After staying flat for a decade, the overdose death rate among U.S. adolescents nearly doubled from 2019 to 2020 — an alarming climb that continued into 2021, a study released Tuesday showed.
The reasons do not include a surge of children in this group — ages 14 to 18 — using drugs, researchers said. If anything, survey data indicate that fewer teens experimented with drugs during the pandemic.
Rather, a main factor is that the supply of increasingly deadly drugs, which has driven overall overdose deaths to more than 100,000 per year, has trickled into what adolescents are using. What teens may think is an opioid painkiller or Xanax diverted from the legal supply is now more likely to be a counterfeit tablet containing fentanyl or similar synthetic opioids.
“Drug use is becoming more dangerous, not more common” among adolescents, said Joseph Friedman, a UCLA addiction researcher and lead author of the paper. “To some degree, I think this is just the national progression of the fentanyl crisis.”
According to the paper, published in the journal JAMA, 518 adolescents died of an overdose in 2010, a rate of 2.40 per 100,000 individuals. In 2019, the rate had changed little, at 492 deaths or 2.36 per 100,000.
In 2020, 954 adolescents fatally overdosed, a rate of 4.57 per 100,000. For the first six months of 2021, the rate increased another 20%, to 5.49 per 100,000.
As of 2021, the overdose death rate for the entire population was 31.06 per 100,000.
Experts interviewed by STAT had different interpretations of how the pandemic contributed to the spike in teen deaths in 2020. Some researchers believe the pandemic, by disrupting shipping networks and closing borders, may have only accelerated how toxic the drug supply was growing.
There’s also the question of whether Covid’s accompanying disconnection and isolation played a role. Teens have reported large increases in depression and anxiety.
Scott Hadland, the chief of adolescent and young adult medicine at Massachusetts General Hospital, who did not work on the new study, said the pandemic worsened mental health issues among teens who do use drugs and may have caused more frequent use, raising the risk of tragic outcomes. The pandemic also interrupted treatment programs.
“Of all my patients with addiction of any kind, and particularly opioid addiction, it’s really the rule and not the exception to have coexisting mental health struggles,” Hadland said.
All the experts agreed that the drug supply was a major component. The study looked at overdose deaths by substance type, and all those included — from prescription opioids to benzodiazepines to cocaine — resulted in fewer than 1 death in 100,000 people throughout the time period studied, from 2010 into 2021. The exception was illicit fentanyl and related synthetic opioids. Rates of overdose mortality from those drugs took off in the past few years, quadrupling from 2018 to 2021.
But if illicit fentanyls have been poisoning the drug supply for years, why was it only in 2020 that their dangers fully reached teenagers? Experts said that it seems to have to do with when the extra potent opioids started appearing in other drugs. They infiltrated heroin supplies years ago, for example, but teens are more likely to try pills than powdered drugs. It’s only been more recently that fentanyl has increasingly been found in supplies of pills. A separate study published last month found that over a quarter of fentanyl seizures by law enforcement are now in pill form.
Ed and Mary Ternan lost their son Charlie to an overdose in 2020. A college senior who loved movies and music, he took what he thought was a Percocet but was a counterfeit fentanyl pill.
Since then, Ed Ternan said he had spoken with parents who’ve lost their teenage children to fentanyl-laced pills. The family started an organization called Song for Charlie, which gives presentations “with the warning that the street market and the online market has been completely flooded with these counterfeit pills,” he said. While law enforcement and the media have publicized the risks, “the information that these pills were out there was not getting to the most vulnerable audience, which is the kids.”
The new study also examined adolescent overdose mortality by race and ethnicity, and found that some of the disparities in this age group echo those found in adult overdose data. The highest adolescent mortality rate, for example, was among American Indian or Alaska Native teens. As of 2020, the same group had the highest overall overdose mortality rate — some 30% higher than that of white people.
There was one notable difference. Overall, the Latino community has a relatively low rate of overdose deaths. But, the new study found, Latino adolescents had the second highest rate.
Jennifer Unger, a public health researcher at the University of Southern California, who did not work on the new study, said one potential reason was the unequal impact of the pandemic. Teens in the Latino community lost more loved ones to Covid and experienced more substantial financial challenges, which increased the stress they felt.
She said education and outreach campaigns need to reach all communities. She has done focus groups with the Latino community in Los Angeles, and many people perceive marijuana to be a bigger threat than opioids.
“The parents were all worried about their kids using cannabis,” Unger said, “but there are much worse drugs out there.”
Experts said that tallying the new adolescent data is crucial so clinicians and policymakers can better tailor their responses for youth — and ensure that the medical community recognizes that some teens need specialized addiction treatment. Past studies, for example, have found that very few adolescents are given medication for opioid use disorder — the gold-standard therapy for opioid addiction — even after they survive an overdose. Parents are sometimes skeptical of the treatments, and there aren’t many providers who specialize in adolescent addiction medicine.
Sarah Bagley is an adult internist and a pediatrician at Boston Medical Center focused on addiction care. She said that among adults, there’s a broad push to expand medication access and to provide the opioid overdose reversal medication naloxone. “And then in the pediatric world, we still have a ways to go,” she said.
To protect adolescents, advocates say that lawmakers should ensure that Good Samaritan laws — which safeguard people who call for emergency help when someone overdoses from prosecution — apply to teens. Schools should have naloxone on hand, and teenagers should be trained to recognize signs of an overdose and how to use naloxone as part of their health classes.
Offering such education doesn’t mean more kids will use drugs, said Sheila Vakharia, the deputy director of research and academic engagement at the Drug Policy Alliance, which has a drug-education curriculum designed for teens. Rather, Vakharia said, “they will be more informed to respond appropriately.”