Suspected Nonfatal Drug-Related Overdoses Among Youth in the US: 2016-2019

Physician Follow-Up of Pediatric and Young Adult Emergency Department Visits for Substance Use in Ontario, Canada

PURPOSE

To study the proportion and predictors of outpatient physician follow-up within 60 days of substance-related emergency department (ED) visits for Ontario youth.

METHODS

We examined administrative data on substance-related ED visits before and during the COVID-19 pandemic among youths aged 10-24 years in Ontario, Canada. Substance-related visits were identified using International Classification of Diseases-10-CA codes. We described demographic characteristics, receipt of mental health services in the year before the ED visit, disposition from the ED, and follow-up services within 60 days of the ED visit.

RESULTS

Between April 1, 2017, and May 31, 2021, 64,236 youth had at least one ED visit for substance use. Visits for alcohol were the most common (49%), followed by cannabis (32.3%). ED visits for all substances were more prevalent during the pandemic than prepandemic, except visits for alcohol. The receipt of follow-up physician care for substance use was low (33.2% prepandemic) but increased during the pandemic (41.7%; adjusted odds ratio 1.34, 95% CI 1.28, 1.39) and varied between substances. Mental health service history in the year before the substance-related ED visit had the strongest association with receipt of follow-up physician care within 60 days (adjusted odds ratio 6.86, 95% CI 6.57, 7.17).

DISCUSSION

Youth frequently do not receive physician follow-ups within two months of the substance-related ED visit, although higher follow-up proportions were seen during the pandemic after the implementation of virtual care. Further research is required to understand why follow-up is low and to examine interventions that can increase connection to care.

Characteristics and Trends of Prehospital Encounters for Opioid Overdoses Among US Youth, 2018-2022

This cross-sectional study analyzes characteristics of prehospital encounters for youth opioid overdoses and trends before and during the COVID-19 pandemic.

Trends in opioid exposures among young children reported to United States poison centers from 2016 to 2023

INTRODUCTION

The objective of this study was to update and expand on previous studies of opioid exposures among young children reported to America's Poison Centers, and to describe how fentanyl and medications for opioid use disorder have contributed.

METHODS

This retrospective study investigated 34,632 reports of single-substance opioid exposure from 2016 to 2023 involving pediatric patients aged one month to six years old. Descriptive statistics, tests for data normality, and significance testing were performed where applicable.

RESULTS

Of 34,632 reported exposures, 96.7% were unintentional. The median age of exposure was 2.0 years (IQR 1.33-3.0 years). Reported exposures decreased by 57.5% over the study period (r = -0.96; P < 0.001). However, there was a 300% absolute increase in deaths and major effects (r = 0.96; P < 0.001). Exposures resulting in minor, no effect, not followed, or unable to follow decreased 66.2% (r = -0.99; P < 0.001). Buprenorphine was most frequently involved, comprising 23.4% of reported exposures. Buprenorphine (OR 1.93; P < 0.001) and methadone (OR 14.98; P < 0.001) were associated with an increased risk of severe effects when compared to other prescription drugs (OR: 1). There was an absolute increase of 512% over time in reports of heroin, fentanyl, synthetic non-pharmaceutical opioids (r = 0.92; P < 0.001), which were also associated with severe effects (OR 20.1; P < 0.001).

DISCUSSION

Pediatric opioid exposures have previously been reported to be relatively stable. It is likely the 57.5% reduction is exaggerated due to underreporting from health care providers. However, decreases in exposures are presumed to be balanced throughout the dataset and, therefore, without differential impact on other points of analysis. Our study highlights the continued need for enhanced poisoning prevention strategies.

CONCLUSIONS

The relative severity of poisonings reported to poison centers worsened over the study period. The opioids implicated have shifted away from hydrocodone, oxycodone, and tramadol, and towards fentanyl and buprenorphine.

Analysis of rising cases of adolescent opioid use presentations to the emergency department and their management

OBJECTIVE

We sought to answer the question of how adolescents (ages 12-17 years old) with opioid-related presentations are currently managed in the ED. The two main outcomes were the proportion of visits where naloxone and buprenorphine were both used and prescribed, and the rate of revisits to the emergency department in the six months following ED presentation.

