Abstract
Objectives:
Opioid intoxication among children is a growing public health concern given the increased prevalence of high-potency synthetic opioids in the United States. This study evaluated trends in pediatric opioid ingestions and associated demographic factors in Washington State.
Methods:
We conducted a retrospective data review of Washington Poison Center nontherapeutic pediatric opioid exposures reported from January 2014 through December 2023 among children and adolescents aged 0 to 17 years. We assessed trends based on opioid type and demographic factors. We performed logistic regression analysis and calculated odds ratios (ORs) and 95% CIs.
Results:
A total of 2873 pediatric opioid ingestions were reported; the mean (range) age was 7.4 (0.1-17.0) years, with a slight female predominance (52%). During the 10-year study period, we found a significant increase in fentanyl ingestion (9700%), a 59% decrease in hydrocodone ingestion, and a 56% decrease in oxycodone ingestion. Fentanyl ingestion (OR = 4.25; 95% CI, 2.88-6.22), adolescent age (OR = 2.00; 95% CI, 1.48-2.70), and a high-level neighborhood socioeconomic disadvantage (OR = 1.91; 95% CI, 1.36-2.73) had increased odds of a major effect (life threatening). We found 9 reported associated deaths.
Conclusions:
Recent trends of pediatric opioid ingestion in Washington State indicate a disproportionate increase in fentanyl ingestion and life-threatening effects associated with socioeconomically disadvantaged neighborhoods. Further studies and policy are needed to improve surveillance and prevention of pediatric opioid ingestions.
Since its beginnings in the 1990s, the opioid epidemic has continued to evolve as a public health crisis. The first 2 waves of the epidemic were characterized by aggressive prescription of opioid medications and illicit use of highly addictive opioids such as heroin. The most recent wave began in 2013 with the marked rise in synthetic opioid overdose–related deaths, namely due to the use of high-potency synthetic opioids such as fentanyl. 1 In 2023, there were 81 083 opioid-related deaths in the United States, representing 75% of all drug overdose–related deaths; 92% of the opioid ingestions involved high-potency synthetic opioids (primarily fentanyl). 2 For reference, fentanyl has a potency approximately 100 times stronger than morphine and approximately 50 times stronger than heroin. Given this potency, fentanyl has been judiciously used therapeutically by physicians to treat acute severe pain. However, the production of fentanyl has shifted from pharmaceutical companies to illicit manufacturing through drug cartels. Illicit fentanyl and its analogues are increasingly mixed with other substances such as sedatives to increase its resultant experienced high but also increase its addictive potential and lethality. 3 In 2023, about 7 in 10 drug overdose deaths in the United States involved illegally manufactured fentanyl. 4 Washington State, compared with the nation, has recently experienced a higher incidence of drug overdose–related deaths: during 2022 and 2023, overdose-attributed deaths decreased by 3.7% nationally and increased by more than 27% in Washington State. 2
Although adolescents and children face increased mortality due to the opioid crisis, the extant literature has focused less on the impact on the pediatric population and more on the adult population. Opioids are the leading cause of fatal poisonings in young children in the United States, having increased from 24.1% in 2005 to 52.2% in 2018 of all pediatric poisoning deaths, and opioid-related overdoses among children aged 1 to 4 years increased more than 200% from 1995 to 2012 in the United States.5,6 Fentanyl is now the primary agent in the pediatric opioid crisis, which mirrors trends noted in the adult opioid crisis, and this high-potency opioid poses increased risk for intensive care unit (ICU) admissions and deaths among hospitalized children.7,8 Given this evidence of the impact of the opioid crisis among the pediatric population, there is a need for more scientific literature that seeks to better understand the role of opioid poisoning, and in particular fentanyl poisoning, among children. To our knowledge, no study has focused on the impact of pediatric opioid poisonings in Washington State. To address this gap in the evidence base, we examined the trends and key factors that affected the health outcomes of opioid ingestion among children and adolescents in Washington State during the most recent wave of the opioid epidemic. We hypothesized that the incidence of pediatric opioid ingestions would be associated with socioeconomic background.
