Estimated Number of Children Who Lost a Parent to Drug Overdose in the US From 2011 to 2021

Christopher M Jones; Kun Zhang; Beth Han; Gery P Guy; Jan Losby; Emily B Einstein; Miriam Delphin-Rittmon; Nora D Volkow; Wilson M Compton

doi:10.1001/jamapsychiatry.2024.0810

. 2024 May 8;81(8):789–796. doi: 10.1001/jamapsychiatry.2024.0810

Estimated Number of Children Who Lost a Parent to Drug Overdose in the US From 2011 to 2021

Christopher M Jones ^1,^✉, Kun Zhang ², Beth Han ³, Gery P Guy ², Jan Losby ², Emily B Einstein ³, Miriam Delphin-Rittmon ¹, Nora D Volkow ³, Wilson M Compton ³

¹Substance Abuse and Mental Health Services Administration, Rockville, Maryland

²National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia

³National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland

Accepted for Publication: March 1, 2024.

Published Online: May 8, 2024. doi:10.1001/jamapsychiatry.2024.0810

^✉

Corresponding Author: Christopher M. Jones, PharmD, DrPH, MPH, Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, 5600 Fishers Ln, Rockville, MD 20852 (christopher.jones@samhsa.hhs.gov).

Author Contributions: Drs Zhang and Han had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Jones, Zhang, Han, Guy, Losby, Einstein, Delphin-Rittmon, Compton.

Acquisition, analysis, or interpretation of data: Jones, Zhang, Han, Volkow, Compton.

Drafting of the manuscript: Jones, Zhang, Han, Guy, Losby, Volkow, Compton.

Critical review of the manuscript for important intellectual content: Zhang, Han, Guy, Einstein, Delphin-Rittmon, Volkow, Compton.

Statistical analysis: Jones, Zhang, Han, Volkow.

Administrative, technical, or material support: Jones, Delphin-Rittmon, Volkow, Compton.

Supervision: Jones, Volkow.

Conflict of Interest Disclosures: Dr Compton reported long-term stock holdings from General Electric, 3M Companies, and Pfizer outside the submitted work. No other disclosures were reported.

Funding/Support: This study was sponsored by the US Centers for Disease Control and Prevention, the National Institutes of Health, and the Substance Abuse and Mental Health Services Administration.

Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The sponsors reviewed and approved the manuscript.

Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention, the National Institutes of Health, the Substance Abuse and Mental Health Services Administration, or the US Department of Health and Human Services.

Data Sharing Statement: See Supplement 2.

^✉

Corresponding author.

PMCID: PMC11079787 PMID: 38717781

Key Points

Question

How many children in the US lost a parent to a drug overdose between 2011 and 2021, and does the rate vary by parent age, sex, or race and ethnicity?

Findings

In this cross-sectional study from 2011 to 2021, an estimated 321 566 community-dwelling children in the US lost a parent aged 18 to 64 years to drug overdose, and the rate of children who lost a parent to overdose increased during this period. In 2021, the highest rate was found among non-Hispanic American Indian and Alaska Native individuals.

Meaning

The findings indicate that responses to the overdose crisis should account for the full burden of overdose on families and children, including addressing the economic, social, educational, and health care needs of children who have lost parents to overdose.

This cross-sectional study estimates the number of children who lost a parent to drug overdose in the US from 2011 to 2021.

Abstract

Importance

Parents’ overdose death can have a profound short- and long-term impact on their children, yet little is known about the number of children who have lost a parent to drug overdose in the US.

Objective

To estimate the number and rate of children who have lost a parent to drug overdose from 2011 to 2021 overall and by parental age, sex, and race and ethnicity.

Design, Setting, and Participants

This was a cross-sectional study of US community-dwelling persons using data from the National Survey on Drug Use and Health (2010-2014 and 2015-2019) and the National Vital Statistics System (2011-2021). Data were analyzed from January to June 2023.