METHODS

This was a multi-center retrospective cross-sectional study. We studied patients presenting to the ED who were 12-17 years old with an opioid-related presentation.

RESULTS

Two-hundred and thirty-one patients were identified out of 571 encounters screened. Of these presentations, 77/231 (33%) were girls and 154/231 (67%) were boys. The majority of patients were Latino (64%; n=147); 26% were white (n=59), 6% were middle eastern or Arab (14), and 4% were black (10). Incidence of opioid use disorder per 100,000 presentations increased by 2800% from 2014 to 2022 (21/100,000 +/- 10 [2014] to 600/100,000 +/- 50 [2022]). A plurality of cases was related to opioid withdrawal (42%; 97). On discharge from the ED, 29% of patients received naloxone. For patients in withdrawal, 4% received a prescription for buprenorphine. Twenty-nine percent of patients had a return to the ED in the six months following initial visit.

CONCLUSIONS

Adolescent opioid-related presentations to the ED are rapidly increasing. Increasing ED presentations, compounded by a high 6-month revisit rate, pose a management challenge amid limited outpatient resources for this population. Opioid agonist therapy and naloxone are not routinely provided. Increasing the use of both are two ways to improve the quality of care for this population.

Is Early Onset of Nonmedical Prescription Stimulant Use Associated With Cocaine Use During Adolescence? Results From a National Study

BACKGROUND

To examine the associations between early onset of nonmedical prescription stimulant use (NPSU) and cocaine use.

METHODS

Nationally representative samples of high school seniors were surveyed annually. Data were collected via self-administered questionnaires in nationally representative public and private schools in the United States (1976-2020) as part of the Monitoring the Future Study. The sample consisted of 45 cohorts of 12th grade students (N = 121 909). The main outcome was lifetime, past-year, and past-month cocaine use.

RESULTS

An estimated one in every 10 (10.1%) individuals reported lifetime NPSU while 8.5% reported any cocaine use. The vast majority of youth (87.2%) initiated NPSU before cocaine among those who reported both substances. Cocaine use was most prevalent among youth who reported early onset of NPSU in 8th grade or earlier (51.7%) followed by those who reported later onset of NPSU in 12th grade (24.7%), and those who never initiated NPSU (3.7%). Binary logistic regression analysis indicated that early onset of NPSU had greater adjusted odds of cocaine use compared to those with later onset of NPSU or those who never reported NPSU. Moreover, the adjusted odds of cocaine use were higher for adolescents who initiated NPSU before or after medical use of prescription stimulants compared to those with no history of medical use or NPSU. Similar results were found for lifetime, past-year, and past-month cocaine use as a function of NPSU onset; this association was stronger among more recent cohorts.

CONCLUSIONS

Early onset of NPSU appears to be a signal of increased risk of cocaine use among US adolescents. NPSU should be included in screening and early prevention strategies among secondary school students. Health professionals, school officials, and families are encouraged to monitor youth for NPSU based on the increased risk of later cocaine use and related consequences.

Investigating the co-occurrence of marijuana use and prescription opioid misuse with multiple suicide attempts among adolescents with a history of suicidal ideation

This study investigated the co-occurrent association of marijuana use and prescription opioid misuse with multiple suicide attempts among adolescents with a history of suicidal ideation. Data came from the 2019 Youth Risk Behavior Survey. The sample was comprised of adolescents ages 14-18 who reported suicidal ideation during the past year (n = 2,562). Multinomial logistic regression was used to examine the co-occurring association of marijuana use and prescription opioid misuse with multiple suicide attempts. Of the 2,562 adolescents who experienced suicidal ideation, 19.2 % also attempted suicide multiple times during the past year and 19.0 % reported ever using marijuana and misusing prescription opioids, 8.8 % misused prescription opioids only, and 33.3 % used marijuana only. In the multivariate model, for adolescents who used marijuana and misused prescription opioid, the risk of attempting suicide once was 1.77 times higher (RRR = 1.77, 95 % CI = 1.22-2.59) and the risk of multiple suicide attempts was 3.23 times higher (RRR = 3.23, 95 % CI = 1.95-5.33) when compared to adolescents who had never used marijuana nor misused prescription opioid. The risk of multiple suicide attempts was greater for bisexual and racial/ethnic minority adolescents and adolescents who felt sad or hopeless. Interventions that prevent prescription opioid misuse among adolescents may be effective in mitigating suicide attempts.

