How Has the Prescription Opioid Epidemic Affected Pediatric Hospitalization Rates in the United States?
JAMA Pediatrics, Original Investigation, October 31, 2016
National Trends in Hospitalizations for Opioid Poisonings Among Children and Adolescents, 1997 to 2012
Question How has the prescription opioid epidemic affected pediatric hospitalization rates in the United States?
Findings This retrospective analysis of 13 052 national hospital discharge records found that pediatric hospitalizations for opioid poisonings increased nearly 2-fold from 1997 to 2012. Hospitalization rates were highest in older adolescents, but the largest percentage increase in hospitalizations over time occurred among the youngest children (toddlers and preschoolers).
Meaning Reducing pediatric opioid exposure and misuse will require a combination of public health interventions, policy initiatives, and consumer-product regulations.
Importance National data show a parallel relationship between recent trends in opioid prescribing practices and hospitalizations for opioid poisonings in adults. No similar estimates exist describing hospitalizations for opioid poisonings in children and adolescents.
Objective To describe the incidence and characteristics of hospitalizations attributed to opioid poisonings in children and adolescents.
Design, Setting, and Participants Retrospective analysis of serial cross-sectional data from a nationally representative sample of US pediatric hospital discharge records collected every 3 years from January 1, 1997, through December 31, 2012. The Kids’ Inpatient Database was used to identify 13 052 discharge records for patients aged 1 to 19 years who were hospitalized for opioid poisonings. Data were analyzed within the collection time frame.
Main Outcomes and Measures Poisonings attributed to prescription opioids were identified by codes from the International Classification of Diseases, Ninth Revision, Clinical Modification. In adolescents aged 15 to 19 years, poisonings attributed to heroin were also identified. Census estimates were used to calculate incidence per 100 000 population. The Cochran-Armitage test for trend was used to assess for changes in incidence over time.
Results From 1997 to 2012, a total of 13 052 (95% CI, 12 500-13 604) hospitalizations for prescription opioid poisonings were identified. The annual incidence of hospitalizations for opioid poisonings per 100 000 children aged 1 to 19 years rose from 1.40 (95% CI, 1.24-1.56) to 3.71 (95% CI, 3.44-3.98), an increase of 165% (P for trend, <.001). Among children 1 to 4 years of age, the incidence increased from 0.86 (95% CI, 0.60-1.12) to 2.62 (95% CI, 2.17-3.08), an increase of 205% (P for trend, <.001). For adolescents aged 15 to 19 years, the incidence increased from 3.69 (95% CI, 3.20-4.17) to 10.17 (95% CI, 9.48-10.85), an increase of 176% (P for trend, <.001). In this age group, poisonings from heroin increased from 0.96 (95% CI, 0.75-1.18) to 2.51 (95% CI, 2.21-2.80), an increase of 161% (P for trend, <.001); poisonings involving methadone increased from 0.10 (95% CI, 0.03-0.16) to 1.05 (95% CI, 0.87-1.23), an increase of 950% (P for trend, <.001).
Conclusions and Relevance During the course of 16 years, hospitalizations attributed to opioid poisonings rose nearly 2-fold in the pediatric population. Hospitalizations increased across all age groups, yet young children and older adolescents were most vulnerable to the risks of opioid exposure. Mitigating these risks will require comprehensive strategies that target opioid storage, packaging, and misuse.
Using a nationally representative sample of pediatric hospital discharge records, we found that the incidence of hospitalizations for prescription opioid poisonings among children and adolescents 1 to 19 years of age increased nearly 2-fold from 1997 to 2012. Although rates increased across all age groups, the largest percentage increase occurred among the youngest children aged 1 to 4 years. The second largest increase occurred among adolescents 15 to 19 years of age, among whom hospitalizations for prescription opioid and heroin poisoning increased. Adolescents in this age group had the highest incidence overall for each of the 6 years examined.
