Epistemic Barriers to Buprenorphine Access for Adolescents With Opioid Use Disorder.

Adolescents with opioid use disorder (OUD) remain vulnerable to fentanyl exposure, opioid‑related harms, and profound treatment gaps, even with recent declines in overdose mortality. Strong evidence demonstrates that buprenorphine is safe and effective for youth, yet adolescents remain the age group least likely to receive medications for OUD (MOUD). This review reassesses buprenorphine access for adolescents through a risk-benefit lens, integrating randomized trials, observational cohorts, international guidelines, and emerging fentanyl‑era data. We synthesized evidence from randomized controlled trials, administrative datasets, qualitative studies, comparative effectiveness research, and narrative reviews through a search of the English-language literature in PubMed for adolescent and young adults; examined U.S., U.K., and WHO policy positions; and evaluated structural, regulatory, and developmental barriers that limit adolescent access to MOUD. Particular attention was given to transmucosal and extended‑release buprenorphine and its potential relevance to adolescent adherence and retention. Across two decades of research, buprenorphine consistently improves retention, reduces opioid use, decreases high‑risk behaviors, and is well tolerated. Longer treatment durations reliably outperform short tapers. Real‑world data show that only 5 to 10% of adolescents with OUD receive MOUD, despite the highest overdose risk of any age group. Comparative effectiveness studies demonstrate lower overdose risk with buprenorphine than methadone, and fentanyl‑era feasibility studies confirm successful induction even among youth using illicit fentanyl exclusively. All major medical organizations, including American Society of Addiction Medicine, the American Academy of Pediatrics, the American Academy of Child & Adolescent Psychiatry, the Society for Adolescent Health and Medicine, the British Columbia Centre on Substance Use, and the WHO, endorse buprenorphine for adolescents with OUD. Persistent undertreatment reflects structural barriers, clinician hesitancy, regulatory misconceptions, and the absence of an FDA indication, not lack of efficacy. Expanding access to both transmucosal and extended‑release formulations is critical to reducing preventable overdose deaths. The evidence supports a shift toward developmentally tailored, medication‑based recovery models that prioritize early initiation, sustained treatment, and removal of structural barriers. With illicitly manufactured synthetic opioids now dominating the drug supply, withholding buprenorphine from adolescents is not evidence‑based; it reflects longstanding epistemic exclusion that has limited youth access to treatments known to save lives.