key: cord-0255234-qsi20mp8
authors: Friedman, J.; Godvin, M.; Shover, C.; Gone, J. P.; Hansen, H.; Schriger, D.
title: Sharp Increases in Drug Overdose Deaths Among High-School-Age Adolescents During the US COVID-19 Epidemic and Illicit Fentanyl Crisis
date: 2021-12-24
journal: nan
DOI: 10.1101/2021.12.23.21268284
sha: 0690af33970d8eb1f2667132d51fa44473c85f78
doc_id: 255234
cord_uid: qsi20mp8

Although overdose deaths in the US have increased exponentially for the past four decades, these shifts have historically affected adults, while pediatric overdose rates remained stable. However, this may be changing, given that the illicit drug supply has become increasingly hazardous in recent years, as illicitly-manufactured-fentanyls (IMFs) and other synthetic opioid and benzodiazepine analogues are increasingly sold as heroin and counterfeit prescription pills. We calculated drug overdose deaths per 100,000 population by 5-year age groups for the 2010-2021 period. For high-school-aged adolescents (age 14-18), we stratified rates by race/ethnicity, census region, associated substance, and ICD-10 cause-of-death intent categories. Adolescent overdose mortality saw a sharp increase between 2019 and 2020, from 2.35 per 100,000 to 4.58 per 100,000, representing a 94.3% increase, the largest percent increase of any 5-year age group. American Indian or Alaska Native (AIAN) adolescents, Latinx adolescents, and adolescents in the West census region were disproportionately affected, overdose death rates 2.15, 1.31, and 1.68 times the national average in 2021, respectively. Trends were driven by fatalities involving IMFs, which nearly tripled from 2019 to 2020, and represented 76.6% of adolescent overdose deaths in 2021. Sharp increases in adolescent drug overdose deaths, despite flat or declining drug use rates, and no increase in deaths from alcohol or most drugs, reinforce that rising fatalities are likely driven by an increasingly toxic, IMF-contaminated drug supply. Rising racial disparities in overdose require a prevention approach that ameliorates deep-seated social and economic inequalities as well as poor access to mental and physical healthcare and social services for AIAN and Latinx adolescents. Our results should also be understood in the context of rising rates of adolescent mental illness during the COVID-19 pandemic. These findings highlight the urgent need for accurate, harm-reduction-oriented education for early adolescents about the risks of an evolving drug supply, as well as greater access to naloxone and services that check drugs for the presence of IMFs.

Although overdose deaths in the US have increased exponentially for the past four decades, these shifts 13 have historically affected adults, while pediatric overdose rates remained stable. However, this may be 14 changing, given that the illicit drug supply has become increasingly hazardous in recent years, as illicitly-15 manufactured-fentanyls (IMFs) and other synthetic opioid and benzodiazepine analogues are 16 increasingly sold as heroin and counterfeit prescription pills. We calculated drug overdose deaths per 17 100,000 population by 5-year age groups for the 2010-2021 period. For high-school-aged adolescents 18

(age 14-18), we stratified rates by race/ethnicity, census region, associated substance, and ICD-10 cause-19

of-death intent categories. rates, and no increase in deaths from alcohol or most drugs, reinforce that rising fatalities are likely 27 driven by an increasingly toxic, IMF-contaminated drug supply. Rising racial disparities in overdose 28 require a prevention approach that ameliorates deep-seated social and economic inequalities as well as 29 poor access to mental and physical healthcare and social services for AIAN and Latinx adolescents. Our 30 results should also be understood in the context of rising rates of adolescent mental illness during the 31 COVID-19 pandemic. These findings highlight the urgent need for accurate, harm-reduction-oriented 32 education for early adolescents about the risks of an evolving drug supply, as well as greater access to 33 naloxone and services that check drugs for the presence of IMFs. 34