In contrast to poisoning intent in younger children, poisonings in those older than 10 years were primarily attributed to suicide or self-inflicted injury. During the 16-year period, poisonings attributed to suicide or self-inflicted injury among those aged 15 to 19 years increased by 140%. These data underscore the dangers associated with the widespread availability of prescription opioids, particularly for adolescents at risk for depression (many adolescents are also thought to self-medicate with prescription opioids).16,40
Although poisonings attributed to suicide or self-inflicted injury among those aged 15 to 19 years exceeded those attributed to accidental poisonings across all time points, accidental poisonings increased at a more rapid rate, 3-fold from 1997 to 2012. Increasing rates of prescription opioid misuse and abuse, rather than therapeutic errors or adverse effects among adolescents prescribed opioids for pain management, are likely driving these trends in accidental poisonings.19
Mirroring demographic trends seen in adults,23,24 we found that approximately three-quarters of hospitalizations occurred in white individuals. Similarly, private insurers were found to be the largest payer. However, the percentage of hospitalizations covered by private payers decreased over time, whereas the percentage paid by Medicaid increased. In 2012, Medicaid covered 44.0% of hospitalizations for pediatric opioid poisonings, up from 24.1% in 1997. This change may reflect trends in Medicaid payments for all hospitalizations; from 1997 to 2011, the percentage of hospitalizations where Medicaid was the primary payer increased by 34%.41 This increase, however, has largely been attributed to a rise in hospitalizations for a small number of conditions. Thus, the shift over time in payers for opioid hospitalizations may instead be indicative of the widening effect of opioid use across sociodemographic groups.
This study—to our knowledge, the first to extensively examine pediatric hospitalizations due to opioid poisonings—contributes to a broader understanding of the public health crisis caused by the now widespread availability of prescription opioids in the United States. Our findings are consistent with previous research demonstrating that as physicians have increasingly relied on prescription opioids to treat chronic pain during the past 2 decades, rates for opioid poisonings have risen in tandem.1- 4,9 For young children, calls to poisoning control centers for opioid ingestion have increased markedly in recent years,19,20,22 as have ED visits across all age groups.17- 21 In addition, a number of studies have examined trends in ED visits and subsequent hospitalizations for pharmaceutical poisonings and found that prescription opioids were among the most commonly implicated medications and that these poisonings frequently resulted in hospital admission.17,19,20
Emerging data suggest that in recent years physicians have been prescribing opioids less frequently. From 2011 to 2013, the number of opioid prescriptions dispensed in the United States slightly decreased.25,42 Our data show a similar marginal decrease in the overall incidence of hospitalizations for prescription opioid poisonings from 2009 to 2012. This change, however, was driven entirely by a slight (7%) but statistically significant decrease in hospitalizations among those aged 15 to 19 years. In contrast, in this age group, hospitalizations involving heroin overdose continued to rise. This finding is consistent with research suggesting that prescription opioid abuse may be a precursor to initiation of heroin use,3,25- 28 which can be explained in part by the low cost of heroin compared with opioid analgesics such as oxycodone.26- 28
Notably, we found that the incidence of hospitalizations for methadone poisonings increased 950% among 15- to 19-year-olds from 1997 to 2012. Methadone is among the most misused of prescription drugs and is commonly diverted for illicit (nonmedical) purposes, such as getting high or to enhance the effects of alcohol or other drugs.3 Our data suggest that the incidence of poisonings attributed to methadone misuse may be slowing. From 2009 to 2012, hospitalization rates for methadone misuse decreased slightly among those aged 15 to 19 years. These findings are consistent with recent data showing that rates for prescription opioid abuse, misuse, and diversion for nonmedical use have plateaued or decreased in the general adult population.43 Declining rates for abuse and diversion have also been seen among those aged 12 to 17 years.44
Nonmedical use of prescription opioids, nevertheless, remains a substantial problem, particularly for adolescents. In 1 study,44,45 nearly 10% of high school seniors reported using opioids nonmedically. Although most acquired these medications from family and friends, the source for nearly 40% of students was their own prior prescription.46 This information is in keeping with findings that adolescents are frequently prescribed opioids for common injury- and non–injury-related indications.46 A recent study of ambulatory care visits in the United States, for example, reports that from 2005 to 2007, opioids were prescribed at 22% of visits among adolescents presenting with back pain.47 A separate study of commercial medical and pharmacy claims data from 2007 to 2008 found that nearly 50% of patients aged 13 to 17 years presenting with first-time complaints of headache received an opioid prescription during the 2-year follow-up, and nearly one-third received 3 or more prescriptions.31 Of note, the US Food and Drug Administration recently extended the off-label use of oxycodone for children as young as 11 years with certain types of intractable pain—namely cancer pain.48 Despite these trends, however, the new national opioid prescribing guidelines49 by the Centers for Disease Control and Prevention fail to include recommendations for patients younger than 18 years.50
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