Methods
Study Design
We conducted a retrospective review of report registry data from the Washington Poison Center (WAPC). 9 The study included all acute opioid ingestions that occurred among Washington State residents aged ≤17 years and were reported to the WAPC from January 2014 through December 2023. All opioid ingestions were nontherapeutic intoxications that occurred within the same day of the call and had a subsequent initial consultation with the WAPC. All opioid ingestions were based on reported observation of the event and medical assessment. Comprehensive confirmatory toxicology was not consistently performed for all reported opioid ingestions. When multiple substances were consumed, we included only the opioid ingestions. We counted each opioid substance as an individual ingestion. We focused on and compared ingestions of 4 opioids: fentanyl, oxycodone, hydrocodone, and hydromorphone.
This study was reviewed in accordance with the University of Washington Office of Research. Under 45 CFR 46 Subpart A, this study constituted a public health surveillance activity and was not classified as human subjects research. Additional protections for research involving children did not apply to this study. Therefore, this study was exempted from review by the University of Washington Office of Research.
Data Source and Selection
One of 53 poison centers nationwide, the WAPC is a nonprofit organization that since 1956 has served as a statewide public health safety net for poison and toxin exposure. 10 WAPC specialists are available 24 hours a day and 7 days a week throughout the entire year to provide immediate, free assistance and expertise. WAPC responds to more than 138 000 calls (~65 000 exposures) per year from both the general population and medical professionals. The WAPC follows each reported ingestion from the initial report to the final resolution of the ingestion with all information included in the registry.
We extracted call report data from manually completed electronic forms and stored these data in a spreadsheet. We excluded from analyses opioid substances other than fentanyl, oxycodone, hydrocodone, and hydromorphone. Demographic variables available from the registry were age, sex (male or female), confirmed home zip code of the affected child, and county of residence of the child. The registry records age in the following groups: young child (0-3 y), child (4-9 y), preadolescent (10-13 y), and adolescent (14-17 y). We also included the Area Deprivation Index (ADI) for the child’s home zip code. ADI is a multifactorial proxy that uses US Census data to assess socioeconomic advantage in a US neighborhood relative to the state or nation.11,12 Lower ADI deciles and percentiles signify less neighborhood deprivation. Our analysis included the ADI for each zip code for the state decile and national percentile. We also included the ADI for each Accountable Community of Health (ACH) in the state; Washington State has 9 ACHs. ACHs are regional organizations where health care providers and community organizations collaborate to address health and social needs–related projects and activities in their region. 13 Acute ingestion–related variables included year of ingestion, number of substances ingested, the opioid’s name and formulation, reason for ingestion, location of ingestion (in or outside the child’s home), and medical outcome for each incident. We defined medical outcome as (1) hospital level of care (discharge home from emergency department, admission to acute care, or admission to the ICU) and (2) effect (no effect, minor effect, moderate effect, major effect, or death). We defined minor effect as mild, transient (<2 h) symptomatology without any lasting physiological effects, moderate effect as a physiological effect without threat to life but that required several hours of medical observation and medical treatment for resolution, and major effect as life-threatening injuries requiring ICU admission for prolonged medical treatment (≥1 d).
Analysis
We examined trends in opioid poisoning over time among children and adolescents in Washington State as a function of demographic factors, the type of opioid ingested, and medical outcome. We conducted tests of statistical differences over time by using unpaired t tests for continuous variables and a Pearson χ2 or Fisher exact test based on size of the sample for categorical variables. P < .05 denotes a statistically significant association. We expressed continuous variables as mean (SD). We also performed univariate and multivariable logistic regression analyses; we calculated results as odds ratios (ORs) and 95% CIs. We used R software version 4.5 (R Project for Statistical Computing) to conduct all analyses.
Results
The sample consisted of 2873 unique pediatric opioid ingestions reported to the WAPC from 2014 through 2023 (Table 1). Almost all reports included an ingested opioid; 120 instances of 2 ingested opioids and 7 instances of 3 ingested opioids occurred. The mean (SD [range]) age was 7.4 (6.5 [0.1-17.0]) years; more than half were aged ≤3 years (51%) or female (52%). King and Pierce counties, each of which has approximately 15% of the state’s population, had the largest number of ingestions (n = 691 [24%]; n = 500 [17%], respectively).
Pediatric fentanyl ingestions stratified by demographic factors (N = 2873), Washington State, 2014-2023 a
Abbreviation: ADI, Area Deprivation Index.
