Abstract
Background and Objectives:
The prevalence of opioid use disorder (OUD) among adolescents has increased, yet few adolescents receive medication for OUD (MOUD), particularly buprenorphine. However, initiation can be challenging, as the medication, a high-affinity partial agonist at the mu opioid receptor, can precipitate withdrawal if administered inappropriately. Many adolescents lack access to appropriate levels of supervised care, making it increasingly important for physicians to feel equipped to initiate buprenorphine at home. This is a preliminary feasibility case series for a protocol used in a pediatric addiction clinic for home initiation of buprenorphine in patients 18 and younger. The primary objective is to outline the protocol used, and the secondary objective is to examine the rate of successful initiation.
Methods:
Patients aged 18 years old and younger, who entered treatment for OUD in a child and adolescent outpatient psychiatry clinic between 2022 and 2024 and who chose home buprenorphine initiation were consecutively included. Data from the intake appointment and planned follow-ups at the 1 and 3 month mark were collected. The data collected included characteristics of adolescents who entered treatment and the proportion who successfully initiated buprenorphine. Successful initiation was defined as those who self-reported initiation of buprenorphine at the first follow-up appointment.
Results:
Out of 19 patients (mean age = 15.7), we found that 10 (53%) adolescents initiated buprenorphine at the first follow-up appointment, 3 (16%) were successful at subsequent follow-up appointments, and 6 (32%) adolescents dropped out of treatment. We also identified several individual and systemic barriers to successful initiation including insurance status, transportation and housing status, and relapse on fentanyl.
Conclusions:
This early descriptive study finds that a standard protocol for buprenorphine initiation in adolescents implemented by a trained health care professional in an outpatient setting is preliminarily feasible.
Introduction
In the United States, approximately 312,000 children aged 12–17 have opioid use disorder (OUD) (NSDUH, 2024). The growing prevalence of illicitly manufactured fentanyl has contributed to a sharp rise in overdose fatalities among youth (Friedman et al, 2022; Friedman and Hadland, 2024). Buprenorphine, a medication for OUD (MOUD), has demonstrated strong efficacy in treating adolescents with OUD (Marsch et al., 2016, 2005; Woody et al., 2008). However, despite these well-established benefits of MOUD for adolescents, recent data indicate that fewer than 5% of adolescents with OUD received a prescription for buprenorphine or naltrexone (Hadland et al., 2024, 2018). There is some evidence to support that MOUD, especially buprenorphine, is accepted by adolescent patients and their families as a treatment option (Kaliamurthy et al., 2025). However, traditional inpatient and supervised outpatient initiation models are limited, as they require adolescents to be admitted to the hospital or spend more time in the clinic. A protocol has been published for inpatient buprenorphine induction in adolescents; however, protocols for alternate settings are limited to case series with variable dosing (Trope et al., 2023; Kumar et al., 2024). Additionally, a review of literature found that younger age is associated with shorter retention in MOUD treatment, highlighting the importance of alternative initiation strategies (Viera et al., 2020).
Given the life-saving potential of MOUD in this population, it is critical to explore more accessible options for treatment such as home-based initiation. At-home initiation practices have been mentioned in the literature for adults, particularly during the COVID-19 pandemic. A review of studies on OUD treatment via telehealth noted similar efficacy of virtual MOUD initiation compared with face-to-face care (Chan et al., 2022). More recently, a study explored the effectiveness of at-home low-dose buprenorphine initiation in adults (Suen et al., 2025). Home-based initiation can allow for increased patient autonomy and flexibility in starting MOUD but has not been studied in adolescents under age 18.
This study focuses on at-home buprenorphine initiation among adolescents with OUD seen in a child and adolescent addiction psychiatry outpatient clinic. The primary focus of the study is to outline the clinic’s protocol for at-home initiation, and secondary aims include describing the proportion who successfully initiate buprenorphine, and the barriers encountered during the initiation process.
Methods
Setting and population
The child and adolescent addiction psychiatry clinic at Children’s National Hospital provides outpatient-based addiction treatment to adolescents. All adolescents with a diagnosis of moderate or severe OUD were offered MOUD, specifically naltrexone and buprenorphine/naloxone. The clinic is not certified as an Opioid Treatment Program, and hence, methadone was not offered.
