I recently reviewed the case of a 17-year-old who came into the emergency department (ED) after a friend found him unresponsive at a party. He had taken what he thought was a Percocet. It was fentanyl. He survived because his friend called 911 and paramedics arrived with naloxone in time. But here is what happened next: nothing. He was observed, medically cleared, and discharged. No one offered him naloxone to take home. No one screened him for opioid use disorder (OUD). No one discussed buprenorphine. He walked out of the ED with discharge instructions that told him to follow up with an addiction medicine doctor. 72 hours later, his mother found him pulseless and cold in his room.

Sadly, this is not an unusual story. According to our review published this month in JAMA Pediatrics, fewer than one in 54 adolescents receive medication for OUD after a nonfatal overdose. Only 5 percent of adolescents with OUD receive any medication treatment at all. Meanwhile, overdose deaths among adolescents have more than doubled since 2019, and 90 percent of those deaths now involve fentanyl.

The medications exist. Buprenorphine decreases opioid-related mortality by approximately 50 percent. It is Food and Drug Administration (FDA)-approved for adolescents aged 16 and older, and clinicians routinely prescribe it off-label for younger teens. Since 2023, the X-waiver requirement has been eliminated. Any clinician with a Drug Enforcement Administration (DEA)-controlled substance license can prescribe buprenorphine for OUD. No additional training, certification, or waiver is required. Naloxone is now available over the counter, including to minors. A parent, a teacher, or the teenager themselves can walk into a pharmacy and purchase it without a prescription.

So why are we still losing these kids? The barriers are not regulatory anymore. They are clinical inertia, discomfort with addiction medicine among generalists, and a persistent belief that adolescents with OUD are somehow different from adults with the same condition. They are not. They respond to the same medications. They benefit from the same treatment. The difference is that we offer it to adults and withhold it from teenagers.

If you see adolescent patients, you need to know two things. First: Prescribe naloxone to any adolescent with known or suspected opioid exposure, and consider it for any adolescent in a high-risk environment. It is a rescue medication, not an endorsement of use. Second: If an adolescent meets criteria for OUD, initiate buprenorphine or refer to someone who will. The X-waiver is gone. You are already authorized to prescribe it.

The story of the 17-year-old should not have ended this soon. The question is what will happen the next time one of his peers ends up in the ED. The answer depends on what we do between now and then.

Chris Buresh is an emergency physician.