Data source: Washington Poison Center. 9
P < .05 denotes a statistically significant association; determined by the Pearson χ2 test.
ADI for the child’s home zip code; 244 ingestions did not have an ADI value. ADI is a multifactorial proxy that uses US Census data to assess socioeconomic advantage in a US neighborhood relative to the state or nation.11,12 Lower ADI deciles and percentiles signify less deprivation in the community.
Missing values for this factor are due to gaps in pediatric opioid ingestion reporting.
Accountable Communities of Health are regional organizations where health care providers and community organizations collaborate to address health and social needs–related projects and activities in their region. 13
Reports of opioid ingestion were primarily from communities in the higher half of the state ADI percentiles at each time point. Fewer than 10% (n = 244) of ingestions did not have an ADI value available because the ADI database does not calculate values for regions where >33% of the population lives in group quarters: pediatric opioid ingestion trends showed a significant increase in the percentage of fentanyl ingestion while the percentages of oxycodone and hydrocodone ingestion decreased (Figure 1).
Trends in pediatric opioid ingestion and association with a major (life-threatening) effect stratified by year in Washington State, 2014-2023. Oxycodone, hydrocodone, and hydromorphone ingestions decreased while fentanyl ingestions increased over time. As fentanyl ingestions increased, the percentage of opioid ingestions with major (life-threatening) effects also increased. Data source: Washington Poison Center. 9
From 2014 through 2023, the number of ingestions increased only for fentanyl. During this period, fentanyl ingestion increased from 1 case to 98 cases (a 9700% increase), while hydrocodone ingestion decreased from 74 to 30 cases (a 59% decrease) and oxycodone ingestion decreased from 101 to 44 cases (a 56% decrease). During this period, 203 fentanyl ingestions were reported: 93 ingestions among young children, 14 among children, 12 among preadolescents, and 84 among adolescents.
The incidence of fentanyl ingestion substantially increased for all age groups during the study period, especially among young children and adolescents (Figure 2). Mean age, age group, sex, and ADI decile were factors significantly associated with pediatric fentanyl ingestion (Table 1). ACH designation was not significantly associated with fentanyl ingestions.
Pediatric fentanyl ingestion over time, stratified by age group (N = 2873), Washington State, 2014-2023. Fentanyl ingestion increased the most in the 0- to 3-year and 14- to 17-year age groups. Data source: Washington Poison Center. 9
Reasons for opioid ingestion were reported as follows: 68% unintentional, 21% intentional (suicide attempted), 8% intentional (abuse), and 3% intentional (misuse). All ingestions among young children were unintentional, while most (72%) of the ingestions among adolescents were intentional, associated with an attempted suicide.
Most ingestions resulted in no effect (n = 816; 28%) or minor effect (n = 1375; 48%). There were 406 ingestions (14%) with moderate effect, 272 ingestions (10%) with major effect, and 9 deaths. Mean age, age group, sex, mean ADI state decile, state ADI decile, fentanyl ingestion, and hydrocodone ingestion were significantly associated with a major effect (Table 2). In univariate logistic regression, mean age, children aged 4 to 9 years, the preadolescent age group, the adolescent age group, female sex, mean ADI state decile, ADI deciles 6 to 10, fentanyl ingestion, and hydrocodone ingestion were associated with a major effect (Table 2). Mean age (OR = 1.04; 95% CI, 1.02-1.06), adolescent age group (OR = 1.98; 95% CI, 1.54-2.55), ADI state decile (overall) (OR = 1.10; 95% CI, 1.04-1.16), ADI state deciles 6 to 10 (OR = 2.11; 95% CI, 1.52-2.99), and fentanyl ingestion (OR = 5.38; 95% CI, 3.86-7.44) had increased odds for a major effect. In multivariable logistic regression analysis, mean age (OR = 1.05; 95% CI, 1.02-1.07), adolescent age group (OR = 2.00; 95% CI, 1.48-2.70), mean ADI state decile (1.09; 95% CI, 1.03-1.16), ADI state deciles 6 to 10 (OR = 1.91; 95% CI, 1.36-2.73), and fentanyl ingestion (OR = 4.25; 95% CI, 2.88-6.22) had increased odds of a major effect. Hydrocodone ingestion was associated with decreased odds of a major effect (OR = 0.36; 95% CI, 0.20-0.55). Regions with more social disadvantage (higher ADI) had a higher incidence of opioid ingestion and major effect (Figure 3). Furthermore, a greater proportion of overall fentanyl ingestions than overall oxycodone ingestions were associated with a major effect.