The current study examined data from Children’s National IRB-approved study #00000295. It consecutively includes all patients who were ≤18 years and presented to the addiction clinic between 2022 and 2024. It included demographic data, psychiatric history, substance use history, choice of treatment from intake appointments, medication adherence, and urine drug screen data at follow-up appointments. All patients who had a diagnosis of moderate or severe OUD and consented to start buprenorphine/naloxone at home to treat OUD were included. Patients who chose to start naltrexone were excluded from the study. Once consent was obtained, patients and families were educated on the mechanism of action of buprenorphine and the risks for precipitating or worsening withdrawal symptoms if taken too early. This education was provided directly by the physician, and patients and families were given a handout prepared by the physician with instructions on how to take the buprenorphine, which was also translated into Spanish. Caregiver involvement or supervision was not required for patients to complete the protocol. The patients and families were also given a copy of the subjective opioid withdrawal scale (SOWS) and taught how to use it (Handelsman et al., 1987). They were instructed to start buprenorphine at home when the adolescent either had reached their maximum capacity for tolerating discomfort from withdrawal symptoms or when they reached a score of ≥17. Adolescents were asked to take Buprenorphine/Naloxone 2/0.5 mg once, repeat in 30 minutes and repeat every 2 hours as needed for a maximum dose of 8/2 mg on day 1. They were asked to start day 2 on the maximum dose reached on day 1 and then take buprenorphine/naloxone 2/0.5 mg every 2 hours as needed guided by subjective feelings of cravings for maximum dose of 16 mg. They were asked to take total dose from day 2, beginning day 3 until follow-up with the physician one week after initiation to titrate dose. Adolescents were also given supportive medications, which they were instructed to take as needed (Table 1). Education was provided on how to administer sublingual buprenorphine/naloxone, anticipatory guidance was given on how to tolerate the negative taste often reported by adult patients. Instruction primarily included: not vaping or smoking 30 minutes prior to medication administration, drinking water prior to make sure their mouth was not dry, and chewing a mint or gum 5 minutes after administration. Opioid overdose education and nasal naloxone prescription were also provided to all patients and families (Fig. 1 details this protocol).
Home Buprenorphine/Naloxone (BUP/NX) Induction Protocol for Adolescents with Opioid Use Disorder. This figure outlines a three-day home initiation protocol adapted from the Substance Abuse and Mental Health Services Administration (SAMHSA) Quick Start Guide.
Supportive Medications to Take as Needed During Buprenorphine Induction
Data collection
Data were collected as part of an institutional review board-approved data repository on all adolescents who presented to the Addiction Clinic between 2022 and 2024. Adolescent characteristics collected included age, sex, race/ethnicity, insurance status, primary language, age at first substance use, age at first opioid use, co-occurring substance use disorder (SUD) diagnoses, and co-occurring mental health diagnoses.
Buprenorphine initiation was considered successful if the patient self-reported initiation of buprenorphine at the 1-week follow-up appointment. If initiation was unsuccessful at that time, documented barriers were reviewed. Subsequent successful initiation at later follow-up visits were recorded. If the adolescent never successfully initiated buprenorphine or disengaged from care, this was also documented. Additionally, side effects and withdrawal symptoms were assessed at follow-up and reported if present in the clinic note (side effects were not systematically collected, so may be underreported).
Results
Sample characteristics
Adolescents (N = 19) presented for intake at the Pediatric Addiction Clinic at an average age of 15.7 years (range 14–18). The average age at which adolescents first used any substance was 12.2 years and the average age at first opioid use was 15.1 years. Co-occurring mental health diagnoses were reported for 42% of adolescents with diagnoses including major depressive disorder, attention deficit hyperactivity disorder, generalized anxiety disorder, and posttraumatic stress disorder. Additionally, 32% of adolescents had a co-occurring SUD including cannabis use disorder and tobacco use disorder. All demographic and medical characteristics are presented in Table 2.
Adolescent Medical and Demographic Characteristics
Initiation outcomes
Out of the 19 adolescents who were prescribed buprenorphine at the Pediatric Addiction Clinic for at-home initiation, 10 (53%) were successful at initiating buprenorphine at their 1-week follow up, utilizing the operative definition of successful initiation established in the methods section above. Of the 9 who were unable to initiate buprenorphine at 1-week, 3 (16%) were eventually successful in initiating, meaning they reported starting buprenorphine at a later follow-up appointment using the same instructions. Adolescents ran into multiple systemic and individual barriers to successful initiation, which were documented in the medical record as they were reported. All patients were asked about barriers to initiation at follow-up appointments, and these barriers were assessed qualitatively. Systemic barriers included lack of access to buprenorphine due to housing instability, lack of transportation, lack of pharmacy supply, and insurance issues. All barriers are described in Table 3.
Summary of Barriers to Successful Initiation
“Individual-Related Barriers” refer to challenges such as not attending follow-up appointments or returning to fentanyl use. In contrast, “Systemic-Related Barriers” include factors such as limited access due to pharmacy availability, insurance coverage, housing instability, or transportation issues.
