PubMedGoogle ScholarCrossref
Chou  R, Korthuis  PT, Weimer  M,  et al. Medication-assisted treatment models of care for opioid use disorder in primary care settings. Technical brief no. 28. (prepared by the Pacific Northwest Evidence-Based Practice Center under Contract No. 290-2015-00009-I). AHRQ Publication No. 16(17)-EHC0. Rockville, MD: Agency for Healthcare Research and Quality; 2016.
Carroll  KM, Weiss  RD.  The role of behavioral interventions in buprenorphine maintenance treatment: a review.  Am J Psychiatry. 2017;174(8):738-747. doi:10.1176/appi.ajp.2016.16070792PubMedGoogle ScholarCrossref
American Society for Addiction Medicine.  The ASAM Performance Measures For the Addiction Specialist Physician. Chevy Chase, MD: American Society for Addiction Medicine; 2014.
New York State Department of Health. Medicaid redesign team (MRT) behavioral health reform work group final recommendations. https://www.health.ny.gov/health_care/medicaid/redesign/docs/mrt_behavioral_health_reform_recommend.pdf. Published October 15, 2011. Accessed December 27, 2017.
Uchtenhagen  A.  Commentary on Metrebian et al (2015): what is addiction treatment research about? some comments on the secondary outcomes of the Randomized Injectable Opioid Treatment Trial.  Addiction. 2015;110(3):491-493. doi:10.1111/add.12821PubMedGoogle ScholarCrossref
Alford  DP, LaBelle  CT, Kretsch  N,  et al.  Collaborative care of opioid-addicted patients in primary care using buprenorphine: five-year experience.  Arch Intern Med. 2011;171(5):425-431. doi:10.1001/archinternmed.2010.541PubMedGoogle ScholarCrossref
LaBelle  CT, Han  SC, Bergeron  A, Samet  JH.  Office-based opioid treatment with buprenorphine (OBOT-B): statewide implementation of the Massachusetts collaborative care model in community health centers.  J Subst Abuse Treat. 2016;60:6-13. doi:10.1016/j.jsat.2015.06.010PubMedGoogle ScholarCrossref
Wakeman  SE.  Another senseless death—the case for supervised injection facilities.  N Engl J Med. 2017;376(11):1011-1013. doi:10.1056/NEJMp1613651PubMedGoogle ScholarCrossref
Saloner  B, Feder  KA, Krawczyk  N.  Closing the medication-assisted treatment gap for youth with opioid use disorder.  JAMA Pediatr. 2017;171(8):729-731. doi:10.1001/jamapediatrics.2017.1269PubMedGoogle ScholarCrossref
Substance Abuse and Mental Health Services Administration. Map—SAMHSA behavioral health treatment services locator. https://findtreatment.samhsa.gov/locator. Accessed February 26, 2018.
Substance Abuse and Mental Health Services Administration. Wachino  V, Hyde  PS. Coverage of behavioral health services for youth with substance use disorders. https://www.medicaid.gov/federal-policy-guidance/downloads/cib-01-26-2015.pdf. Published January 26, 2015. Accessed December 1, 2017.
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity



My Saved Searches

You currently have no searches saved.

With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right