Odds of a major effect outcome from opioid ingestions, by demographic factors based on univariate and multivariate logistic regression (N = 2873), Washington State, 2014-2023 a
Abbreviations: ADI, Area Deprivation Index; OR, odds ratio.
Data source: Washington Poison Center. 9
P < .05 denotes a statistically significant association, determined by logistic regression tests.
Not applicable.
Children and adolescents with a major (life-threatening) effect from pediatric opioid ingestion, stratified by Area Deprivation Index (ADI) quintile in Washington State, 2014-2023. The number of pediatric opioid ingestion episodes with a major effect (red line) is stratified by each ADI quintile (blue bar). The 10.0% of major effect cases in ADI quintile 1 represents 2 of 203 (1.0%) total fentanyl ingestions and 3 of 750 (0.4%) total oxycodone ingestions. The 19.0% of major effect cases in ADI quintile 2 represents 6 of 203 (2.9%) fentanyl ingestions and 5 of 750 (0.7%) oxycodone ingestions. The 15.0% of major effect cases in ADI quintile 3 represents 2 of 203 (1.0%) fentanyl ingestions and 6 of 750 (0.8%) oxycodone ingestions. The 32.0% of major effect cases in ADI quintile 4 represents 13 of 203 (6.4%) fentanyl ingestions and 18 of 750 (2.4%) oxycodone ingestions. The 26.0% of major effect cases in ADI quintile 5 represents 8 of 203 (3.9%) fentanyl ingestions and 6 of 750 (0.8%) oxycodone ingestions. Data source: Washington Poison Center. 9
Discussion
Our study describes incidence trends in pediatric opioid ingestion and associated factors in Washington State during a 10-year period within the current era of the nationwide opioid epidemic, defined by growth in the distribution of high-potency opioids. Few studies have evaluated opioid intoxication among this population. Literature describing opioid intoxication among children and adolescents has a national scope; state-specific analyses are lacking.8,14,15 Our study focused on ingestions among children and adolescents aged <18 years in Washington State, given the state’s disproportionately higher incidence of drug overdoses compared with other states. The Washington State Department of Health has publicly available data on opioid drug overdoses, but these data lack a granular focus on the population aged <18 years, and analyses do not include neighborhood socioeconomic measures.16,17
In our study, the incidence of fentanyl ingestion among the pediatric population disproportionately increased from 2014 to 2023 compared with other opioid drugs and was associated with older age (particularly adolescents aged 14-17 y) and higher ADI state decile. Oregon also published analyses on pediatric opioid ingestions. 18 The increase in reported fentanyl ingestion in Washington State is consistent with data from Oregon. The Oregon Poison Center reported a substantial rise in illicit fentanyl ingestion among children aged ≤6 years in that state: from 0 ingestions in 2013 and 2 ingestions in 2021 to 16 ingestions in 2023. 18 The incidence of reported fentanyl ingestions, particularly among young children, is higher in Washington State. Our study also showed that older age (especially the adolescent age group), higher ADI decile, and fentanyl ingestion were associated with increased odds of life-threatening injuries. Prior literature showed that the severity of poisonings has increased in recent years along with a rise in pediatric ingestions involving fentanyl and that assessing incidence may be affected by underreporting of pediatric opioid exposures. 19
The reasons for ingestion reported in our study suggest that the young child and adolescent age groups have distinct risk factors; identification of these distinctions allows for tailored public health policy. The unintentional ingestions by young children point to exposures in a home where opioid substances are not properly secured out of the child’s reach. The intentional ingestions, particularly those related to suicide attempts among adolescents, point to underlying mental and behavioral health needs that have not been adequately addressed.20-22 Our data also indicate a disproportionately higher incidence of pediatric opioid ingestions, especially of fentanyl, in more disadvantaged neighborhoods and counties. Socioeconomic factors are a key factor in exposure and life-threatening or fatal outcomes of opioid drug intoxication among adults. 23 Parental opioid misuse and abuse has been noted as a risk factor for pediatric opioid exposure, thus suggesting that access to health care and addiction treatment, which addresses the incidence of opioid ingestion among adults, would likely also help address the incidence of opioid ingestion among children and adolescents. 24 However, the pediatric population has its own particular risk factors; addressing this population necessitates awareness of risk factors first.
