Beyond the rising rates of deaths related to opioid use, a new analysis of hospital records shows significantly higher rates also affecting children being hospitalized for opioid poisoning
Interview with Julie R. Gaither, PhD, MPH, RN and G. Caleb Alexander, MD, MS
As the deadly consequences of opioid abuse in the US remain in the spotlight, recent findings indicate a stark rise in rates of children also being hospitalized for opioid poisonings.1
Researchers looked at hospitalization records from 1997 to 2012 to better understand the trend in opioid poisonings in children. The results suggest a nearly 2-fold increase in hospitalizations related to opioid poisonings over the past 15 years.1
The study, published in the Journal of the American Medical Association, presents some of the first data to look at how opioid poisonings have affected the pediatric population since opioid prescriptions quadrupled from 1999 to 2010.1 However, doctors may be surprised by the reasons related to these pediatric hospitalizations; the majority are not accidental.
Opioid Poisonings in Children
In 2014, 18,893 deaths were attributed to excess opioids.2,3 The public reaction to what is now considered a public health epidemic has led to a renewed focus on comprehensive opioid reform.
However, emergency department (ED) visits by children for opioid poisonings also have risen over the years; yet scant research was available to explain the upward trend in opioid poisonings, or how these hospitalizations may differ by age group.
In a retrospective analysis,1researchers gathered 13,052 hospital discharge records over a 15 year period, all of which were related to opioid poisonings in pediatric patients (age 1 to 19 years). The annual incidence of opioid poisoning hospitalizations rose by 165%, from 1.40 (95% CI, 1.24-1.56) to 3.71 (95% CI, 3.44-3.98) per 100,000 children (P<0.001).1
“To date there has not been a lot of research really focusing on the pediatric community, so we were definitely surprised by what we found,” Julie R. Gaither, PhD, MPH, RN, from the department of epidemiology and public health at the Yale School of Medicine in New Haven, Connecticut, told Practical Pain Management.
It may be conceivable that opioid poisonings would rise in tandem with spikes in opioid mortality rates. However, every age group showed significant rises in hospitalizations, a worrying sign that the proliferation of opioid prescriptions in American homes has increased significantly, as has the risk of opioid poisoning among children of all ages.
- In children age 1 to 4 years, hospitalization incidence increased by 205%, from 0.86 (95%CI, 0.60-1.12) in 1997 to 2.62 (95%CI, 2.17-3.08) in 2012 (P<0.001)
- Among adolescents age 15 to 19 years, hospitalization incidence increased by 176%, from 3.69 (95%CI, 3.20-4.17) in 1997 to 10.17 (95%CI, 9.48-10.85) in 2012 (P<0.001)
That the youngest age group, children between 1 and 4 years old, showed the greatest increase in hospitalizations could be a sign providers need to be more proactive in informing parents about the dangers of having an opioid prescription in the home before they write a prescription to better safeguard children, according to Dr. Gaither.
“I think that a big part of this is for providers to educate the adults they are prescribing to, and to specifically ask if there are children in the home; and if so, caution parents about the steps they need to take,” said Dr. Gaither.
For instance, adults may take their medication and leave the open bottle on a counter while drinking from a glass of water. In a split instant, a child is able to ingest the opioid. However, keeping pills in medicine cabinets may not always be far enough out-of-reach. Studies have shown that some toddlers have managed to reach medicine cabinets and open child-proof pill containers. Also, patients are frequently unaware of how to dispose of opioids when they are finished with them, Dr. Gaither pointed out.
“At this very moment, there are millions of US households where prescription opioids are sitting [unused] in bathroom cabinets and on bedroom nightstands, and all too often, these medicines are used non-medically—often by friends and family members of those receiving a prescription,” said G. Caleb Alexander, MD, MS, the co-director for the Center for Drug Safety and Effectiveness.
Opioids in the Home: The Dangers of Self-Harm
More opioid poisonings can be attributed to suicide attempts or self-inflicted injury in older children than accidental circumstances, and while this may surprise some doctors, the trend has existed since 1997.4.5
“We found at each time point that the majority of poisonings in those children 10 or older can be attributed to suicide intent,” Dr. Gaither said. The trends were especially prevalent in adolescents age 15 to 19 years, where there was a 140% increase in poisonings related to suicide attempt of self-harm. Poisonings attributed to accidental intent also markedly increased, rising by 303% over the study period.
