We determine trends in fatal pediatric drug overdose from 1999 to 2018 and describe the influence of contextual factors and policies on such overdoses.
Combining restricted CDC mortality files with data from other sources, we conducted between-county multilevel models to examine associations of demographic and socioeconomic characteristics with pediatric overdose mortality and a fixed-effects analysis to identify how changes in contexts and policies over time shaped county-level fatal pediatric overdoses per 100,000 children under 12 years.
Pediatric overdose deaths rose from 0.08/100,000 children in 1999 to a peak of 0.19/100,000 children in 2016, with opioids accounting for an increasing proportion of deaths. Spatial patterns of pediatric overdose deaths are heterogenous. Socioeconomic characteristics are not associated with between-county differences in pediatric overdose mortality. Greater state expenditures on public welfare (B = −0.099; CI: [−0.193, −0.005]) and hospitals (B = −0.222; CI: [−.437, −.007]) were associated with lower pediatric overdose mortality. In years when a Good Samaritan law was in effect, the county-level pediatric overdose rate was lower (B = −0.095; CI: [−0.177, −0.013]).
Pediatric overdose mortality increased since 1999, peaking in 2016. Good Samaritan laws and investment in hospitals and public welfare may temper pediatric overdoses. Multi-faceted approaches using policy and individual intervention is necessary to reduce pediatric overdose mortality.
Pediatric fatalities from psychoactive substances have risen within the U.S. since 1999.
Higher levels of state spending on public welfare and hospitals are significantly associated with lower pediatric overdose mortality rates.
The implementation of Good Samaritan laws is significantly associated with lower pediatric overdose mortality rates.
We identified no county-level sociodemographic factors associated with pediatric overdose mortality.
The findings indicate that a multi-faceted approach to the reduction of pediatric overdose is necessary.
Subscribe to Journal
Get full journal access for 1 year
only $30.69 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Tax calculation will be finalised during checkout.
Rent or Buy article
Get time limited or full article access on ReadCube.
All prices are NET prices.
Birnbaum, H. G. et al. Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain Med. 12, 657–667 (2011).
Dart, R. C. et al. Trends in opioid analgesic abuse and mortality in the United States. N. Engl. J. Med. 372, 241–248 (2015).
Hedegaard, H., Miniño, A. M. & Warner, M. Drug overdose deaths in the United States, 1999–2019. NCHS Data Brief, no 394 (National Center for Health Statistics, 2020).
Ciccarone, D. The triple wave epidemic: supply and demand drivers of the US opioid overdose crisis. Int. J. Drug Pol. 71, 183 (2019).
Jalal, H. et al. Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016. Science 361, eaau1184 (2018).
Bohnert, A. S. B. et al. Overdose and adverse drug event experiences among adult patients in the emergency department. Addict. Behav. 86, 66–72 (2018).
Martins, S. S. et al. Prescription opioid use disorder and heroin use among youth nonmedical prescription opioid users from 2002 to 2014. Addict. Behav. 65, 236–241 (2017).
Whiteside, L. K. et al. Nonmedical prescription opioid and sedative use among adolescents in the emergency department. Pediatrics 132, 825–832 (2013).
Allen, J. D. et al. Prescription opioid exposures among children and adolescents in the United States: 2000–2015. Pediatrics 139, e20163382 (2017).
Lovegrove, M. C., Weidle, N. J. & Budnitz, D. S. Trends in emergency department visits for unsupervised pediatric medication exposures, 2004–2013. Pediatrics 136, e821–e829 (2015).
Gaither, J. R., Shabanova, V. & Leventhal, J. M. US national trends in pediatric deaths from prescription and illicit opioids, 1999-2016. JAMA Netw. Open 1, e186558 (2018).
Wang, G. S., Olsen, H., Severtson, G., Green, J. L. & Dart, R. C. The impact of the prescription opioid epidemic on young children: trends and mortality. Drug Alcohol Depend. 211, 107924 (2020).
Patrick, S. W., Davis, M. M., Lehmann, C. U. & Cooper, W. O. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J. Perinatol. 35, 650–655 (2015).
Tolia, V. N. et al. Increasing incidence of the neonatal abstinence syndrome in U.S. neonatal ICUs. N. Engl. J. Med. 372, 2118–2126 (2015).
Patrick, S. W. et al. Improving care for neonatal abstinence syndrome. Pediatrics 137, e20153835 (2016).