Exposure

Parental drug overdose death, stratified by age group, sex, and race and ethnicity.

Main Outcomes and Measures

Numbers, rates, and average annual percentage change (AAPC) in rates of children losing a parent aged 18 to 64 years to drug overdose, overall and by age, sex, and race and ethnicity.

Results

From 2011 to 2021, 649 599 adults aged 18 to 64 years died from a drug overdose (mean [SD] age, 41.7 [12.0] years; 430 050 [66.2%] male and 219 549 [33.8%] female; 62 606 [9.6%] Hispanic, 6899 [1.1%] non-Hispanic American Indian or Alaska Native, 6133 [0.9%] non-Hispanic Asian or Pacific Islander, 82 313 [12.7%] non-Hispanic Black, 485 623 [74.8%] non-Hispanic White, and 6025 [0.9%] non-Hispanic with more than 1 race). Among these decedents, from 2011 to 2021, an estimated 321 566 (95% CI, 276 592-366 662) community-dwelling children lost a parent aged 18 to 64 years to drug overdose. The rate of community-dwelling children who lost a parent to drug overdose per 100 000 children increased from 27.0 per 100 000 in 2011 to 63.1 per 100 000 in 2021. The highest rates were found among children of non-Hispanic American Indian or Alaska Native individuals, who had a rate of 187.1 per 100 000 in 2021, more than double the rate among children of non-Hispanic White individuals (76.5 per 100 000) and non-Hispanic Black individuals (73.2 per 100 000). While rates increased consistently each year for all parental age, sex, and race and ethnicity groups, non-Hispanic Black parents aged 18 to 25 years had the largest AAPC (23.8%; 95% CI, 16.5-31.6). Rates increased for both fathers and mothers; however, more children overall lost fathers (estimated 192 459; 95% CI, 164 081-220 838) than mothers (estimated 129 107; 95% CI, 112 510-145 824).

Conclusions and Relevance

An estimated 321 566 children lost a parent to drug overdose in the US from 2011 to 2021, with significant disparities evident across racial and ethnic groups. Given the potential short- and long-term negative impact of parental loss, program and policy planning should ensure that responses to the overdose crisis account for the full burden of drug overdose on families and children, including addressing the economic, social, educational, and health care needs of children who have lost parents to overdose.

Introduction

The US overdose crisis continues to impact communities at historic levels, with data from the US Centers for Disease Control and Prevention (CDC) estimating more than 107 000 lives lost to overdose in 2022.¹ Overdose and substance use impact not only the individuals using substances, but also families and communities, and can have profound short- and long-term effects for children of persons who use substances.^{2,3,4,5,6,7,8,9}

Although more than 1 million lives have been lost in the US to overdose in the past 2 decades,¹⁰ to our knowledge, no study has estimated the number of children who have lost a parent to overdose. A small number of studies have indirectly examined this issue. For example, Ghertner et al⁴ found that a 10% increase in county-level drug overdose death rates was associated with a 4.4% increase in county-level foster care entry rates. Beatty et al¹¹ reported that counties with higher overdose mortality rates had greater rates of grandparents as primary caregivers. Caudillo et al¹² found that higher overdose death rates were associated with fewer children living with 2 married parents and with children living in family structures that may differentially affect developmental outcomes.

Prior research on parental loss and bereavement in general indicates that children who lose a parent can have both short- and long-term challenges with substance use, mental health, and physical health as well as schooling challenges, financial insecurity, housing instability, and disruption in essential nurturing during critical development periods.^{9,13,14,15,16,17,18,19,20} Further, growing up in a household with a parent who uses substances, itself an adverse childhood experience, is associated with an increased risk of exposure to other childhood adversities, further compounding the impacts of parental loss due to overdose.²¹ Parental loss can also strain already overwhelmed foster care systems and place new demands on other family members to provide kinship care.^4,9,10,18

In this exploratory, cross-sectional study, we sought to answer 3 research questions. First, how many community-dwelling children younger than 18 years lost a parent to a drug overdose in the US from 2011 to 2021? Second, how do the number and rate of community-dwelling children younger than 18 years who have lost a parent to drug overdose vary by parental sex, age, and race and ethnicity? Third, what are the rates overall and by parental sex, age, and race and ethnicity? Given the potential impacts of parental loss, these estimates are pivotal to informing policy and programmatic planning moving forward to holistically address the needs of affected children, families, and communities.