The United States is in the midst of an unprecedented drug overdose crisis, recently crossing the 36 milestone of 100,000 deaths in a 12-month period 1 . Although overdose deaths in the US have increased 37 exponentially for the past four decades, these shifts have historically affected adults, while pediatric 38 overdose rates remained stable 2 . The illicit drug supply has become increasingly hazardous in recent 39 years, as illicitly-manufactured-fentanyls (IMFs) and other synthetic opioid and benzodiazepine 40 analogues are increasingly sold as heroin and counterfeit prescription pills 3 . Although the number of 41 adolescents using drugs reportedly declined in 2021 4 , media accounts of overdose deaths among high-42 school-age adolescents have become more frequent, often implicating counterfeit pills containing IMFs. 43

We calculated drug overdose deaths per 100,000 population by 5-year age groups for the 2010-2021 45 period using data from the National Center for Health Statistics (see appendix). Records from 2020-2021 46 were provisional and may underestimate final mortality. Data from 2021 corresponded to January-May 47 and were scaled proportionally to represent annual death counts and rates. For high-school-aged 48 adolescents (age 14-18), we stratified rates by race/ethnicity, census region, associated substance, and 49 ICD-10 cause-of-death intent categories. Analyses were conducted using R version 4.0.3. This work was 50 deemed exempt from review by the University of California, Los Angeles, as it deals with anonymized 51 and publicly available records. 52

Between 2010 and 2018, adolescents aged 14-18 had stable overdose mortality, substantially below the 54 high and rising rates seen among the general population (supplemental Table) . However, adolescents 55 saw a sharp increase between 2019 and 2020, from 2.35 per 100,000 to 4.58 per 100,000, representing 56 a 94.3% increase ( Figure 1A ). This was much larger than the percent increase observed among the all-57 age population in 2020, of 30.6% ( Figure 1B ). 14-18-year-old-individuals saw the highest percent 58 increase in 2020 of any 5-year age group for whom trends could be assessed ( Figure 1C) . Overdose 59 death rates among adolescents rose further in the first 5 months of 2021 to 5.50 per 100,000. 60 61 Stratified by race/ethnicity, American Indian or Alaska Native (AIAN) adolescents saw disproportionate 62 overdose mortality, especially after 2017. In provisional data from January-May 2021 overdose mortality 63 in this group was 2.15-fold higher than the national average ( Figure 1D ). Latinx adolescents were also 64 disproportionately affected, with a rate 1.31 times greater than the national average in 2021. Although 65 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this this version posted December 24, 2021. ; https://doi.org/10.1101/2021.12.23.21268284 doi: medRxiv preprint adolescents in all census regions saw sharp increases in 2020-2021, those in the West were 66 disproportionately affected, with an overdose death rate 1.68 times the national average. (Figure 1A) . 67

Increases in adolescent overdose deaths can be attributed to rising fatalities involving IMFs and other 68 synthetic opioids, which nearly tripled from 2019 to 2020, and represented 76.6% of all deaths by 2021 69 (Figure 2A) . Throughout available data, most adolescent overdose deaths were categorized as 70 unintentional, with a minority categorized as suicides, representing 84.5% and 13.4% of deaths in 2021, 71 respectively ( Figure 2B) . 72

For decades, overdose mortality among high-school-aged adolescents remained stable and substantially 74 lower than rates among the general population. However, beginning in 2020 they saw the largest annual 75 percent change of any age group. The predominance of adolescent overdose deaths on the West coast 76 may be related to the region's high prevalence of counterfeit oxycodone and benzodiazepine pills 77 containing high quantities of IMFs 3 . Sharp increases in adolescent drug overdose deaths, despite flat or 78 declining drug use rates, and no increase in deaths from alcohol or most drugs, reinforce that rising 79 fatalities are likely driven by an increasingly toxic, IMF-contaminated drug supply. 80

We noted sharp racial disparities for AIAN adolescents, of larger magnitude than those seen among 81 adults in this population 5 . Disproportionately high trends among Latinx adolescents stand in contrast to 82 relatively lower rates among Latinx adults 5 . Rising racial disparities in overdose require a prevention 83 approach that ameliorates deep-seated social and economic inequalities as well as poor access to 84 mental and physical healthcare and social services for AIAN and Latinx adolescents. 85