Gummin, D. D. et al. 2018 Annual report of the American Association of Poison control centers’ National Poison Data System (NPDS): 36th annual report. Clin. Toxicol. 57, 1220–1413 (2019).
Groenewald, C. B., Rabbitts, J. A., Gebert, T. & Palermo, T. M. Trends in opioid prescriptions among children and adolescents in the United States: a nationally representative study from 1996 to 2012. Pain 157, 1021–1027 (2016).
Bailey, J. E., Campagna, E. & Dart, R. C. The underrecognized toll of prescription opioid abuse on young children. Ann. Emerg. Med. 53, 419–424 (2009).
Finkelstein, Y. et al. Overdose risk in young children of women prescribed opioids. Pediatrics 139, e20162887 (2017).
Burghardt, L. C. et al. Adult prescription drug use and pediatric medication exposures and poisonings. Pediatrics 132, 18–27 (2013).
Voepel-Lewis, T., Wagner, D. & Tait, A. R. Leftover prescription opioids after minor procedures: an unwitting source for accidental overdose in children. JAMA Pediatr. 169, 497–498 (2015).
Graham, J., Leonard, J., Banerji, S. & Wang, G. S. Illicit drug exposures in young pediatric patients reported to the National Poison Data System, 2006-2016. J. Pediatr. 219, 254–258 (2020).
Yin, S. Malicious use of pharmaceuticals in children. J. Pediatr. 157, 832–836 (2010).
Kane, J. M., Colvin, J. D., Bartlett, A. H. & Hall, M. Opioid-related critical care resource use in US children’s hospitals. Pediatrics 141, e20173335 (2018).
Davis, C. S. & Carr, D. Legal changes to increase access to naloxone for opioid overdose reversal in the United States. Drug Alcohol Depend. 157, 112–120 (2015).
Davis, C. S. & Carr, D. State legal innovations to encourage naloxone dispensing. J. Am. Pharm. Assoc. 57, S180–S184 (2017).
Fishman, S. M., Papazian, J. S., Gonzalez, S., Riches, P. S. & Gilson, A. Regulating opioid prescribing through prescription monitoring programs: balancing drug diversion and treatment of pain. Pain Med. 5, 309–324 (2004).
Gugelmann, H. M. & Perrone, J. Can prescription drug monitoring programs help limit opioid abuse? JAMA 306, 2258–2259 (2011).
Haegerich, T. M., Paulozzi, L. J., Manns, B. J. & Jones, C. M. What we know, and don’t know, about the impact of state policy and systems-level interventions on prescription drug overdose. Drug Alcohol Depend. 145, 34–47 (2014).
Wheeler, E., Davidson, P. J., Jones, T. S. & Irwin, K. S. Community-based opioid overdose prevention programs providing naloxone—United States, 2010. MMWR Morb. Mortal. Wkly Rep. 61, 101 (2012).
Carlson, R. G., Nahhas, R. W., Martins, S. S. & Daniulaityte, R. Predictors of transition to heroin use among initially non-opioid dependent illicit pharmaceutical opioid users: a natural history study. Drug Alcohol Depend. 160, 127–134 (2016).
Mars, S. G., Bourgois, P., Karandinos, G., Montero, F. & Ciccarone, D. “Every ‘never’ I ever said came true”: transitions from opioid pills to heroin injecting. Int. J. Drug Pol. 25, 257–266 (2014).
Powell, D., Pacula, R. L. & Jacobson, M. Do medical marijuana laws reduce addictions and deaths related to pain killers? J. Health Econ. 58, 29–42 (2018).
Scholl, L., Seth, P., Kariisa, M., Wilson, N. & Baldwin, G. Drug and opioid-involved overdose deaths — United States, 2013–2017. MMWR Morb. Mortal. Wkly Rep. 67, 1419 (2019).
Allison, P. Fixed Effects Regression Models (SAGE, 2009).
Halaby, C. N. Panel models in sociological research: theory into practice. Annu. Rev. Sociol. 30, 507–544 (2004).
Winship, C. & Morgan, S. L. The estimation of causal effects from observational data. Annu. Rev. Sociol. 25, 659–706 (1999).
Rudd, R. A., Seth, P., David, F. & Scholl, L. Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. MMWR Morb. Mortal. Wkly Rep. 65, 1445–1452 (2016).
Eckenrode, J., Smith, E. G., McCarthy, M. E. & Dineen, M. Income inequality and child maltreatment in the United States. Pediatrics 133, 454–461 (2014).
