An unprecedented number of adolescents were identified as having an opioid use disorder (OUD) in 2021.1 Residential treatment facilities are part of the American Society for Addiction Medicine’s levels of care for adolescents with OUD,2 yet little is known about treatment facility practices. Buprenorphine is the only OUD treatment approved by the US Food and Drug Administration for use in adolescents aged 16 years or older; the Society for Adolescent Health and Medicine states that medications for OUD, including buprenorphine, should be offered with behavior therapy (eg, family-based therapy) to all adolescents with OUD, although adolescents who do not pursue behavior therapy should not be denied medications for OUD.3 Despite this, buprenorphine treatment is limited among adolescents.4 This study surveyed US adolescent residential addiction treatment facilities (hereafter referred to as facilities) to assess treatments used for adolescents younger than 18 years seeking OUD treatment.
We adapted a “secret shopper” approach to simulate calls inquiring about treatment to all identified facilities in the US from October to December 2022.5 We identified facilities using the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Locator and SpyFu, a website that captures Google advertising data. We called as the aunt or uncle of a 16-year-old with a recent nonfatal fentanyl overdose to make calls more plausible if we did not have all requested information about the adolescent. Four investigators (C.K., N.S., D.B., and P.B.) called facilities in random order and asked to speak to someone about residential treatment. We called facilities up to 7 times on different days. We asked specific questions about buprenorphine use and open-ended questions about other available treatments (Supplement 1). Data were analyzed using StataIC version 16.1 (StataCorp). The Oregon Health & Science University institutional review board deemed this study non–human subject research.
We identified 354 facilities, reached 327 (92.4%), and confirmed that 160 (45.2%) provided residential treatment to patients younger than 18 years (Figure). Of 160 facilities, 39 (24.4%) offered buprenorphine, including through partnership with outside clinicians, which varied by US region (18.0% in the West to 40.0% in the Northeast) (Table). Twelve facilities (7.5%) offered buprenorphine initiation but discontinued before discharge, 17 (10.6%) initiated buprenorphine and offered ongoing treatment, and 3 (1.9%) offered buprenorphine for ongoing treatment only. Twelve facilities (7.5%) offered buprenorphine to adolescents younger than 16 years. Four facilities (2.5%) offered long-acting injectable buprenorphine.
Among the 121 facilities that did not offer buprenorphine or were unsure, 57 (47.1%) indicated that adolescents who were prescribed buprenorphine by their own clinician could continue receiving it, at least temporarily, although some facilities indicated they would discontinue it before discharge, and 27 (22.3%) required adolescents to not be receiving buprenorphine at admission. Sixty-three facilities (39.4%) indicated that adolescents could undergo on-site withdrawal. Of those facilities, 18 (28.6%) offered buprenorphine and some did not offer any medication adjuncts.
Of 160 facilities, 140 (87.5%) had someone available who could prescribe medications for psychiatric comorbidities (eg, depression). Overall, 124 (77.5%) had naloxone on site, 24 (15.0%) did not, and 11 (6.9%) were unsure.
Family members were included in adolescent treatment in 86 facilities (53.8%). Leading approaches for adolescent treatment included mutual help frameworks (eg, 12-step program; n = 59 [36.9%]), cognitive behavior therapy (n = 52 [32.5%]), community reinforcement/adolescent community approach (n = 44 [27.5%]), art therapy (n = 40 [25.0%]), and equine therapy (n = 40 [25.0%]) (Table).
In contrast to the standard of care,2 only 1 in 4 US facilities offered buprenorphine and 1 in 8 offered buprenorphine for ongoing treatment. By comparison, nearly two-thirds of adult residential facilities offer buprenorphine.5 The average parent would need to call 9 facilities on the SAMHSA Treatment Locator list to find one that offered buprenorphine and 29 to find one for an adolescent younger than 16 years.
Therapeutic programming across facilities was unstandardized. Only half of facilities reported including families in treatment. No other evidence-based treatment was used by more than one-third of facilities. Despite limited evidence of its efficacy, equine therapy was more common than buprenorphine use.6
Limitations include that 27 facilities were unreachable by phone and that other facilities not identified may have been excluded. Therapy types, other than buprenorphine, were not explicitly elicited during calls; this may have led to underreporting of other therapies.
Accepted for Publication: March 29, 2023.
Correction: This article was corrected on July 7, 2023, to fix the Conflict of Interest Disclosures and Funding/Support in the acknowledgments section.
Corresponding Author: Caroline King, PhD, MPH, Oregon Health & Science University, 3181 Sam Jackson Park Rd, Portland, OR 97212 (kingca@ohsu.edu).
Author Contributions: Dr King had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: King, Beetham, Englander, Hadland, Bagley, Korthuis.
Acquisition, analysis, or interpretation of data: King, Beetham, Smith, Hadland, Bagley, Korthuis.
Drafting of the manuscript: King, Englander.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: King.
Obtained funding: King, Korthuis.
Administrative, technical, or material support: King, Beetham, Smith.
Supervision: King, Englander, Korthuis.
Conflict of Interest Disclosures: Dr Hadland reported having consulting agreements with Boston University School of Medicine and the American Academy of Pediatrics. Dr Bagley reported being a paid speaker for the Opioid Response Network. No other disclosures were reported.
Funding/Support: Dr Hadland reported receiving grants from the National Institute on Drug Abuse/National Institutes of Health and the Centers for Disease Control and Prevention. Dr Bagley reported receiving grants from the National Institute on Drug Abuse/National Institutes of Health and Centers for Disease Control and Prevention. Dr Korthuis reported receiving grants from the National Institute on Drug Abuse/National Institutes of Health. Dr Englander reported receiving grants from the National Institute on Drug Abuse/National Institutes of Health (UG1DA015815). Dr King received support from the Oregon Health & Science University Addiction Medicine Research Seed Grant Program. Dr Beetham received support from the Agency for Healthcare Research and Quality (T32HS017589). This publication was made possible with support from the Oregon Clinical and Translational Research Institute (grant UL1TR002369) from the National Center for Research Resources, a component of the National Institutes of Health, and the National Institutes of Health Roadmap for Medical Research.
Role of the Funder/Sponsor: The funders 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.
Data Sharing Statement: See Supplement 2.
Additional Contributions: We thank Olivia Rae Wright, MD (University of Washington), for sharing her experience as a physician who treats adolescents with OUD in the community setting, which enhanced the study design and manuscript. We would also like to thank Ryan Cook, PhD, MSPH (Oregon Health & Science University), for his statistical expertise, and Patrick Brown, MD (Oregon Health & Science University), and Dana Button, MD (Oregon Health & Science University), for their assistance with protocol development and data collection. These individuals did not receive compensation for this work.