January 18, 2019, 10:25 am Michael Devitt – It's no surprise that most news stories and published research on the opioid crisis have focused on the number of opioid-related deaths in adults. What is surprising is how little research has been done on opioid-related deaths in young people.
While the 2017 National Survey on Drug Use and Health estimated that about 769,000 children aged 12 to 17 misused opioids and about 14,000 used heroin in the past year, the survey did not discuss how many children and adolescents may have died from using these drugs as a result. Other evidence suggests that millions of kids are exposed to opioids on a regular basis, which increases their risk of serious injury and hospitalization.
A new study from researchers at the Yale School of Medicine has opened a window into the effect of the opioid epidemic on this segment of the population. Their analysis of CDC mortality data, published Dec. 28 in JAMA Network Open, found that the use of prescription and illicit opioids caused the deaths of almost 9,000 children and adolescents in the United States between 1999 and 2016. During the same time, the pediatric mortality rate from opioid poisoning increased more than twofold.
The researchers analyzed the Multiple Cause of Death file, part of the CDC's Wide-Ranging Online Data for Epidemiologic Research database, to identify all poisonings from prescription and illicit opioids between Jan. 1, 1999, and Dec. 31, 2016.
Deaths from any opioid were identified using ICD-10 codes for opium, heroin, natural and semisynthetic opioids, methadone, synthetic opioids other than methadone, and other and unspecified narcotics. The researchers also used ICD-10 codes to determine whether the manner of death was a homicide, suicide, of undetermined intent or unintentional.
Deaths were categorized into four age groups (0 to 4, 5 to 9, 10 to 14, and 15 to 19 years) and classified by race, gender and place of death. In the oldest age group, the researchers also examined deaths that involved one or more prescription or illicit substances.
The researchers identified 8,986 children and adolescents who died from opioid poisonings between 1999 and 2016. Most of these deaths, 79.9 percent, occurred in non-Hispanic whites. Just over 73 percent of deaths occurred in males.
Year-by-year analysis showed that the number of opioid-related deaths increased at a steady rate from 1999 through 2008, when more than 650 deaths occurred. Annual deaths began to decline slightly for each of the next three years, followed by a sharper decline from 2012 to 2014. The researchers attributed this decline in part to a corresponding decrease in opioid prescriptions.
In 2015, however, the number of opioid deaths increased substantially, and in 2016 the number of deaths again topped 650.
"While there was a decline in the death rates in 2008 and 2009 that corresponded with a decrease in prescribing trends, the rates are going up again," Julie Gaither, Ph.D., M.P.H., R.N., the study's lead author, told Yale News. "It's due to a rise in heroin and synthetic opioid use among teens."
Across all age groups, prescription opioids were the contributing factor in 73 percent of deaths. In those aged 15 to 19, however, almost a quarter of all deaths (1,872) were attributed to heroin and 13 percent (1,023) were attributed to synthetic opioids. Of those 1,023 deaths, 468 occurred between 2014 and 2016.
No age group was completely spared, however. While 88 percent of the opioid deaths occurred in adolescents 15 to 19, the next highest percentage of deaths -- 6.7 percent -- occurred in infants and children aged four years and younger.
More than one-third of adolescent opioid deaths also involved the use of one or more prescription or illicit substances. The most common substances found in addition to opioids were benzodiazepines, cocaine, alcohol, antidepressants and psychostimulants.
The authors drew distinctions between their research and previous research on opioid-related deaths in children and adolescents, which used different study criteria. For example, they cited a JAMA Pediatrics study from 2016 in which Gaither also was the lead author. The 2016 study examined trends in pediatric hospitalizations for opioid poisonings and found that approximately 30 children died during hospitalization each year. "Results from the present study make it clear that the number of children and adolescents dying each year in the United States from opioid poisonings is actually closer to 500," they wrote.
The authors also suggested that children and adolescents have been ignored with regard to the risks opioids pose. "Of the hundreds of state and federal initiatives enacted to contain the opioid crisis, nearly all focus on adults," they wrote.
In particular, the authors noted that many commonly prescribed opioids do not come in childproof packaging. They also warned that as medication-assisted treatment for opioid use disorder increases among adults, children and adolescents will be more likely to be exposed to opioids such as methadone and suboxone unless more restrictive safety measures are put in place.
The bottom line, the authors wrote, is that solutions that focus on just one aspect of the opioid epidemic are unlikely to produce long-lasting results. In their opinion, it will take an all-encompassing approach that attacks the problem from several angles to substantially reduce or prevent opioid deaths.
"This public health problem is likely to grow unless parents, legislators, public health officials and clinicians -- including physicians who prescribe opioids to adults -- begin to take a wider view of what is a systemic crisis," they concluded.
Family physician Daron Gersch, M.D., who practices in Albany, Minn., previously served as chair of the AAFP Commission on Health of the Public and Science's Subcommittee on Public Health Issues. He has personally witnessed the effects of the opioid crisis on children and adolescents.
"I cover emergency rooms in three local rural hospitals and have seen the increase in opioid use, especially in older teens," Gersch told AAFP News. "In rural central Minnesota this has just started to transition from hydrocodone and oxycodone to synthetic opioids and heroin. While I personally have not had a teen opioid death while working in the ER, if the trend continues, it will only be a matter of time."
Gersch currently serves as the AAFP's representative to the Prevention of Overdoses and Treatment Errors in Children Taskforce Initiative, a collaborative effort that has devised a number of recommendations family physicians can share to keep young children from accidentally consuming medications they shouldn't have access to -- although keeping them out of the hands of children sometimes is easier said than done.
"I have had some of my patients who have had their opioids stolen by a child or grandchild," Gersch added. "I warn people to be careful about storage of their medications."
Gersch's advice for prescribing and storing opioids may depend on the circumstances, but it basically boils down to the following points.
"First and foremost, we have to be very careful and aware of how we are prescribing opioid medications," he said, adding that the lowest effective dose should be used in no greater quantity than what is needed for patients in severe pain.
"For my chronic pain patients, I strongly recommend that they have a locked safe that they put their medications in and only take out a few days at a time so there is never a large amount sitting out in the open for teenagers to abuse or little children to accidentally get into.
"Finally, during well-child visits and sports physicals I try and take a little bit of time to talk to the children and parents about drug abuse and drug safety."
In addition to storage, timely and proper disposal of medications is key to preventing access by children and adolescents. The AAFP and the AMA Task Force to Reduce Opioid Abuse have published a resource on opioid storage and disposal. Similar resources are available on AAFP.org and FamilyDoctor.org.
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