Kenney, G. M., Long, S. K. & Luque, A. Health reform in Massachusetts cut the uninsurance rate among children in half. Health Aff. 29, 1242–1247 (2010).
Post, S., Spiller, H. A., Casavant, M. J., Chounthirath, T. & Smith, G. A. Buprenorphine exposures among children and adolescents reported to US poison control centers. Pediatrics 142, e20173652 (2018).
Budnitz, D. S. & Salis, S. Preventing medication overdoses in young children: an opportunity for harm elimination. Pediatrics 127, e1597–e1599 (2011).
Egan, K. L. et al. Disposal of prescription drugs by parents of middle and high school students. J. Child Adolesc. Subs. Abus. 28, 92–98 (2019).
Rodgers, G. B. The safety effects of child-resistant packaging for oral prescription drugs: two decades of experience. JAMA 275, 1661–1665 (1996).
Hampp, C. et al. The role of unit-dose child-resistant packaging in unintentional childhood exposures to buprenorphine–naloxone tablets. Drug Saf. 43, 189–191 (2020).
Wang, G. S., Severtson, S. G., Bau, G. E., Dart, R. C. & Green, J. L. Unit-dose packaging and unintentional buprenorphine-naloxone exposures. Pediatrics 141, e20174232 (2018).
Centers for Disease Control and Prevention. “Up and Away” campaign. https://www.cdc.gov/medicationsafety/protect/campaign.html (2020).
Buchanich, J. M., Balmert, L. C., Williams, K. E. & Burke, D. S. The effect of incomplete death certificates on estimates of unintentional opioid-related overdose deaths in the United States, 1999-2015. Public Health Rep. 133, 423–431 (2018).
All phases of this study were supported by The National Institute on Drug Abuse (NIDA), grant #R21DA046447.
The authors declare no competing interests.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Appendix A. Descriptive statistics (pooled over counties and year, N = 50,079)
|County-level overdose rate|
|All pediatric psychoactive substance overdoses||0.14 (2.46)|
|Prescription drug monitoring program||68.62%|
|Good Samaritan law for drug overdoses||9.55%|
|Naloxone possession—no criminal liability||1.60%|
|Pain management clinic law||11.16%|
|State-level per capita expenditures ($)|
|Public welfare||1.24 (0.42)|
|Unemployment rate||4.19 (1.81)|
|Median household income||41,761 (11,461)|
|Percent living in poverty||11.40 (5.65)|
|Percent with Bachelor’s degree||13.36 (6.63)|
|Percent foreign-born||4.09 (5.33)|
|Percent female-headed households||6.39 (2.45)|
|Percent Black||9.25 (14.35)|
|Percent Hispanic||7.81 (12.86)|
|Large central metro||2.14%|
|Large fringe metro||11.70%|
Appendix B. Descriptive information on all psychoactive substances involved in pediatric overdoses, 1999–2018
|Substance (ICD-10 code)||N (%)||% of single substance||% of combination|
|Prescription opioid (T40.2)||427 (37.9%)||82.2%||17.8%|
|Methadone (T40.3)||247 (21.9%)||91.1%||8.9%|
|Synthetic opioid (T40.4)||128 (11.4%)||78.1%||21.9%|
|Psychostimulants (T43.6)||95 (8.4%)||86.3%||13.7%|
|Cocaine (T40.5)||77 (6.8%)||75.3%||24.7%|
|Antidepressants (T43.0, T43.2)||75 (6.7%)||69.3%||30.7%|
|Benzodiazepines (T42.4)||56 (5.0%)||26.8%||73.2%|
|Unidentified narcotic (T40.6)||50 (4.4%)||64.0%||36.0%|
|Other sedatives (T42.6, T42.7, T42.8)||39 (3.5%)||66.7%||33.3%|
|Antipsychotics (T43.3, T43.5)||38 (3.4%)||60.5%||39.5%|
|Heroin (T40.1)||23 (2.0%)||39.1%||60.9%|
|Barbiturates (T42.3)||12 (1.1%)||75.0%||25.0%|
Note: Percentage of deaths do not add to 100 because multiple psychoactive substances can be involved in a single death. There is no overlap for substances classified within different categories.
About this article
Cite this article
Kelly, B.C., Vuolo, M. & Frizzell, L.C. Pediatric drug overdose mortality: contextual and policy effects for children under 12 years. Pediatr Res (2021). https://doi.org/10.1038/s41390-021-01567-7