Our results should be understood in the context of rising rates of adolescent mental illness during the 86 COVID-19 pandemic 6 . Although detected suicides remain a small proportion of adolescent overdose 87 deaths, sharply increasing youth suicidal ideation may be a key contextual factor. These findings 88 highlight the urgent need for accurate, harm-reduction-oriented education for early adolescents about 89 the risks of an evolving drug supply, as well as greater access to naloxone and services that check drugs 90 for the presence of IMFs. 91 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Overdose deaths among high-school-aged adolescents (age 14-18) are shown per 100,000 individuals of the same age by substance used (A) and ICD-10 drug-related cause of death intent (B). A vertical dashed line separates trends before and during the COVID-19 pandemic (A). *2021 refers to January-May 2021, and rates and counts have been annualized. **Alcohol-related overdose deaths are shown here for comparative purposes but are not included in drug overdose rates shown elsewhere in the analysis, including Figure 1 .

. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint

The copyright holder for this this version posted December 24, 2021. ; https://doi.org/10.1101/2021.12.23.21268284 doi: medRxiv preprint

Products -Vital Statistics Rapid Release -Provisional Drug Overdose Data

Changing dynamics of the drug 96 overdose epidemic in the United States from 1979 through 2016

The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose 99 crisis. Current Opinion in Psychiatry

Percentage of Adolescents Reporting Drug Use Decreased Significantly in 2021 as the COVID-19

Black and Native Overdose Mortality Overtook That of White Individuals 104 During the COVID-19 Pandemic

Protecting Youth Mental Health: The U.S. Surgeon General's Advisory. Surgeon General

X40 (Accidental poisoning by and exposure to nonopioid analgesics, antipyretics and antirheumatics

X41 (Accidental poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified) X42 (Accidental poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified) X43 (Accidental poisoning by and exposure to other drugs acting on the autonomic nervous system) X44 (Accidental poisoning by and exposure to other and unspecified drugs, medicaments and biological substances) X60 (Intentional self-poisoning by and exposure to nonopioid analgesics

X61 (Intentional self-poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified) X62 (Intentional self-poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified) X63 (Intentional self-poisoning by and exposure to other drugs acting on the autonomic nervous system) X64 (Intentional self-poisoning by and exposure to other and unspecified drugs, medicaments and biological substances) X85

Y10 (Poisoning by and exposure to nonopioid analgesics, antipyretics and antirheumatics

Y11 (Poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified, undetermined intent) Y12 (Poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified, undetermined intent) Y13 (Poisoning by and exposure to other drugs acting on the autonomic nervous system, undetermined intent) Y14 (Poisoning by and exposure to other and unspecified drugs, medicaments and biological substances

Population data corresponding to the provisional period 128 (2020-2021) were not available, so values from 2019 were used for these years, assuming no 129 population change. Population change has been very small year-to-year, however this 130 assumption could lead to slightly elevated rates

134 8. With the exception of alcohol overdose deaths, substance-specific drug overdose deaths were 135 defined by the following multiple cause of death ICD-10 codes

to-year percent increase space. This is particularly notable after many years of flat trends. 152However, these findings should not discount the importance of drug overdose among adults, 153 whose overall rates still remain higher. Rather, as has been seen for numerous demographic 154 groups (e.g., Black communities in urban areas) early exponential increases may precede 155 subsequent large increases in level. Therefore, there may be an opportunity now for early 156 intervention among a segment of the population with rapidly growing overdose mortality. Many 157 of these considerations can be seen in the primary results when shown numerically, as below: 158

Year This category is known to represent almost entirely illicitly-manufactured fentanyls and other synthetic opioids. A very small percentage of this category now includes prescription fentanyl. Methamphetamine MCD Code "T43.6 (Psychostimulants with abuse potential)"This category is known to represent almost entirely illicit methamphetamine, and is traditionally referred to as such. See: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2774859 Prescription Opioids MCD Code "T40.2 (Other opioids)" This category refers almost entirely to prescription opioids, such as oxycodone, not including methadone or prescription fentanyl.