CME Author: Zeena Nackerdien
Study Authors: Julie R. Gaither, Veronika Shabanova, et al.
Target Audience and Goal Statement: Pediatricians, pain management specialists, and primary care physicians
The goal was to explore how U.S. mortality rates have changed for pediatric poisonings over the past 2 decades.
- How many children die each year in the U.S. from opioid poisonings?
- How did the mortality rates change over time since the opioid epidemic began in the late 1990s?
- What were the national trends in pediatric deaths from opioid poisonings as related to age, race/ethnicity, manner of death, specific opioid, and setting (e.g., medical vs residential)?
Synopsis and Perspective:
Opioids are rarely indicated in the long-term treatment of chronic nonmalignant pain in children, although the drugs may be beneficial in certain painful conditions with clearly defined etiologies, according to the American Pain Society (APS). The APS cited sickle cell disease, incurable degenerative joint, and neurodegenerative diseases as examples of such chronic conditions.
Nevertheless, based on one estimate, nearly 5,000 children <6 years old are evaluated each year in emergency departments for opioid exposures. From 1997 to 2012, hospitalizations for opioid poisonings rose almost twofold across all pediatric age groups. The largest proportion of hospitalizations over time occurred among toddlers and preschoolers, according to a 2016 study.
What is known about opioid misuse has largely been obtained from the adult overdose literature. Prior studies typically excluded youths from analyses or grouped them into one (e.g., <25 years) or two (e.g., ages 0-14 and 15-24) broad categories. Thus, the extent to which the pediatric population was harmed over the last 17 years from opioid misuse was obscured in prior analyses.
To quantify the impact of opioid poisonings on youths from 1999 to 2016, Julie R. Gaither, PhD, MPH, RN, of the Yale School of Medicine in New Haven, Connecticut, and colleagues, examined the Multiple Cause of Death File within the U.S. Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (WONDER) system of databases to determine the number of poisonings from prescription and illicit opioids across the study period.
Children were stratified according to four age groups — 0 to 4, 5 to 9, 10 to 14, and 15 to 19. Deaths in each age group were then further subdivided based on intention — i.e, undetermined intent, homicide, suicide, or unintentional death.
From 1999 to 2016, a total of 8,986 children and adolescents who were mostly male (6,567; 73.1%) were found to have died of prescription and illicit opioid poisonings. Most of the deaths occurred in non-Hispanic white children (79.9%) and in boys (73.1%), the researchers reported.
Deaths due to opioid poisonings occurred mostly among adolescents ages 15 to 19 (7,921; 88.0%) and to a lesser extent among younger children ages 0 to 4 (605; 6.7%). Overall, the rise in the death rate over nearly 2 decades represented an increase of 268.2% (0.22 [95% CI, 0.19-0.25] to 0.81 [95% CI, 0.76-0.88] per 100,000; P for time effect < 0.001).
The proportion of deaths due to homicide for children younger than 5 years old was 24.5% (148). Heroin was implicated in 1,872 deaths among adolescents (ages 15 to 19), representing an increase over time of 404.8%. Of the 1,508 opioid deaths that occurred in this age group from 2014 to 2016, a total of 468 deaths (31.0%) were attributed to synthetic opioids.
“While a prior estimate of pediatric opioid deaths that focused only on hospitalizations put the annual death toll at approximately 30 deaths per year, the current study, which includes deaths in all settings, shows that the yearly total is closer to 500, Gaither and co-authors wrote. Nearly 40% of children died at home,” according to a related report.
“The primary thing is that we need to consider — public health officials, legislators, clinicians, and parents — how everyone is affected in the home when an adult brings an opioid into the house,” Gaither told MedPage Today, adding that this includes administering safety recommendations and disposal instructions based on who is in the home.
Study limitations, the researchers noted, included that because they used population-based data collected from U.S. death certificates, there was a potential for misclassification of the cause and manner of death. Another limitation was the fact that it was not possible to report on the circumstances of the deaths or provide more precise information about the opioids implicated in the poisonings.
Source Reference: JAMA Network Open, online Dec. 28, 2018;1(8):e186558
Study Highlights: Explanation of Findings
Over the 17-year period of the study, 8,986 children and adolescents died from prescription and illicit opioid poisonings. The mortality rate over this same period rose 268.2%. Rates were highest among adolescents ages 15 to 19, increasing by 252.6%, followed by a 225.0% increase among children ages 0 to 4, a 150% increase among children 10 to 14, and a 100% increase in children 5 to 9.
Although most deaths occurred in non-Hispanic white males, with each passing year a rising trend was noted among the other races, the researchers found. For instance, when compared with the threefold increase among non-Hispanic white males, black children had a nearly fourfold increase of opioid-related deaths. Similar trends across time were also observed for females. The aforementioned demographic trends are similar to those observed for adults, where rates were increasing rapidly among blacks and women, Gaither and co-authors said.
They noted that several federal and state initiatives to contain the opioid crisis are currently in place that focus almost exclusively on adults, but that this is the first study to specifically address trends in pediatric deaths attributable to the opioid crisis.
Discussing the importance of childproof packaging, the authors also noted that a transdermal patch of fentanyl is available in foil wrappers that could easily be opened by children. Given the pharmacokinetic/pharmacodynamic profiles of the medications that were developed mainly for adults, the researchers said, there is also a concern that a child’s minimal exposure could lead to respiratory arrest and death.
The study found that methadone was implicated in more than one-third of opioid deaths, but that declined steadily after 2007, corresponding to an advisory issued by the U.S. Food and Drug Administration warning physicians of the dangers of using methadone for pain management; however, from 2007 to 2016 more than 11,000 calls were made to U.S. poison control centers for pediatric buprenorphine exposures, for which most of the calls were for children younger than the age of 6, and most of the events occurred in the homes of children.
In addition, given that most pediatric deaths occurred outside of the medical setting and because of the substantial rise of adolescent deaths from heroin and synthetic opioids, Gaither and colleagues said they applaud recent initiatives to increase naloxone availability in homes and communities.
The team also raised the alarm about the large percentage of deaths among the youngest children (0-4 years) that were due to homicides and intentional harm. There is a need to examine what roles abuse, neglect, and parental substance abuse (especially opioid abuse) played in these tragic outcomes, Gaither and co-authors said.
Overall, they said, the results serve as a call to action to engage in pediatric-specific and family-centered interventions to address pediatric opioid poisonings in the U.S.
Elizabeth Hlavinka wrote the original story for MedPage Today.
Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco