Abstract
Importance
One in 100 adolescents and young adults (hereafter “youths”) in the US has an opioid use disorder (OUD), yet little is known about the extent to which they receive care aligned with national quality measures.
Objective
To evaluate progression through the OUD cascade of care (COC) among Medicaid-enrolled youths, with key stages of treatment aligned with national quality measures.
Design, Setting, and Participants
This cohort study used enrollment and health insurance claims from all US states and Washington, DC, from the 2016-2023 Transformed Medicaid Statistical Information System Analytic Files. Participants had OUD and were aged 13 to 25 years. Data were analyzed from November 3, 2025, to July 24, 2026.
Exposures
Diagnosis of OUD and receipt of addiction treatment, including behavioral health services and medications for OUD (MOUD; buprenorphine, methadone, or extended-release naltrexone).
Main Outcomes and Measures
Progression through COC stages aligned with national quality measures: treatment initiation, engagement, MOUD receipt, and 180-day MOUD retention.
Results
Among 229 847 youths with OUD enrolled in Medicaid (median age, 22 [IQR, 20-24] years; 117 920 females [51.3%]), 116 458 (50.7%) initiated treatment within 14 days of diagnosis, and 75 614 (32.9%) engaged in care (ie, had 2 or more additional treatment encounters within 34 days of treatment initiation). Among the 75 614 youths who engaged in treatment, 35 011 (46.3%) received MOUD, representing 15.2% of all 229 847 youths with OUD. However, only 554 of 8352 adolescents younger than 18 years who engaged in treatment received MOUD (6.6%), compared with 34 457 of 67 262 young adults 18 years and older (51.2%). Buprenorphine was the most initiated medication (n = 23 990 of 35 011 [68.5%]), followed by methadone (n = 8911 [25.5%]) and extended-release naltrexone (n = 2110 [6.0%]). Overall, only 7070 of 229 847 youths (3.1%) continued medication for 180 days or more. Among youths receiving MOUD, retention was highest for methadone (n = 2334 of 8911 [26.2%]), followed by buprenorphine (n = 4613 of 23 990 [19.2%]) and extended-release naltrexone (n = 123 of 2110 [5.8%]). Median time receiving MOUD varied by medication: methadone, 59 days (IQR, 15-189 days); buprenorphine, 45 days (IQR, 18-128 days); and extended-release naltrexone, 31 days (IQR, 28-82 days) (log-rank test,
P
< .001). Younger adolescents aged 13 to 15 years and racially minoritized youths had consistently lower progression through the COC.
Conclusions and Relevance
In this cohort study of Medicaid-enrolled youths with OUD, most did not receive timely, evidence-based treatment, and only 1 in 32 received sustained pharmacotherapy. Gaps and persistent disparities exist across the COC, particularly for youths of color, underscoring the need for policies and care models that expand equitable treatment access.