Methods

Data Sources

This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. The NSDUH data collection protocol was approved by the Institutional Review Board at the Research Triangle Institute International. Oral informed consent was obtained from each participant in the National Surveys on Drug Use and Health (NSDUH). This study used NSDUH data and deidentified mortality data from the National Vital Statistics System Multiple Cause of Death files and was deemed exempt from institutional review board review by the CDC and the National Institutes of Health.

National Survey on Drug Use and Health

Household composition and parental drug use data were from the 2010 to 2019 NSDUH. The NSDUH provides nationally representative data on demographic characteristics, past-year drug use, and household composition among the US civilian, noninstitutionalized population aged 12 years and older.²² For the 2010 to 2019 NSDUH, the annual mean weighted interview response rate was 70.1%. Additional details about NSDUH methods are available.^22,23

National Vital Statistics System

Annual drug overdose death data were examined using the 2011 to 2021 CDC National Vital Statistics System (NVSS) multiple-cause-of-death files.²⁴ These files contain information recorded from all death certificates filed in the 50 states and the District of Columbia.

Measures

Household Composition

For each sampled respondent, the NSDUH collected the number of people residing in the same household and their age and relationship with the respondent. The NSDUH defines a parent as a biological parent, adoptive parent, stepparent, or adult guardian. Race and ethnicity of parents were determined according to NSDUH sampled parent self-classification of racial and ethnic origin and identification based on classifications developed by the US Census Bureau. This information was included in the present study to assess disparities by race and ethnicity.

Parental Past-Year Drug Use

For the 2010 to 2014 NSDUH data, we defined parental past-year drug use as a parent who reported using cocaine, heroin, inhalants, or hallucinogens or using psychotherapeutic drugs (ie, prescription pain relievers, stimulants, sedatives, and tranquilizers) nonmedically in the past 12 months. Due to the partial survey redesign in 2015, including addition of methamphetamine as a specific drug category, parental past-year drug use from the 2015 to 2019 NSDUH was defined as a parent who reported using cocaine, heroin, inhalants, hallucinogens, or methamphetamine or misusing psychotherapeutic drugs in the past 12 months. Parents could have used multiple substances. Any parent with past-year use of cannabis only was excluded from analyses.

Drug Overdose Deaths

Consistent with CDC definitions, drug overdose deaths were identified using the International Classification of Diseases, Tenth Revision (ICD-10), underlying cause-of-death codes for poisoning: X40-X44 (accidental), X60-X64 (intentional), X85 (homicide), and Y10-14 (undetermined intent). Although these codes capture overdose deaths involving a range of substances, data from medical examiners and coroners indicate that most drug overdose deaths (>95%) involve prescription or illicit opioids, prescription or illicit stimulants, or other controlled substances, concordant with past-year drug use variables included from the NSDUH.²⁵ Using 2011 to 2021 NVSS data, we identified annual drug overdose decedents by parental age (18-25 years, 26-40 years, and 41-64 years), sex, and race and ethnicity. Race and ethnicity categories were consistent with those collected in NSDUH.

Statistical Analyses

Number of Children Who Lost a Parent to Drug Overdose

First, we examined number of children younger than 18 years living with at least 1 nonelderly adult parent within the same household overall and by parental age, sex, and race and ethnicity, and by past-year drug use status based on the 2010 to 2014 and 2015 to 2019 NSDUH data, separately. SUDAAN software release 11.0.3 (Research Triangle Institute) was used to account for the NSDUH’s complex sample design and sample weights. Weighted mean number of children and associated standard error (SE) were estimated by sex, age, and race and ethnicity.