Discussion
This study demonstrates the preliminary feasibility of at-home buprenorphine initiation among adolescents with severe OUD in an outpatient pediatric addiction clinic. Using a standardized protocol with structured education, caregiver involvement, and physician follow-up, more than half (53%) of patients successfully initiated buprenorphine at home within one week. An additional 16% succeeded after subsequent attempts, bringing the overall initiation success rate to 69%. These early findings highlight the feasibility of expanding access to MOUD among youth through outpatient-based, family-supported home induction.
Adolescents and their families, when given structured guidance and follow-up, can manage buprenorphine induction at home. Several aspects of the protocol appeared to support success. These included bilingual materials, the use of the SOWS to guide the timing of initiation, and anticipatory guidance to reduce discomfort or misuse (e.g., avoiding smoking/vaping before medication administration, etc.). Education on medication side effects and opioid overdose prevention further empowered patients and families to participate in care.
No adverse safety events were documented in the medical record, and no overdose incidents occurred during the initiation period. Notably, data on adverse events were not systematically collected and were only collected when reported by patients. However, barriers to successful initiation were common. Systemic factors such as lack of pharmacy stock, insurance delays, and transportation issues contributed to unsuccessful initiations. These challenges highlight the need for structural support in addition to clinical protocols, especially for adolescents who disproportionately face access-related barriers. Some solutions to address these barriers can include the clinic having a list of pharmacies that are known to have buprenorphine on stock readily available for patients to access.
To our knowledge, there is no prior literature on home buprenorphine initiation in adolescents. Prior studies in adults have shown that home initiation, when combined with clear instructions and follow-up, can be effective and acceptable (Cunningham et al., 2011). The data in this study represent one of the first efforts to publish outcomes from systematically adapting adult models to pediatric populations.
In our sample, successful initiations often included the involvement of an informed and supportive adult who could assist in managing timing, dosage, and adherence. The data presented here support a descriptive association between caregiver involvement and successful initiation. This underscores the importance of including families as partners in care, especially when delivering treatment in community or home-based models.
The use of a home initiation model in minors introduces several clinical and ethical considerations. Physicians must ensure that adolescents and caregivers are adequately educated, emotionally prepared, and supported to manage a complex medication. The need to assess developmental maturity, health literacy, and motivation also requires clinical judgment and flexibility. In this model, the structured one-week follow-up visit and interim check-ins were essential components to reinforce adherence, troubleshoot challenges, and assess safety. More frequent check-ins with physicians or nursing staff in the clinic by phone to support the initiation process may also help address some of the barriers mentioned earlier in a timely manner.
Importantly, even among those who initially were unsuccessful at initiating buprenorphine, re-engagement was possible. Three adolescents successfully initiated after an unsuccessful first attempt, using the same protocol at a later date. Potential implications of these results include that providing repeated, flexible engagement opportunities may increase overall treatment uptake and reduce the risk of disengagement. By equipping pediatric physicians with home induction tools, training, and decision aids, more adolescents can be initiated on life-saving treatment earlier in the course of illness.
Limitations include a single site with a relatively small sample size, which limits generalizability. Additionally, the study relies on patient report for successful initiation and barriers. While short-term success and barriers were captured, long-term treatment engagement and retention data were not available at the time of analysis. Finally, although safety events were not reported in our sample, rare complications and lack of systematic data collection on side effects and adverse effects likely limited detection in a small sample size.
Future research should explore the efficacy of home initiation protocols in larger, more diverse samples and across multiple sites. Randomized comparisons of home versus supervised initiation, as well as qualitative studies exploring patient and caregiver experiences, could further refine best practices. Implementation science frameworks may also support effective adaptation and dissemination of protocols in real-world clinical settings.
Conclusion
This case series demonstrates preliminary feasibility of a structured at-home buprenorphine initiation protocol for adolescents with OUD, but additional research is needed to determine safety and effectiveness. Despite systemic and logistical barriers, most adolescents were able to successfully begin MOUD in a family-supported outpatient model. These findings suggest that cautious, flexible, and education-driven approaches to buprenorphine initiation may expand access to treatment for high-risk youth and warrant further study to inform best practices in pediatric addiction care.
Clinical Significance
Home-based buprenorphine initiation may be a feasible approach to expanding access to medication treatment for adolescents with opioid use disorder, particularly in settings where supervised induction is not readily available.
Authors’ Contributions
S.K. conceptualized and designed the study, helped draft the initial article, critically reviewed and revised the article. E.S. drafted the initial article, performed data collection and analysis, and critically reviewed and revised the final article. P.K. helped draft the initial article, performed data collection, critically reviewed and revised the final article. All authors approved the final article as submitted and agree to be accountable for all aspects of the work.
Footnotes
Author Disclosure Statement
The authors have no conflicts of interest to report.