Decreasing the incidence of pediatric opioid ingestions will involve removing access to these drugs in homes, developing safe practices in opioid medication storage, and promoting harm reduction. In 2024, the Washington State legislature adopted House Bill 6109, 25 which directly addresses child safety in the context of fentanyl exposure and measures for removing children from opioid-related abuse and neglect. In the same year, House Bill 1956 26 directly responded to opioid-related injury among the pediatric population in Washington State, addressing preventive measures for high-potency opioids such as fentanyl. The bill establishes education for the public, including in schools. Education is an important part of prevention: nearly half of adults receiving opioid medication do not recall being given information for safe storage, thus putting children in the home at risk of ingestion. 27 The Washington State Health Care Authority has a Starts With One initiative that sends individuals free medication mail-back envelopes on request. 28 Health care providers can play a role in educating patients on the safe use of opioids; patients at an outpatient palliative clinic were significantly more likely to practice safe use techniques (proper storage and disposal) after receiving information through discussion with their health care provider and a written brochure compared with those who did not receive this education. 29 Equipping individuals and families with naloxone is a safety practice and a form of harm reduction. Naloxone is an opioid antagonist that effectively reverses respiratory depression and other physiological effects of opioid overdose and can also be used in children and adolescents. Washington State has a standing order for naloxone for people with Medicaid, but the state could also expand the distribution of naloxone kits to schools, which the South Carolina Department of Public Health is doing. 30
Limitations
Our study had several limitations. First was the study’s retrospective approach. Given this approach, we could show factors associated with pediatric opioid ingestion, but we could not determine causation. Second, confirmatory toxicology testing was not consistently performed for all reported ingestions. Therefore, the contents of reported substances may have included additional substances that the caller did not know about. These unknown substances may have also contributed to side effects seen in children and adolescents. Illicit opioid ingestion was based on reported statements by the caregiver and emergency medical services, and, thus, the possibility of traces of unknown substances could not be ruled out. Third, data were based on voluntarily reported ingestions. The annual rate of cases reported to the WAPC and use of the WAPC in terms of reporting cases of poison ingestion throughout the state is fairly consistent, with an average of 6.13 cases of toxin ingestion per 100 000 people (adults and children) in 2023. The counties with the largest number of pediatric ingestions in our study, King and Pierce counties, had 5.9 and 7.6 cases of toxin ingestion per 100 000 people (adults and children), respectively, in 2023. Washington State does not mandate the reporting of toxin ingestion (including opioids) by parents/guardians or health professionals. Thus, the incidence of pediatric opioid ingestions in this study likely underestimates the true incidence.
Fourth, poison center data also do not include information on race and ethnicity, a demographic factor that is known to be associated with socioeconomic status. We included socioeconomic status as a demographic factor in our study via the validated proxy measure ADI. Because ADI is based on US Census data, scores for zip codes with very small populations (<100 people) or a high density of the population living in group homes were suppressed. To avoid stark outliers in the population data, the Neighborhood Atlas, which provides ADI scores, does not calculate a decile block group for these zip codes. Suppressed values comprised a very small subset of our data. In addition, about 15% of calls reported a location of ingestion that was different from the patient’s home. For these occurrences, the zip code recorded was the local health care facility in the child’s neighborhood.
Conclusion
Pediatric opioid ingestion is a growing problem within the overall opioid epidemic and remains understudied. Current trends of pediatric opioid ingestion in Washington State indicate a disproportionate increase in pediatric fentanyl ingestion, compared with other opioid substances. Fentanyl ingestion and life-threatening effects are associated with adolescent age and being from a socioeconomically disadvantaged community. Our study makes a first step in characterizing the current landscape of pediatric opioid ingestions in Washington State. We hope to motivate further collaborative studies and policy measures that bring awareness to the problem of pediatric opioid ingestion, improve data reporting, and address risk factors tailored by age group. Further studies and policy are needed to address this important public health issue.
Footnotes
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.