US-Mexico Border Stress and Daily Substance Use among Latino Youth: a Cross-Sectional Study

Background

Historically marginalized youth are at risk for daily substance use. Daily use may be associated with social and environmental factors.

Methods

In March 2018, we surveyed primarily Latino adolescents ages 14-18 who lived on the US-Mexico border and assessed associations between daily substance use, neighborhood stress, border community and immigration stress, and family support.

Results

Of 443 surveyed adolescents, 41 (9%) reported daily use. Those who used daily were more likely to be older, identify as male, and reported lower social support and higher neighborhood and border community stress compared to those who did not use daily. Perceived neighborhood stress (OR = 1.95, 95% CI 1.37-2.80) and border community and immigration stress (OR = 1.55, 95% CI 1.12-2.02) were associated with increased odds of daily substance use.

Discussion

Latino adolescents who live near the US-Mexico border experience unique socioenvironmental stress which is associated with daily substance use.

Identifying early intervention opportunities for illicit stimulant use: A cross-sectional study of factors associated with illicit stimulant use among young people accessing integrated youth services in British Columbia, Canada

INTRODUCTION

Illicit stimulant (cocaine and/or amphetamine) use among young people aged 12-24 is a public health priority given that substance use initiation tends to peak in this developmental period and significant associated immediate and long-term harms are associated with its use. Young people using stimulants must be engaged in services as early as possible to reduce these harms. To inform early intervention opportunities, this study aimed to identify the risk/protective factors associated with illicit stimulant use among young people.

METHODS

We conducted a cross-sectional study on routinely collected self-reported data among young people accessing integrated youth services in British Columbia (Canada) between April 2018 and January 2022. Data were collected on young peoples' socio-demographic characteristics, and social, behavioral, and health profiles. Variable selection was guided by established risk/protective factors for substance use among young people. The study used multivariable logistic regression to identify risk/protective factors that were independently associated with past 30-day illicit stimulant use.

RESULTS

The analytic sample included n = 5620 young people aged 12-24 and a total of 163 (2.9 %) reported past 30-day illicit cocaine and/or amphetamine use. Demographic characteristics that were independently associated with illicit stimulant use included older age (aOR = 1.27, 95 % CI = 1.17-1.38) and gender identity as man vs woman (aOR = 1.71, 95 % CI = 1.10-2.70). Social and environmental risk factors included recently witnessing or experiencing violence (aOR = 2.32, 95 % CI = 1.47-3.68) and higher past-year crime/violent behaviors score (aOR = 1.39, 95 % CI = 1.13-1.69). Finally, regular alcohol (aOR = 6.90, 95 % CI = 2.36-25.42), regular (aOR = 3.74, 95 % CI = 1.95-7.54) or social (aOR = 3.06, 95 % CI = 1.44-6.60) tobacco use, and lifetime hallucinogen (aOR = 3.24, 95 % CI = 1.8-5.91) and ecstasy/MDMA (aOR = 2.53, 95 % CI = 1.48-4.39) use were also statistically significant risk factors.

CONCLUSIONS

These risk/protective factors support identification of young people who may benefit from further screening, assessment, and treatment for illicit stimulant use. This study also underscores the need to expand early intervention and harm reduction programs that can comprehensively respond to young peoples' stimulant use, health, and social needs.

Adolescent Drug Ingestions Requiring ICU Stay: Single-Center Retrospective Cohort Study

OBJECTIVES

Ingestions are a prevalent form of self-harm in teenagers and are unfortunately an increasingly common reason for admission to both acute care and critical care services. The goal of this study was to identify characteristics associated with requiring PICU stay among adolescents hospitalized for ingestions.

DESIGN

Retrospective cohort study comparing patients admitted to hospital medicine service and critical care service from January 2019 to December 2019.

SETTING

Freestanding children's hospital in the midwestern United States.

