Opioid-Related Deaths Up Threefold in Children

Pauline Anderson

January 04, 2019

The mortality rate from opioid poisoning among children and adolescents in the United States increased almost threefold between 1999 and 2016, a new study shows.

The increase was most profound among those aged 15 to 19 years, a group that sustained a substantial rise in deaths from heroin and synthetic opioids.

The study found that opioids were responsible for almost 9000 deaths among children and adolescents during the period studied and that almost 40% of them died at home.

The opioid crisis should be viewed as a "family problem," where "everyone is affected and likely exposed" when these drugs are brought into the home, lead author Julie R. Gaither, PhD, an epidemiologist and instructor, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, told Medscape Medical News.

"I would love it if physicians who treat adults with opioids would consider who else is in the household, whether it's an elderly family member or children."

Gaither stressed that although the opioid epidemic is complex, some of the answers to it "are just common sense," and these include "basic safety measures" such as telling patients that an opioid can kill a child.

The study was published online December 28 in JAMA Network Open.

The authors report that almost 5000 children under age 6 years are evaluated every year for opioid exposure in emergency departments across the United States. Hospitalizations for opioid poisonings increased almost twofold among children and adolescents between 1997 and 2012.

However, it's unclear how many children die each year from opioid poisonings and how mortality rates have changed over time since the opioid epidemic began in the late 1990s.

For this new study, researchers used the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER). This database includes US county-level death certificate data from the National Center for Health Statistics.

Investigators identified poisonings from prescription and illicit opioids between January 1, 1999, and December 31, 2016. They used International Statistical Classification of Diseases, 10th revision (ICD-10) codes to categorize deaths from any opioid.

Under the label "prescription opioids," Gaither and colleagues grouped all but synthetic opioids. The exception was methadone, a synthetic opioid that was included in the prescription category.

The other synthetic opioids (including pharmaceutically and illicitly manufactured fentanyl) and heroin were assessed separately and only in adolescents aged 15 to 19 years.

Researchers classified deaths as unintentional, suicide, homicide, or undetermined.

They categorized children and adolescents by age group: 0 to 4 years, 5 to 9 years, 10 to 14 years, and 15 to 19 years.

In the oldest age group, researchers also examined deaths involving one or more other drugs.

Researchers used a generalized smoothing spline Poisson regression model to estimate mortality rates and assess temporal changes in rates over time (time effect).

They found that 8986 children and adolescents died from prescription and illicit opioid poisonings between 1999 and 2016. Of these, 88.1%, were aged 15 to 19 years, and 6.7% were under 5 years. Most deaths were among non-Hispanic whites (79.9%) and males (73.1%).

During the study period, the annual estimated mortality rate for all children and adolescents rose from 0.22 (95% CI, 0.19 - 0.25) to 0.81 (95% CI, 0.76 - 0.88) per 100,000, an increase of 268.2% (P for time effect < .001).

Broken down by age group, the increases in mortality rates (all P for time effect < .001) were:

  • Ages 0 to 4 years: From 0.08 (95% CI, 0.06 - 0.10) to 0.26 (95% CI, 0.22 - 0.31) per 100,000, an increase of 225.0%.

  • Ages 5 to 9 years: From 0.02 (95% CI, 0.01 - 0.03) to 0.04 (95% CI, 0.03 - 0.06) per 100,000, an increase of 100.0%.

  • Ages 10 to 14 years: From 0.04 (95% CI, 0.03 - 0.06) to 0.10 (95% CI, 0.07 - 0.13) per 100,000, an increase of 150.0%.

  • Ages 15 to 19 years: From 0.78 (95% CI, 0.68 - 0.88) to 2.75 (95% CI, 2.55 - 2.96) per 100,000, an increase of 252.6%.

The authors noted that children under 5 years, who they called "a highly vulnerable group for which the consequence of the opioid crisis has been somewhat overshadowed by opioid-related morbidity among neonates and older teens," had the second highest mortality rate.

Systemic Problem

The overall mortality rate for males increased by 241.9%, compared with 323.1% for females (all P for time effect < .001).

"Most poisonings are still in males, and in white males in particular, but rates are rising at a faster rate among girls as well as among Hispanics and blacks," commented Gaither. Black children had almost a fourfold increase in rates.

"This is indicative of the fact that this is a systemic problem and it's continuing to spread to all segments of society," she said.

Among non-Hispanic white children and adolescents, mortality rates increased by 289.3%.

About 80.8% of deaths were unintentional, 5.0% were because of suicide, and 2.4% were attributed to homicide.

But the manner of death varied significantly by age group. Among those 15 to 19 years, 85.3% of deaths were unintentional and 4.8% were attributed to suicide, while among children under 5 years, 38.0% of deaths were unintentional, 24.5% were because of homicide, and the manner of death could not be determined in 37.5% of cases.

The percentage of deaths because of homicide was highest in those younger than 1 year (34.5%).