Second, to estimate annual number of children who lost a parent to drug overdose, we assumed the distribution of number of children of nonelderly adults who died from a drug overdose is the same as distribution of number of children of parents aged 18 to 64 years with past-year drug use of the same sex, age, and race and ethnicity. Specifically, we applied the estimated mean numbers of children (denoted by C̅) living with a parent with past-year drug use by parental sex, age, and race and ethnicity category from NSDUH data to the corresponding numbers of drug overdose decedents (denoted by D) of the same sex, age, and race and ethnicity category from annual NVSS data (ie, C̅ × D). We applied specific estimates from 2010 to 2014 NSDUH to corresponding overdose decedents in each year of 2011 to 2014 NVSS data and estimates from 2015 to 2019 NSDUH to each year of 2015 to 2021 NVSS data. Due to COVID-19–related NSDUH changes, we applied the family structures from the 2015 to 2019 NSDUH to the 2020 and 2021 mortality data.

Third, we assumed a Poisson distribution for the number of children. Since the mean is equal to the variance, the SE (denoted by σ) of the product of C̅ × D was derived as the following: SE(C̅ × D) = σ × |D|. Fourth, we combined our annual estimates to generate 2011 to 2021 total overall estimates and for each sex, age, and race and ethnicity category.

Rates of Children Who Lost a Parent to Drug Overdose

To estimate rates of children who lost a parent to drug overdose by parental sex, age, and race and ethnicity category, we first estimated the population denominator for total annual number of children living with a parent and stratified by parental age and race and ethnicity category regardless of parental drug use using NSDUH data. Next, we estimated rates by dividing the total number of children who lost a parent to drug overdose by the corresponding total number of children living with a parent. Rates were stratified by parental sex, age group, and race and ethnicity category.

Finally, we analyzed rates for each year from 2011 to 2021 by parental race and ethnicity categories, sex, and age groups. We used joinpoint regression and generalized linear regression to analyze trends of rates in specific sex, age, and race and ethnicity groups from 2011 to 2021 and to report the average annual percent change (AAPC) in rates. For each analysis, AAPC was deemed significantly different from 0 at α = .05. We used SAS software version 9.4 (SAS Institute). Data were analyzed from January to June 2023.

Results

Based on the 2010 to 2014 NSDUH data, we examined 110 000 men and 124 500 women 18 years and older, including 14 900 men and 12 300 women with past-year drug use, excluding cannabis-only use. Similarly, using the 2015 to 2019 NSDUH data, we examined 119 000 men and 135 700 women aged 18 years and older, including 16 200 men and 14 000 women with past-year drug use, excluding cannabis-only use.

Among community-dwelling men aged 18 to 64 years who reported past-year drug use, an estimated 20.8% (95% CI, 19.6-22.0) and 20.1% (95% CI, 19.2-21.0) reported having at least 1 child residing with them within the same household in 2010 to 2014 and 2015 to 2019, respectively. Similarly, among community-dwelling women aged 18 to 64 years who reported past-year drug use, an estimated 31.6% (95% CI, 30.1-33.0) and 28.4% (95% CI, 27.4-29.5) reported having at least 1 child residing with them in 2010 to 2014 and 2015 to 2019, respectively. Weighted mean numbers of children by parental past-year drug use, age, sex, and race and ethnicity are presented in eTable 1 in Supplement 1. For both men and women, the largest mean number of children was among parents aged 26 to 40 years, followed by parents aged 41 to 64 year and 18 to 25 years.

