Legal and other barriers to buprenorphine prescribing for adolescents with opioid use disorder: a provider survey

Opioid-related morbidity and mortality among adolescents continue to rise, yet buprenorphine remains underused in pediatric settings despite strong evidence of effectiveness and professional society endorsement. Identifying modifiable barriers to prescribing, such as legal and regulatory uncertainty, parental consent, and restrictive beliefs about MOUD, is essential to expanding adolescent access to medications for opioid use disorder (MOUD). We conducted a cross-sectional, anonymous online survey of US pediatric prescribers using snowball sampling. Eligible participants were MD/DO physicians, nurse practitioners, and physician assistants authorized to prescribe opioids or MOUD and actively providing pediatric care. Survey domains assessed legal awareness, clinical knowledge, prescribing confidence, parental consent concerns, and beliefs about MOUD. Responses were compared by self-reported history of ever prescribing buprenorphine for adolescent opioid use disorder. Group differences were assessed using chi-square tests with Monte Carlo estimation, and adjusted associations were estimated using multivariable logistic regression reported as odds ratios (ORs) with 95% confidence intervals. Among 600 respondents, 309 (52%) reported ever prescribing buprenorphine for adolescent opioid use disorder and 291 (48%) reported never prescribing. Prescribers reported less uncertainty about the legal landscape governing buprenorphine prescribing to minors, including whether their state restricts under-18 prescribing (26.5% vs. 32.3%, p = 0.017), though self-reported awareness of under-18 laws was higher among non-prescribers (94.2% vs. 86.7%, p = 0.008). In adjusted analyses, greater legal clarity (OR 2.58, 95% CI 1.13–5.98), male gender (OR 1.64, 95% CI 1.16–2.33), and reporting parental consent barriers (OR 1.59, 95% CI 1.11–2.28) were each associated with higher odds of prescribing history. Office-based group practice (OR 0.52, 95% CI 0.29–0.93), fewer than 5 years in practice (OR 0.53, 95% CI 0.32–0.88), and 16–20 years in practice (OR 0.55, 95% CI 0.31–0.98) were associated with lower odds relative to solo practice and the 5–10-year reference group, respectively. In this non-probability sample of US pediatric prescribers, buprenorphine prescribing history was more strongly associated with legal clarity, and practice characteristics, and beliefs about MOUD than with clinician type. Targeted efforts to improve legal clarity and address practice-level and normative barriers represent actionable opportunities to expand evidence-based treatment access for adolescents with OUD.