PATIENTS

Adolescents 12-18 years old hospitalized for ingestion.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Out of 209 patients included in the study cohort, 95 required PICU admission. High-risk behaviors (having had sex or usage of alcohol, drugs, tobacco, or vaping) were endorsed by 190 of 209 patients (91%). We compared patient characteristics, ingestion history, workup, and pharmacological and PICU-specific interventions between patients hospitalized on the hospital medicine service and the PICU. We failed to identify an association between reason for ingestion, substance ingested, and previously identified suicide risk factors including previous suicide attempt, previous self-harm, and psychiatric comorbidity and admission to PICU, as opposed to non-PICU admission. PICU stay was associated with longer peak corrected QT interval value, receiving a pharmacological intervention, and longer duration of hospital stay. Fifteen of 95 patients (16% [95% CI, 9-25%]) in the PICU received a PICU-specific intervention.

CONCLUSIONS

We failed to identify specific patient demographics or mental behavioral health characteristics associated with PICU stay after ingestion. Therefore, we believe that all adolescents hospitalized due to ingestion-irrespective of disposition-should receive standardized high-risk behavior screening due to the pervasive nature of these behaviors among this patient population. PICU-specific care, beyond observation, could be needed in as high as one-in-four PICU admissions. Further research is needed to inform optimal disposition and resource allocation for this patient population.

Addressing adolescent substance use with a public health prevention framework: the case for harm reduction

Adolescence is a developmental stage defined in part by risk-taking. Risk-taking is critical to normal development and has important benefits including trying new activities and exploring new relationships. Risk-taking is also associated with the initiation of substance use. Because substance use often begins in adolescence, much focus has been on primary prevention with the goal of preventing initial substance use. Secondary or tertiary prevention approaches, such as counselling to eliminate substance use or offering treatment, are common approaches for adolescents with problematic substance use or a substance use disorder. While this is important, for some adolescents, treatment or cessation of use may not be desired. In these cases, Healthcare Practitioners (HCPs) can offer clear advice that incorporates harm reduction. Harm reduction, which is often applied for adults who use substances, reduces the negative impacts associated with drug use without requiring abstinence. Harm reduction is crucial to keeping adolescents safe and healthy and can offer opportunities for future engagement in treatment. The objective of this review is to describe strategies for integrating harm reduction principles in clinical settings that are developmentally appropriate. A patient-centered, harm reduction approach can validate perceived benefits of substance use, offer strategies to minimise harm, and advise reduction of use and abstinence.KEY MESSAGES:Substance use often begins in adolescence and traditional approaches are often rooted in prevention framework.Harm reduction should be incorporated for adolescents with problematic substance use or a substance use disorder.This review offers strategies for integration of harm reduction principles tailored towards adolescents.

Attitudes and training related to substance use in pediatric emergency departments

BACKGROUND

In recent years, pediatric emergency departments (PED) have seen an increase in presentations related to substance use among their adolescent patient population. We aimed to examine pediatric emergency medicine (PEM) physicians' knowledge, attitudes, and beliefs on caring for adolescents with substance use.

METHODS

We conducted a cross-sectional online survey of PEM physicians through the American Academy of Pediatrics Pediatric Emergency Medicine Collaborative Research Committee (PEM-CRC) listserv. The 41-item survey contained the following domains: demographics, current protocols and education for managing adolescent substance use, and attitudes about treatment of substance use. We calculated descriptive statistics for each variable within the domains.

RESULTS

Of 177 respondents (38.2% response rate), 55.4% were female, 45.2% aged ≥ 50 years, 78% worked in a children's hospital, and 50.8% had > 15 years clinical practice. Overall, 77.8% reported caring for adolescents with a chief complaint related to non-opioid substance use and 26.0% opioid use at least once a month. Most (80.9%) reported feeling comfortable treating major medical complications of substance use, while less than half were comfortable treating withdrawal symptoms. 73% said that they were not interested in prescribing buprenorphine.

CONCLUSIONS

Among this national sample of PEM physicians, 3 of 4 physicians managed substance-related visits monthly, but 52% lacked comfort in managing withdrawal symptoms and 73.1% were not interested in prescribing buprenorphine. Almost all PEM physician identified substance use-related education is important but lacked access to faculty expertise or educational content. Expanded access to education and training for PEM physicians related to substance use is needed.

