Too young for medication? prescriber perspectives on how age shapes medication for opioid use disorder prescribing in transition-age adults

BACKGROUND: Transition-age (TA) adults are less likely than adults aged 26 and older to receive medications for opioid use disorder (MOUD), and among those treated, disproportionately receive naltrexone over more effective agonist MOUD (buprenorphine and methadone). Given that prescribers ultimately determine medication selection, understanding how age influences their clinical decisions is essential to addressing these disparities. This study examines how prescribers incorporate age into MOUD prescribing decisions for this developmentally vulnerable population. METHODS: Using 2022 New York State Medicaid claims, we identified MOUD prescribers with substantial experience (treating n ≥ 5 TA adults) and conducted semi-structured interviews with 18 outpatient prescribers (MD/DOs, NPs, PAs) from diverse geographic and clinical settings. We applied an inductive thematic analysis approach to explore how prescribers incorporated age and age-related factors into their clinical decision-making around MOUD. RESULTS: Most prescribers did not endorse chronological age as a factor influencing their prescribing patterns, but rather described tailoring treatment based on age-related factors more commonly seen in TA adults. These included developmental characteristics (perceived lack of commitment, peer influence), socioeconomic barriers (e.g., unreliable transportation leading to missed appointments), family influence, and concerns about MOUD dependence. In response to these age-related factors, prescribers implemented harm-reduction principles by adjusting MOUD type prescribing to accommodate TA adults' life-stage realities. In contrast, a small subset of prescribers explicitly cited chronological age as directly influencing MOUD prescribing, expressing hesitations about initiating buprenorphine or referring TA adults for methadone due to long-term dependence concerns. CONCLUSION: These findings suggest two key mechanisms through which age may influence MOUD prescribing disparities among TA adults: (1) prescribers' responses to age-related life-stage challenges (e.g., developmental and social factors, structural barriers) and (2) explicit prescriber age-based hesitancy about initiating long-term agonist maintenance in younger patients. The first mechanism appeared more influential than explicit hesitancy. These mechanisms may help explain documented disparities in MOUD type prescribed. Addressing these disparities may require multi-level interventions: prescriber education affirming agonist MOUD effectiveness for TA adults, efforts to reduce MOUD misconceptions among patients and families, peer-based approaches that leverage social influence positively, and flexible harm-reduction-oriented clinic policies that accommodate structural barriers while supporting access to evidence-based MOUD.