From 2011 to 2021, 649 599 adults aged 18 to 64 years died from a drug overdose (mean [SD] age, 41.7 [12.0] years; 430 050 [66.2%] male and 219 549 [33.8%] female; 62 606 [9.6%] Hispanic, 6899 [1.1%] non-Hispanic American Indian or Alaska Native, 6133 [0.9%] non-Hispanic Asian or Pacific Islander, 82 313 [12.7%] non-Hispanic Black, 485 623 [74.8%] non-Hispanic White, and 6025 [0.9%] non-Hispanic with more than 1 race). Among these decedents, we estimate that from 2011 to 2021, 321 566 (95% CI, 276 592-366 662) community-dwelling children lost a parent aged 18 to 64 years to drug overdose (Table 1). The largest number of children was found among parental overdose decedents aged 26 to 40 years (175 355; 95% CI, 157 064-193 646), followed by those aged 41 to 64 years (139 236; 95% CI, 113 864-164 729) and 18 to 25 years (6975; 95% CI, 5664-8287). Across parental racial and ethnic groups, the largest number of children who lost a parent to drug overdose was among non-Hispanic White parents (234 164; 95% CI, 211 731-256 598), followed by Hispanic parents (40 062; 95% CI, 32 449-47 675) and non-Hispanic Black parents (35 743; 95% CI, 26 795-44 692). Overall and across all age groups, a larger number of children lost a father to overdose (192 459; 95% CI, 164 081-220 838) compared to a mother (129 107; 95% CI, 112 510-145 824). Year-, age-, sex-, and race and ethnicity–specific estimates are presented in eTable 2 in Supplement 1.

Table 1. Estimates of Community-Dwelling Children Who Lost a Parent to Drug Overdose in the US, 2011-2021, by Parental Age, Sex, Race, and Ethnicity^a.

Variable	Estimate (95% CI)
	Parental age group, y			Overall
	18-25	26-40	41-64	Overall
Overall	6975 (5664-8287)	175 355 (157 064-193 646)	139 236 (113 864-164 729)	321 566 (276 592-366 662)
By parental sex
Male	3363 (2590-4137)	103 907 (92 186-115 627)	85 189 (69 305-101 073)	192 459 (164 081-220 838)
Female	3612 (3074-4149)	71 448 (64 878-78 019)	54 047 (44 558-63 656)	129 107 (112 510-145 824)
By parental race and ethnicity^b
Hispanic	1268 (986-1550)	22 525 (19 487-25 562)	16 269 (11 976-20 563)	40 062 (32 449-47 675)
Non-Hispanic American Indian or Alaska Native	290 (118-462)	3987 (2412-5561)	1751 (333-3291)	6028 (2863-9314)
Non-Hispanic Asian or Pacific Islander	38 (6-70)	1295 (768-1822)	1971 (764-3179)	3304 (1538-5071)
Non-Hispanic Black	1030 (763-296)	22 246 (18 414-26 079)	12 467 (7617-17 317)	35 743 (26 795-44 692)
Non-Hispanic White	4215 (3711-4718)	123 802 (115 014-132 590)	106 148 (93 006-119 290)	234 164 (211 731-256 598)
Non-Hispanic with >1 race	136 (79-192)	1501 (969-2032)	629 (168-1089)	2265 (1217-3313)

Open in a new tab

^{^a}

National Vital Statistics System 2011-2021 data were used to obtain information on drug overdose deaths among individuals aged 18 to 64 years by sex, race, and ethnicity; National Survey on Drug Use and Health 2010-2014 and 2015-2019 data were used to obtain number of children aged 0-17 years living with people who used drugs by age group, sex, race, and ethnicity of those using drugs.

^{^b}

Race and ethnicity data were collected via self-report based on classifications consistent with what was reported in the National Surveys on Drug Use and Health and included to assess disparities by race and ethnicity.

The rate of community-dwelling children who lost a parent to drug overdose per 100 000 children increased from 27.0 per 100 000 (95% CI, 23.5-30.3) in 2011 to 63.1 per 100 000 (95% CI, 55.8-69.9) in 2021, a 134% increase (Figure 1). The highest rates were consistently found among children of non-Hispanic American Indian or Alaska Native people throughout the study period. In 2021, the rate among children of non-Hispanic American Indian or Alaska Native individuals was 187.1 (95% CI, 110.7-244.2) per 100 000, followed by children of non-Hispanic White (76.5; 95% CI, 71.1-81.7), non-Hispanic Black (73.2; 95% CI, 58.7-86.7), and Hispanic (40.6; 95% CI, 34.7-46.1) individuals.