Young Adult Substance Use and Healthcare Use Associated With Screening, Brief Intervention and Referral to Treatment in Pediatric Primary Care

PURPOSE

Screening, brief intervention, and referral to treatment (SBIRT) may impact future comorbidity and healthcare utilization among adolescents screening positive for substance use or mood problems.

METHODS

In a randomized trial sample, we compared an SBIRT group to usual care for substance use, mental health, medical diagnoses, and healthcare utilization over 7 years postscreening.

RESULTS

In logistic regression models adjusting for patient characteristics, the SBIRT group had lower odds of any substance (Odds Ratio[OR] = 0.80, 95% Confidence Interval [CI] = 0.66-.98), alcohol (OR = 0.69, 95% CI = 0.51-0.94), any drug (OR = 0.73, 95% CI = 0.54-0.98), marijuana (OR = 0.70, 95% CI = 0.50-0.98), and tobacco (OR = 0.83, 95% CI = 0.69-1.00) diagnoses, and lower odds of any inpatient hospitalizations (OR = 0.59, 95% CI = 0.41-0.85) compared with usual care. Negative binomial models examining number of visits among adolescents with at least one visit of that type found that those in the SBIRT group had fewer primary care (incidence rate ratio[iRR] = 0.90, p < .05) and psychiatry (iRR = 0.64, p < .01) and more addiction medicine (iRR = 1.52, p < .01) visits over 7 years compared with usual care. In posthoc analyses, we found that among Hispanic patients, those in the SBIRT group had lower odds of any substance, any drug and marijuana use disorder diagnoses compared with usual care, and among Black/African American patients, those in the SBIRT group had lower odds of alcohol use disorder diagnoses compared with usual care.

DISCUSSION

Beneficial effects of adolescent SBIRT on substance use and healthcare utilization may persist into young adulthood.

Stimulant misuse among youth

Rates of stimulant use, including misuse of prescription stimulants and use of cocaine and methamphetamine, are rising rapidly among adolescents and young adults ("youth"). Stimulant misuse is associated with overdose, polysubstance use, substance use disorders, and other medical harms. Substance use is often initiated during adolescence and young adulthood, and interventions during these crucial years have the potential to impact the lifetime risk of stimulant use disorder and associated harms. In this narrative review, we review recent data on prescription and illicit stimulant use in youth. We describe the rising contribution of stimulants to polysubstance use involving opioids and other substances and to overdose, as well as ways to minimize harm. We also discuss prescription stimulant misuse, which is especially prevalent among youth relative to other age groups, and the limited evidence on potential pathways from prescription stimulant use to illicit stimulant use. Last, we assess potential strategies for the prevention and treatment of stimulant use disorder in youth.

Caregiver Practices and Knowledge Regarding Leftover Prescription Medications in Homes With Children

OBJECTIVES

The aims of the study were to determine the frequency of and factors associated with leftover or expired prescription medication ("leftover medication") presence in homes with children and to assess caregivers' reported behaviors and knowledge regarding disposal of leftover medications in the home.

METHODS

This study is a planned secondary analysis from a survey of primary caregivers of children aged 1 to 17 years presenting to an emergency department. The survey assessed leftover medications in the home and medication disposal practices, knowledge, and guidance. The survey was developed iteratively and pilot tested. Multivariable logistic regression was used to identify factors associated with leftover medication presence in the home.

RESULTS

We enrolled 550 primary caregivers; 97 of the 538 analyzed (18.0%; 95% confidence interval [CI], 14.8-21.5) reported having leftover medications in their home, most commonly antibiotics and opioids. Of respondents, 217/536 (40.5%) reported not knowing how to properly dispose of medications and only 88/535 (16.4%) reported receiving guidance regarding medication disposal. Most caregivers reported throwing leftover medications in the trash (55.7%) or flushing them down the toilet (38.5%). Caregivers with private insurance for their child were more likely to have leftover medications (adjusted odds ratio [aOR], 1.99; CI, 1.15-3.44), whereas Hispanic caregivers (aOR, 0.24; CI, 0.14-0.42) and those who received guidance on leftover medications (aOR, 0.30; CI, 0.11-0.81) were less likely to have leftover medications in the home.

CONCLUSIONS

Leftover medications are commonly stored in homes with children and most caregivers do not receive guidance on medication disposal. Improved education and targeted interventions are needed to ensure proper medication disposal practices.

