Courtney Locker was 12 years old when she started abusing prescription pills. By age 14, she was addicted to heroin.

Her drug use wasn't addressed until a couple of years later when her mother, Tracey Cavacino, sent her to a Utah ranch for at-risk teens. Tracy had enrolled her daughter at Turn-About Ranch to treat her anxiety and depression; she was not aware her daughter was addicted to heroin.

The program didn't provide Courtney, now 18, with any medication to reduce the painful physical effects of her opioid withdrawal or help curb her cravings. When she returned home, she was clean – and has been ever since – but wanted to find a treatment program to keep her from relapsing.

What she and Tracey discovered: Finding effective help for Courtney's opioid use disorder was far more difficult than finding treatment for her other mental health issues.

"I would sit online and just go through doctors and call them," says Tracey, describing the hours she spent searching for an inpatient treatment program – ideally one that would provide medication to help control Courtney's cravings – and a psychiatrist.

The U.S. opioid crisis has been a top concern across government and the medical community for years now, but Courtney's plight highlights how one group has largely been left out of the conversation: America's youth.

Just as it has among adults, opioid use among minors has drastically increased since the 1990s. A study published last month by Yale University researchers says nearly 9,000 children and adolescents in the U.S. died from prescription and illicit opioid poisonings between 1999 and 2016, and that the related mortality rate surged by nearly 270 percent during that period. The vast majority of opioid deaths were unintentional and occurred among those 15 to 19 years old.

Winnie-the-Pooh decorations are seen over the crib of Courtney Locker's son, Dakota. Adolescents suffering from opioid addiction can face a difficult road to recovery. (Michelle Gustafson for USN&WR)

"The underrecognition of the risks that prescription and illicit opioids pose to children and adolescents is reflected in the current policies and practices in place in the United States today," the study states. "Of the hundreds of state and federal initiatives enacted to contain the opioid crisis, nearly all focus on adults."

The same opioids abused by adults have taken their toll on younger generations: prescription painkillers, heroin and, increasingly, the synthetic substance fentanyl, says Dr. Scott Hadland, a pediatrician, assistant professor at Boston University and researcher at Boston Medical Center 's Grayken Center for Addiction.

"Because the opioid crisis is so widespread, it knows no boundaries," he says.

Adolescents suffering from opioid addiction can face a difficult road to recovery, as only a small percentage receive medication-assisted treatment – a mix of counseling, behavioral therapy and craving-reducing medications like buprenorphine or naltrexone that's widely accepted as an effective means of rehabilitation. (Federal regulations bar most patients under 18 from entering a treatment program using methadone, a third drug used in what's known as MAT.)

A study by Hadland and others of nearly 5,000 Medicaid-enrolled youths between the ages of 13 and 22 with a diagnosed opioid use disorder in 2014 and 2015 found that less than a quarter received medication for their treatment within three months of being diagnosed, and most received only behavioral health services. Only 5 percent of those under age 18 received timely treatment with medication.

Access is part of the problem. Even with health insurance coverage, Tracey was unable to find an in-network, inpatient treatment center within 100 miles of her Pennsylvania home that would accept someone under 18. The few adolescent-specific, substance use disorder treatment programs she found elsewhere would not accept Courtney unless she tested positive for opioids. Because she'd stopped using, she couldn't meet that requirement – even though she still needed help.

"So here's somebody trying not (to use drugs) and they're saying she won't be accepted. That totally shocked us," Tracey says.

Tracey eventually found an intensive outpatient program that was covered by their insurance. Through a local support group, she also got the name of a medication-prescribing psychiatrist for Courtney, whose services they paid for out of pocket, and enrolled her in The Bridge Way School , a high school for students recovering from addiction.

Courtney – who had a baby boy, Dakota, in September – says both the outpatient program and her psychiatrist provided her with naltrexone, but only after she did her own research and asked for it. Experts say the public is largely unaware that such resources aren't readily available to many younger Americans.

"It's a secret … it really is," says Dr. Sharon Levy, director of the Adolescent Substance Use and Addiction Program at Boston Children's Hospital and an associate professor of pediatrics at Harvard Medical School .

Courtney Locker feeds her son, Dakota, who was born in September. (Michelle Gustafson for USN&WR)

Levy was lead author of the the American Academy of Pediatrics' 2016 recommendations that called for "increasing resources to improve access to medication-assisted treatment of opioid-addicted adolescents and young adults." The recommendations also encouraged pediatricians to consider offering such treatment to patients in that age range with severe opioid use disorders.