Figure 1. — National Vital Statistics System 2011-2021 data were used to obtain information on drug overdose deaths among individuals aged 18 to 64 years by sex, race, and ethnicity; National Survey on Drug Use and Health 2010-2014 and 2015-2019 data were used to obtain number of children aged 0-17 years living with people who used drugs by age group, sex, race, and ethnicity of those using drugs.

The highest rates by parents’ age group were consistently found among children whose parents were aged 41 to 64 years followed by those aged 26 to 40 years and 18 to 25 years (Figure 2). The rate among children whose parents were aged 41 to 64 years increased from 41.3 (95% CI, 33.6-48.6) per 100 000 in 2011 to 81.2 (95% CI, 68.0-93.8) in 2021—a 97% percent increase. Among children whose parents were aged 26 to 40 years, rates increased 165% from 22.1 (95% CI, 20.5-23.6) per 100 000 in 2011 to 58.6 (95% CI, 54.0-62.8) in 2021. Rates among children whose parents were aged 18 to 25 years increased 142% from 7.9 (95% CI, 6.8-9.1) per 100 000 in 2011 to 19.1 (95% CI, 15.3-22.7) in 2021. The rate among children whose decedent parent was male increased from 14.8 (95% CI, 12.7-16.7) per 100 000 in 2011 to 40.0 (95% CI, 35.1-44.6) in 2021. Among children whose decedent parent was female, rates increased from 12.3 (95% CI, 10.8-13.6) per 100 000 in 2011 to 23.1 (95% CI, 20.7-25.3) in 2021 (Figure 3).

Figure 2. — National Vital Statistics System 2011-2021 data were used to obtain information on drug overdose deaths among individuals aged 18 to 64 years by sex, race, and ethnicity; National Survey on Drug Use and Health 2010-2014 and 2015-2019 data were used to obtain number of children aged 0-17 years living with people who used drugs by age group, sex, race, and ethnicity of those using drugs.

Figure 3. — National Vital Statistics System 2011-2021 data were used to obtain information on drug overdose deaths among individuals aged 18 to 64 years by sex, race, and ethnicity; National Survey on Drug Use and Health 2010-2014 and 2015-2019 data were used to obtain number of children aged 0-17 years living with people who used drugs by age group, sex, race, and ethnicity of those using drugs.

Across all parental age, sex, and race and ethnicity groups, rates increased consistently each year but at different magnitudes (Table 2). For example, from 2011 to 2021, the AAPC among children with parents aged 26 to 40 years was 10.6% (95% CI, 7.4-13.9), followed by parents aged 18 to 25 years (AAPC, 9.6%; 95% CI, 4.5-15.1) and 41 to 64 years (AAPC, 7.3%; 95% CI, 5.9-8.2). Across parental age and race and ethnicity groups, children from non-Hispanic Black parents aged 18 to 25 years had the largest AAPC (23.8%; 95% CI, 16.5-31.6), followed by parents aged 26 to 40 years who were non-Hispanic and multiple races (AAPC, 19.7%; 95% CI, 16.0-23.5), non-Hispanic Black (AAPC, 19.3%; 95% CI, 16.7-23.7), and non-Hispanic American Indian or Alaska Native (AAPC, 17.3%; 95% CI, 13.5-21.5).

Table 2. Rate of Community-Dwelling Children Younger Than 18 Years Who Lost a Parent to Drug Overdose per 100 000 Children in the US, 2011-2021, by Parental Age Group and Sex, Race, and Ethnicity^a^,^b.

