Rising Stimulant Overdoses Among Young People in the United States Scott E. Hadland, MD, MPH, MS,a,b Brandon D.L. Marshall, PhDc

Although commonly described as an waves.5,6 The first wave, beginning in opioid crisis, the drug overdose the early 2000s, was largely driven by epidemic in the United States increases in prescription opioid-related increasingly involves use of substances overdoses, likely fueled by aggressive other than opioids.1,2 In this issue of industry marketing of opioid products.7 Pediatrics, Roehler et al3 describe Concomitant with a decrease in opioid a concerning rise in overdoses among prescribing, heroin began to supplant children, adolescents, and young adults prescription opioids during the second related to stimulants such as cocaine, wave of the early 2010s. From late aDepartment of Pediatrics, Boston Medical Center, Boston, b methamphetamine, and prescription 2013 onwards, highly potent fentanyl Massachusetts; Division of General Pediatrics, Department fl of Pediatrics, School of Medicine, Boston University, Boston, drugs (including those commonly ooded drug markets and contributed Massachusetts; and cDepartment of Epidemiology, School of used to treat attention deficient/ to unprecedented mortality during the Public Health, Brown University, Providence, Rhode Island hyperactivity disorder). third wave. Now, in the fourth wave of Opinions expressed in these commentaries are the crisis, clinicians, public health Drawing on 2016–2019 surveillance those of the author and not necessarily those of the experts, and policymakers are American Academy of Pediatrics or its Committees. data from a plurality of US emergency grappling with rising overdose fatalities departments across 47 states, the DOI: https://doi.org/10.1542/peds.2020-031526 involving stimulants, particularly authors found that whereas visits for Accepted for publication Oct 8, 2020 cocaine and methamphetamine. drug overdoses rose only slightly Address correspondence to Scott E. Hadland, MD, among children ,15 and remained Pediatricians and other clinicians MPH, MS, Boston Medical Center, 801 Albany St, Room 2055, Boston, MA 02119. unchanged in adolescents and young caring for youth should be concerned. E-mail: [email protected] adults 15 to 24, visits for stimulant Approximately 1 in 25 high school PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, overdoses increased across all ages. students has used cocaine, and 1 in 50 1098-4275). Specifically, over each quarter between has used methamphetamine.8 Racial Copyright © 2021 by the American Academy of April 2016 and September 2019, inequities are pernicious; previous Pediatrics stimulant overdose visits among young work has revealed that Black and people aged 0 to 10, 11 to 14, and 15 to fi FINANCIAL DISCLOSURE: The authors have indicated Latinx youth are signi cantly less likely fi 24 years increased by 3%, 4%, and 2%, they have no nancial relationships relevant to this to receive timely evidence-based article to disclose. respectively. addiction treatment.9 These inequities FUNDING: Dr Hadland received grant support from These findings mirror other recent are critical not only because of the the National Institute on Drug Abuse (K23DA045085, national drug overdose trends. excess risk for overdose without L40DA042434) and the Thrasher Pediatric Fund Early Although the overall US overdose recommended care, but also because Career Award. Dr Marshall received grant support youth of color are significantly more from the National Institute on Drug Abuse (R01- mortality rate plateaued in 2018 after DA046620). climbing for 2 decades,4 preliminary likely than white youth to be incarcerated for drug-related charges POTENTIAL CONFLICT OF INTEREST: The authors have 2019 data suggest a return to indicated they have no potential conflicts of interest 1 and to experience lifelong adverse increasing year-over-year rates. to disclose. health consequences stemming from Nationally, deaths involving cocaine and COMPANION PAPER: A companion to this article can criminal justice involvement. other stimulants increased sharply be found online at www.pediatrics.org/cgi/doi/10. after 2016, including among youth ages 1542/2020-003491. What should also concern clinicians is 15 to 24.1,5 the exceptional difficulty of treating The overdose crisis is complex and stimulant use disorder. Whereas opioid To cite: Hadland SE and Marshall BDL. Rising evolving. Public health experts have use disorder is effectively treated Stimulant Overdoses Among Young People in the United States. Pediatrics. 2021;147(1):e2020031526 described it as having occurred in with US Food and Drug

Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 147, number 1, January 2021:e2020031526 COMMENTARY Administration–approved Understanding whether the opioid and other drug-related medications,10 there are no approved widespread availability of overdoses among youth in the US, pharmacotherapies for stimulant use prescription stimulants is related to 2016–2019. Pediatrics. 2020;147(1): disorder, and most behavioral rising overdose rates, or if it is simply 2020003491e therapies are disappointingly coincidental, could inform prescribing 4. Wilson N, Kariisa M, Seth P, Smith H IV, ineffective.11 Similarly, whereas guidelines. Davis NL. Drug and opioid-involved widespread distribution of the opioid overdose deaths - United States, overdose reversal agent naloxone in In the meantime, pediatricians and 2017–2018. MMWR Morb Mortal Wkly – the United States has averted other clinicians can take immediate Rep. 2020;69(11):290 297 12 action. They can routinely screen for innumerable deaths, no comparable 5. Kariisa M, Scholl L, Wilson N, Seth P, antidote exists for stimulants. substance use using a validated tool Hoots B. Drug overdose deaths Preventing stimulant use disorder (eg, Screening to Brief Intervention, involving cocaine and psychostimulants from developing in the first place https://www.drugabuse.gov/ast/ with abuse potential - United States, – remains our best hope for averting s2bi/; Brief Screener for Tobacco, 2003 2017. MMWR Morb Mortal Wkly Rep. 2019;68(17):388–395 downstream harms. Alcohol, and other Drugs, https:// www.drugabuse.gov/ast/bstad/; Car, 6. Gaither JR, Shabanova V, Leventhal JM. US Roehler et al draw much-needed Relax, Alone, Forget, Family/Friends, national trends in pediatric deaths from early attention to this worsening Trouble, https://crafft.org/), counsel prescription and illicit opioids, 1999–2016. public health problem. Further on substance use, and refer to JAMA Netw Open. 2018;1(8):e186558 studies are needed. The authors addiction treatment when 7. Hadland SE, Cerdá M, Li Y, Krieger MS, examine overdoses among 15- to 24- 20,21 needed. As respected citizens in Marshall BDL. Association of year-olds collectively; more granular their communities, clinicians can pharmaceutical industry marketing of age data would shed light on the advocate for evidence-based opioid products to physicians with precise times that overdoses are prevention programming in schools subsequent opioid prescribing. JAMA rising during adolescence and young and other settings. When clinicians Intern Med. 2018;178(6):861–863 adulthood. Data are also needed on prescribe stimulants, they can 8. US Centers for Disease Control and how stimulant overdoses in youth counsel parents that they should Prevention. YRBSS results. 2020. are related to rising fentanyl ensure safe, locked storage of Available at: https://www.cdc.gov/ 6 overdose and to polysubstance use medications, which is especially healthyyouth/data/yrbs/results.htm. more broadly, including use of critical given the rising rates of Accessed September 11, 2020 benzodiazepines and alcohol.13,14 presumably unintentional stimulant 9. Hadland SE, Wharam JF, Schuster MA, Finally, researchers should take care overdoses observed in younger ages ZhangF,SametJH,LarochelleMR.Trends to identify differences by race and in the study by Roehler et al. Given in receipt of buprenorphine and ethnicity to ensure that our clinical that preliminary national 2019 data naltrexone for opioid use disorder among and public health responses reduce suggest that overdose rates have once adolescents and young adults, 2001–2014. inequities rather than exacerbate again resumed their climb,1 JAMA Pediatr. 2017;171(8):747–755 15 them. addressing stimulant misuse and 10. Committee on Substance Use and Researchers should also pursue overdose early in the life course is Prevention. Medication-assisted a greater understanding of which urgent. treatment of adolescents with opioid use disorders. Pediatrics. 2016;138(3): stimulants are involved in the e20161893 pathway to misuse, addiction, REFERENCES 11. Ronsley C, Nolan S, Knight R, et al. and overdose and whether they 1. O’Donnell J, Gladden RM, Mattson CL, Treatment of stimulant use disorder: are illicit drugs like cocaine and Hunter CT, Davis NL. Vital signs: a systematic review of reviews. PLoS methamphetamine, prescription pills, characteristics of drug overdose One. 2020;15(6):e0234809 or both. Treating attention deficient/ deaths involving opioids and stimulants hyperactivity disorder is not - 24 states and the District of Columbia, 12. Pitt AL, Humphreys K, Brandeau ML. associated with risk for substance-use January–June 2019. MMWR Morb Modeling health benefits and harms of disorder; clinicians should continue Mortal Wkly Rep. 2020;69(35):1189–1197 public policy responses to the US opioid epidemic. Am J Public Health. 2018; to prescribe stimulants when 2. Liu S, Scholl L, Hoots B, Seth P. Nonfatal 108(10):1394–1400 appropriate.16 Nonetheless, there has drug and polydrug overdoses treated in been a simultaneous rise in stimulant emergency departments - 29 states, 13. Lembke A, Papac J, Humphreys K. Our prescribing,17 misuse among young 2018–2019. MMWR Morb Mortal Wkly other prescription drug problem. – – adults (particularly college Rep. 2020;69(34):1149 1155 N Engl J Med. 2018;378(8):693 695 students),18 and pharmaceutical 3. Roehler DR, Olsen EO, Mustaquim D, 14. White AM, Castle IP, Hingson RW, Powell industry marketing to pediatricians.19 Vivolo-Kantor AM. Suspected nonfatal PA. Using death certificates to explore

Downloaded from www.aappublications.org/news by guest on September 28, 2021 2 HADLAND et al changes in alcohol-related mortality in Territories, 2006 to 2016. PLoS One. Analysis of pharmaceutical industry the United States, 1999 to 2017. Alcohol 2018;13(11):e0206100 marketing of stimulants, 2014 through Clin Exp Res. 2020;44(1):178–187 2018. JAMA Pediatr. 2020;174(4): 18. Schulenberg JE, Johnston LD, O’Malley 385–387 15. Jordan A, Mathis ML, Isom J. Achieving PM, Bachman JG, Miech RA, Patrick ME. mental health equity: addictions. Monitoring the Future National Survey 20. Levy SJ, Williams JF; Committee on Psychiatr Clin North Am. 2020;43(3): Results on Drug Use 1975–2019: Volume Substance Use and Prevention. 487–500 2, College Students & Adults Ages Substance use screening, brief 19–60. Ann Arbor, MI: Institute for Social intervention, and referral to 16. Humphreys KL, Eng T, Lee SS. Stimulant Research, The University of Michigan; treatment. Pediatrics. 2016;138(1): medication and substance use 2020. Available at: www. e20161211 outcomes: a meta-analysis. JAMA monitoringthefuture.org/pubs/ 21. Steele DW, Becker SJ, Danko KJ, et al. Psychiatry. 2013;70(7):740–749 monographs/mtf-vol2_2019.pdf. Brief behavioral interventions for Accessed September 15, 2020 17. Piper BJ, Ogden CL, Simoyan OM, et al. substance use in adolescents: a meta- Trends in use of prescription 19. Hadland SE, Cerdá M, Earlywine JJ, analysis. Pediatrics. 2020;146(4): stimulants in the United States and Krieger MS, Anderson TS, Marshall BDL. e20200351

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