The article nods to the stigma that can accompany medication-assisted treatment, which can include the idea that a person is substituting the use of one drug for another. But Levy says such perceptions are outdated and the benefits of the medications outweigh any associated risks.

"Policies, attitudes, and messages that serve to prevent patients from accessing a medication that can effectively treat a life-threatening condition may be harmful to adolescent health," her AAP article states.

Naltrexone is approved by the Food and Drug Administration for use in patients age 18 and older and buprenorphine is approved for patients 16 and older, though doctors legally can write an "off-label" prescription for the medication should a younger patient need one. But many pediatricians aren't licensed to prescribe buprenorphine or may not feel comfortable doing so. In order to prescribe it, primary care providers have to undergo eight hours of training and apply for a federal waiver , which allows them to offer the medication to a limited number of patients.

Evidence points to efficacy: Hadland's research also showed that youths who received buprenorphine within three months of diagnosis were 42 percent less likely to discontinue treatment than those without medication, while those given naltrexone or methadone were 46 percent and 68 percent less likely to do so, respectively.

Levy says pediatricians have been slow to apply for buprenorphine waivers, which became available through federal legislation passed in 2000, possibly because they think treating an opioid use disorder is complicated and requires specialized help beyond a primary care office.

But pediatricians treat other complicated issues all the time, Levy argues, noting that they have to spend months in an intensive care unit taking care of incredibly ill kids during their residency training, which builds both their confidence and abilities.

"Pediatricians treat tough stuff. It's not easy to treat kids with (attention deficit hyperactivity disorder) or with depression or eating disorders, and yet we're expected to do all of that," Levy says.

But there's no similar training in addiction medicine, so pediatricians often refer their patients to treatment programs that many patients might never be able to qualify for or afford.

"If you think about it, it's really bizarre that we set up a whole parallel medical system to treat one single disorder, right?" Levy says.

Levy and a colleague at Boston Children's Hospital started a program a few years ago to try to change that dynamic. The hospital is working with pediatric primary care offices to increase their capacity to treat opioid use disorders in-house, so patients don't have to go to a hospital or treatment center for help. The program recently received a five-year, $4.75 million federal grant that will help it expand to more primary care offices.

In Levy's model, a social worker is embedded in the primary care office to work alongside a doctor who can prescribe buprenorphine. The goal is for a young patient to be fully treated by his or her physician while continuing to attend school and participate in other activities.

"I'm a firm believer that a lot of these kids can be treated in the community," Levy says.

Courtney Locker was 12 years old when she started abusing prescription pills – a problem that morphed into a heroin addiction by the time she was 14. With the help of her mother, Tracey Cavacino, she was able to access treatment that's helped her stay clean since late 2016. (Michelle Gustafson for USN&WR)

Getting treatment through a patient's existing primary care office makes weekly visits more feasible, increasing the likelihood a patient will continue the course. It also may reduce the stigma surrounding drug treatment, since patients are going to the same place they would to get a vaccination or an annual physical.

The first office to try Levy's model was Wareham Pediatric Associates in Wareham, Massachusetts, in 2016. Shannon Mountain-Ray, clinical director of social work in Levy's Adolescent Substance Use and Addiction Program, was at the office as a social worker during the project's pilot phase, and says she was constantly collaborating with doctors and would answer substance use questions from doctors and patients. She also developed a screening process to identify children who are addicted to opioids or other substances, or are at risk of becoming addicted.

Within the first year of the program, the pediatric practice identified five young people with opioid use disorder. Once a patient enters the program, he or she is monitored closely at first and asked to come to the practice once a week.

"We take our time (with treatment)," Mountain-Ray says, describing how patients are monitored physically and psychosocially, and are allowed to continue with the program even if they turn 18 during treatment.

Five other offices have signed up to work with Levy and her team using the federal grant funding, and Levy says her goal is to expand the program to all 85 or so primary care offices within the Boston Children's Hospital network.

Levy emphasizes that there absolutely is an appropriate time and place for substance use treatment at a specialized facility. But by properly preparing pediatricians to treat opioid use disorder, she says her program is helping to move addiction treatment to the broader realm where it belongs.