Anecdotal evidence suggests parents may be giving their child an opioid to sedate them or help get them to sleep, commented Gaither.

Prescription opioids were implicated in 73.0% of deaths. Methadone alone caused 35.9% of prescription opioid deaths; however, the mortality rate for methadone peaked in 2007 and by 2016 had decreased by 76.7%.

Heroin was responsible for 23.6% of deaths among adolescents aged 15 to 19 years. Rates for fatal heroin poisonings in this group increased by 404.8%, whereas rates for prescription opioids increased by 94.7% (all P for time effect < .001).

"Huge Surge"

In this age group, mortality rates for synthetic opioids increased by 2925.0% (P for time effect < .001).

"For synthetic opioids, the rates were essentially flat until about 2014, and then there was a huge surge," said Gaither. "Over time, there was this almost 3000% increase in deaths from synthetic opioids, and since 2014, a third of all poisoning deaths — so prescription, everything — were due to synthetic opioids."

Among older adolescents, 38.5% of deaths involved another prescription or illicit substances in addition to an opioid. These included benzodiazepines (19.6%), cocaine (11.6%), alcohol (6.6%), antidepressants (4.1%), psychostimulants (4.0%), cannabis (1.6%), antipsychotics/neuroleptics (1.2%), or barbiturates (0.3%).

Almost two thirds of deaths (61.6%) occurred outside of a medical facility, with 38.0% occurring at home or other residential setting.

Julie R. Gaither, PhD

Gaither said she was surprised at the high number of opioid poisonings every year in kids. "There has been a perception that few kids actually die from opioid poisoning."

Contributing to the surge in opioid-related deaths in kids is the sheer number of these drugs now available, which increases the chances that children will be somehow exposed.

Teens, for example, may find the drugs in the medicine cabinet or in their mother's purse, while younger children may come across part of a drug strip on the floor or counter and put it in their mouth.

"We don't have child-proof packaging on all opioids, including the fentanyl patch [Duragesic] and Suboxone," the combination form of buprenorphine and naloxone used to treat opioid addiction, said Gaither.

Duragesic comes in foil wrappers that can be easily opened by a child, and Suboxone, now sold in brightly colored film strips, also poses a danger to children, she said.

The rate of opioid poisoning among young people could increase further with initiatives aimed at increasing the availability of naloxone in homes and communities, especially given that most pediatric deaths occur outside a medical setting.

"I personally am not sure how that affects very young kids," said Gaither. "I think we need further research to be able to say what parents of young child should be doing."

She urged clinicians to consider the individual patient in the context of the family "and to think about how everyone in the home is affected and likely exposed to opioids."

The study relied on data from death certificates, so it's possible that misclassification of cause and manner of death occurred, the researchers noted.

Tip of the Iceberg

Asked to comment for Medscape Medical News, Lloyd Werk, MD, MPH, chief, Division of General Pediatrics, Department of Pediatrics, Nemours Children's Health System, Orlando, Florida, said the new study "reveals the extent of opioid deaths that had not been known in pediatrics."

But the surge in opioid deaths is just "the tip of the iceberg," said Werk.

"With this study showing so many youth experiencing opioid deaths, that tells us there are even more youth experiencing mental and physical consequences from opioids, including depression, anxiety, school failure, risk for illnesses like hepatitis, and pregnancy."

Such consequences can even include heart infections because of intravenous drug use and stroke, he added.

Because of the increased consequences of opioid use, it's even more important to screen young people for drug use.

Several screening tools are available. Some of the more well-known are SBIRT (Screening, Brief Intervention, and Referral to Treatment) and HEADSS (Home, Education/Employment, Peer Group Activities, Drugs, Sexuality, and Suicide/Depression).

Results of screening can give youth positive reinforcement if they're staying away from drugs, and if they're struggling, support and referrals can be provided, said Werk.

Are kids likely to be honest about their drug use? "If it becomes a routine part of regular office visits and is done confidentially without the parents in the room, there is evidence that there is a decent response," said Werk.

But the first step is to just ask youth about drug use. "If you ask the question early enough, you can potentially save a life."

Primary care physicians generally start such screening at about age 11 or 12 years, said Werk.

Some research has linked drug use in youth, along with mental health problems and poor health, to earlier exposure to events such as divorce, abuse, and a parent being incarcerated. 

"If we can identify folks at risk, maybe we help them build resilience, build their ability to cope," he said.

The fact that some prescribed opioids are still not in childproof packages is "crazy," Werk added. "Here you have a substance that can cause you to stop breathing, especially if you're a toddler, and that's potentially fatal. We could do a better job of child-proofing containers that hold opioids."

Gaither reported grants from the National Center for Advancing Translational Sciences, National Institutes of Health during the conduct of the study. Werk has reported no relevant financial relationships.

JAMA Netw Open. Published December 28, 2018. Full text

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