The most dramatic increases in opioid events over the last several years were seen among teenagers and young adults, 15 to 24 years of age, including a 6-fold increase in deaths attributed to opioid use.4 This age group appears to be particularly vulnerable to opioid events and far more prone to illicit use of opiates than younger children.
For instance, poisonings attributed to heroin use in teens increased by 161% from 0.96 (95%CI, 0.75-1.18) in 1997 to 2.51 (95%CI, 2.21-2.80) in 2012 (P<0.001).5 According to Dr. Gaither, the data illustrates how many teens may progress to heroin use after becoming accustomed to abusing opioid medications.5-9
“Somehow the teen is getting addicted to opioids and becoming reliant on them, either because they are no longer able to access the prescription or because they have found a cheaper source, then they’re switching. And we’ve seen this trend also with adults,too” Dr. Gaither noted.
Perhaps even more alarming are the skyrocketing number of opioid poisonings due to methadone use, which have raisen by 950%, from 0.10 (95% CI, 0.03-0.16) in 1997 to 1.05 (95% CI, 0.87-1.23) in 2012 (P<0.001).6 Methadone’s significantly high affinity for opioid receptors and antagonism of serotonin norepinephrine reuptake inhibitor make it a potent analgesic with high risk of adverse events.
Methadone also frequently has been abused as a narcotic, and like heroin, it has been circulating on the black market. Many teenagers may seek out the drug as an alternative to the other opioid medications they had started taking illicitly, Dr. Gaither noted.
“I think it’s important to note that the teen is often using their own prescription,” said Dr. Gaither, “There are other studies that have shown that for teens who do abuse or misuse them, about 40% of them, the source of the drug is their own prescription.”
There are many instances where younger patients may be prescribed opioids to treat acute or chronic pain conditions, such as: post-operatively, for acute treatment of sports-related injuries, after dental procedures, and in chronic pain management, said Dr. Gaither.
Fortunately, emerging data from 2011 to 2013 does show opioid prescriptions in the US have decreased somewhat.7,10 Indeed, Dr. Gaither and her colleagues found a 7% decrease in prescriptions from 2009 to 2012. While a small change, the drop was statistically significant, and even methadone hospitalizations decreased slightly in patients age 15 to 19 years from 2009 to 2012.
In future studies, Dr. Gaither intends to explore the motivations behind misuse of opioids by teens, especially in the context of suicide. Demographically, the trend leans toward white males, and there may be many reasons why the medications are misused unrelated to self-harm, including self-medicating for anxiety and sleep deprivation.
- Gaither JR, Leventhal JM, Ryan SA, et al. National trends in hospitalizations for opioid poisonings among children and adolescents, 1997 to 2012.JAMA Pediatrics. 2016.
- Manchikanti L, Helm S II, Fellows B, et al. Opioid epidemic in the United States.Pain Physician. 2012;15(3)(suppl):ES9-ES38.
- National Center for Health Statistics. Number and age-adjusted rates of drug-poisoning deaths involving opioid analgesics and heroin: United States 2000-2014. https://www.cdc.gov/nchs/data/health_policy/AADR_drug_poisoning_involving_OA_Heroin_US_2000-2014.pdf. Published 2014. Accessed October 31, 2016.
- Calcaterra S, Glanz J, Binswanger National trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose deaths: 1999-2009.Drug Alcohol Depend. 2013;131(3):263-270.
- Pollini RA, Banta-Green CJ, Cuevas-Mota J, et al. Problematic use of prescription-type opioids prior to heroin use among young heroin injectors. Subst Abuse Rehabil. 2011;2(1):173-180
- Dart RC, Surratt HL, Cicero TJ, et al. Trends in opioid analgesic abuse and mortality in the United States.N Engl J Med. 2015;372(3):241-248.
- Meiman J, Tomasallo C, Paulozzi L. Trends and characteristics of heroin overdoses in Wisconsin, 2003-2012.Drug Alcohol Depend. 2015;152:177-184.
- Cicero TJ, Ellis MS, Surratt HL. Effect of abuse-deterrent formulation of OxyContin.N Engl J Med. 2012;367(2):187-189.
- Cicero TJ, Ellis MS. Abuse-deterrent formulations and the prescription opioid abuse epidemic in the United States: Lessons learned from OxyContin.JAMA Psychiatry. 2015;72(5):424-430.
- Unick GJ, Rosenblum D, Mars S, et al. Intertwined epidemics: National demographic trends in hospitalizations for heroin- and opioid-related overdoses, 1993-2009.PLoS One. 2013;8(2):e54496.