Perceived Normalization of Drug Trafficking and Adolescent Substance Use on the US-Mexico Border

BACKGROUND

Historically marginalized youth are at risk for daily substance use. Daily use may be associated with social and environmental factors.

METHODS

In March 2018, we surveyed primarily Latino adolescents ages 14-18 who lived on the US-Mexico border and assessed associations between daily substance use, neighborhood stress, border community and immigration stress, and family support.

RESULTS

Of 443 surveyed adolescents, 41 (9%) reported daily use. Those who used daily were more likely to be older, identify as male, and reported lower social support and higher neighborhood and border community stress compared to those who did not use daily. Perceived neighborhood stress (OR = 1.95, 95% CI 1.37-2.80) and border community and immigration stress (OR = 1.55, 95% CI 1.12-2.02) were associated with increased odds of daily substance use.

DISCUSSION

Latino adolescents who live near the US-Mexico border experience unique socioenvironmental stress which is associated with daily substance use.

Pediatric suicides reported to U.S. poison centers

INTRODUCTION

As the pediatric mental health crisis worsens, the rate of adolescent suicide-related cases is increasing, including adolescent cases of self-poisoning.

METHODS

Data from the National Poison Data System was analyzed for trends in rates and frequencies of all pediatric suspected suicides between 2015 and 2020.

RESULTS

There were 514,350 pediatric suspected suicides analyzed, with the largest increase in rate of suspected suicides occurring in children ages 10 to 12 years (109.3%, p = 0.002). Rates also increased significantly in children ages 13 to 15 years (30.3%, p < 0.001) and 16 to 19 years (18.1%, p < 0.05). The most commonly utilized substances were ibuprofen and acetaminophen, with the largest increase in rate of exposures seen for acetaminophen. Discussion: This data demonstrates concerning rises in cases of self-poisoning, suggesting that the pediatric mental health crisis is worsening and extending into younger populations. Pediatric populations have easier access to over-the-counter medications, potentially explaining the likelihood of utilization of these medications in pediatric suspected suicides.

CONCLUSIONS

Initiation of appropriate mental health screenings and interventions should be considered in these young age groups in order to prevent further rises in self-poisoning cases and associated morbidity and mortality.

Dopamine Supersensitivity: A Novel Hypothesis of Opioid-Induced Neurobiological Mechanisms Underlying Opioid-Stimulant Co-use and Opioid Relapse

Emergent harms presented by the co-use of opioids and methamphetamine highlight the broader public health challenge of preventing and treating opioid and stimulant co-use. Development of effective therapeutics requires an understanding of the physiological mechanisms that may be driving co-use patterns, specifically the underlying neurobiology of co-use and how they may facilitate (or be leveraged to prevent) continued use patterns. This narrative review summarizes largely preclinical data that demonstrate clinically-meaningful relationships between the dopamine and opioid systems with direct implications for opioid and stimulant co-use. Synthesized conclusions of this body of research include evidence that changes in the dopamine system occur only once physical dependence to opioids develops, that the chronicity of opioid exposure is associated with the severity of changes, and that withdrawal leaves the organism in a state of substantive dopamine deficit that persists long after the somatic or observed signs of opioid withdrawal appear to have resolved. Evidence also suggests that dopamine supersensitivity develops soon after opioid abstinence and results in increased response to dopamine agonists that increases in magnitude as the abstinence period continues and is evident several weeks into protracted withdrawal. Mechanistically, this supersensitivity appears to be mediated by changes in the sensitivity, not quantity, of dopamine D2 receptors. Here we propose a neural circuit mechanism unique to withdrawal from opioid use with implications for increased stimulant sensitivity in previously stimulant-naïve or inexperienced populations. These hypothesized effects collectively delineate a mechanism by which stimulants would be uniquely reinforcing to persons with opioid physical dependence, would contribute to the acute opioid withdrawal syndrome, and could manifest subjectively as craving and/or motivation to use that could prompt opioid relapse during acute and protracted withdrawal. Preclinical research is needed to directly test these hypothesized mechanisms. Human laboratory and clinical trial research is needed to explore these clinical predictions and to advance the goal of developing treatments for opioid-stimulant co-use and/or opioid relapse prevention and withdrawal remediation.