Background: Although effective treatments exist, alcohol use disorder (AUD) is undertreated. We used a cascade of care framework to understand gaps in care between diagnosis and treatment for persons with AUD. Methods: Using 2015-2018 National Survey on Drug Use and Health data, we evaluated the following steps in the cascade of care: 1) prevalence of adults with AUD; 2) proportion of adults who utilized health care in the past 12 months; 3) were screened about alcohol use; 4) received a brief intervention about alcohol misuse; 5) received information about treatment for alcohol misuse; and 6) proportion of persons with AUD who received treatment. Analyses were stratified by AUD severity. Results: Of the 171,766 persons included in the sample, weighted prevalence of AUD was 7.9% (95% CI 7.7-8.0%). Persons with AUD utilized health care settings at similar rates as those without AUD. Cascades of care showed the majority of individuals with AUD utilized health care and were screened about alcohol use, but the percent who received the subsequent steps of care decreased substantially. For those with severe AUD, 83.5% (CI: 78.3%-88.7%) utilized health care in the past 12 months, 73.5% (CI: 68.1%-78.9%) were screened for alcohol use, 22.7% (CI: 19.4%-26.0%) received a brief intervention, 12.4% (CI: 10%-14.7%) received information about treatment, and 20.5% (CI: 18%-23.1%) were treated for AUD. The greatest decrease in the care continuum occurred from screening to brief intervention and referral to treatment. More persons with severe AUD received treatment than were referred, indicating other pathways to treatment outside of the healthcare system. Conclusions: Persons with AUD utilize health care at high rates and are frequently screened about alcohol use, but few receive treatment. Health care settings- particularly primary care settings- represent a prime opportunity to implement pharmacologic treatment for AUD to improve outcomes in this high-risk population.

Background and Aims: Adolescents with opioid use disorder (OUD) are an understudied and vulnerable population. We examined the association between age and six-month treatment retention, and whether any such association was moderated by medication treatment. Methods: In this retrospective cohort study, we used an insurance database with OUD treatment claims from 2006-2016. We examined 261,356 OUD treatment episodes in three age groups: adolescents (ages 12-17), young adults (18-25) and older adults (26-64). We used logistic regression to estimate prevalence of six-month retention before and after stratification by treatment type (buprenorphine, naltrexone, or psychosocial services only). Insurance differences (commercial vs Medicaid) in medication treatment prevalence were also assessed. Results: Adolescents were far less likely to be retained compared to adults (17.6%; 95% CI 16.5-18.7% for adolescents; 25.1%; 95% CI 24.7-25.4% for young adults; 33.3%; 95% CI 33.0-33.5% for older adults). This disparity was markedly reduced after adjusting for treatment type. For all ages, buprenorphine was more strongly associated with retention than naltrexone or psychosocial services. Adolescents who received buprenorphine were more than four times as likely to be retained in treatment (44.5%, 95% CI 40.6-49.0) compared to those who received psychosocial services (9.7%, 95% CI 8.8-10.8). Persons with commercial insurance were more likely to receive medication than those with Medicaid (73.3% vs 36.4%, (χ2=57,870.6, p<.001). Conclusions: Age disparities in six-month treatment retention are strongly related to age disparities in medication treatment. Results point to need for improved implementation of medication treatment for persons with OUD, regardless of age or insurance status.