Variable	Year, rate per 100 000											AAPC (95% CI)^c^,^d^,^e
Variable	2011	2012	2013	2014	2015	2016	2017	2018	2019	2020	2021	AAPC (95% CI)^c^,^d^,^e
Age 18-25 y
Overall	7.9	7.5	8.0	8.5	9.7	12.5	13.4	11.6	12.3	17.8	19.1	9.6 (4.5-15.1)^d
Sex
Male	3.9	3.6	3.9	4.0	4.7	6.2	6.3	5.4	5.9	9.0	9.0	9.5 (4.5-14.8)^d
Female	4.1	3.9	4.2	4.4	5.0	6.3	7.1	6.2	6.4	8.8	10.1	9.6 (6.2-13.1)^d
Race and ethnicity^f
Hispanic	3.9	3.5	4.1	4.2	5.6	7.0	7.2	7.1	8.9	14.0	15.1	16.6 (11.2-21.2)^d
Non-Hispanic American Indian or Alaska Native	21.8	20.0	20.4	21.6	21.1	26.6	35.2	22.7	33.6	49.4	65.6	12.5 (7.6-16.5)^d
Non-Hispanic Asian or Other Pacific Islander	2.5	2.3	2.4	2.5	3.0	3.9	4.1	3.6	4.1	6.2	6.0	10.5 (5.3-16.1)^d
Non-Hispanic Black	2.9	3.1	3.5	4.0	5.3	8.6	9.7	9.1	11.2	20.0	22.7	23.8 (16.5-31.6)^d
Non-Hispanic White	12.6	11.9	12.6	13.2	14.2	17.7	18.9	15.9	14.8	19.1	19.8	4.9 (1.9-8.1)^d
Non-Hispanic with >1 race	3.3	4.2	4.3	5.9	5.8	7.0	7.7	6.6	7.9	13.3	12.7	13.1 (10.4-15.8)^d
Age 26-40 y
Overall	22.1	22.2	22.9	25.4	27.9	35.6	39.9	37.8	39.2	52.3	58.6	10.6 (7.4-13.9)^d
Sex
Male	12.0	12.0	12.5	14.2	16.4	21.3	24.2	22.7	23.7	32.1	36.0	12.1 (8.3-16.1)^d
Female	10.2	10.2	10.3	11.2	11.5	14.2	15.7	15.1	15.5	20.2	22.6	9.2 (6.0-11.5)^d
Race and ethnicity^f
Hispanic	11.1	11.0	11.7	12.8	12.7	16.9	19.2	19.5	22.0	31.5	36.6	12.4 (10.3-14.9)^d
Non-Hispanic American Indian or Alaska Native	39.9	44.0	39.0	49.5	73.7	88.7	89.8	91.0	112.9	161.7	190.4	17.3 (13.5-21.5)^d
Non-Hispanic Asian or Other Pacific Islander	4.2	4.0	4.4	4.6	3.0	3.6	4.5	4.6	4.5	6.2	6.6	4.1 (1.2-7.0)^d
Non-Hispanic Black	12.1	11.7	13.1	14.5	18.4	26.2	32.9	32.1	38.2	59.5	74.2	19.3 (16.7-23.7)^d
Non-Hispanic White	31.4	31.6	32.4	36.1	39.2	49.2	54.4	50.7	50.3	63.7	69.1	8.5 (5.3-11.9)^d
Non-Hispanic with >1 race	5.2	7.9	7.6	8.8	13.0	15.7	18.7	19.6	19.7	30.0	36.0	19.7 (16.0-23.5)^d
Age 41-64 y
Overall	41.3	41.4	44.1	45.6	43.7	50.0	54.0	52.1	54.5	68.3	81.2	7.3 (5.9-8.2)^d
Sex
Male	22.9	23.1	24.9	25.8	24.7	29.8	33.2	32.8	35.2	45.3	54.4	9.7 (7.7-10.8)^d
Female	18.4	18.3	19.2	19.8	19.0	20.2	20.8	19.3	19.3	23.0	26.8	3.7 (2.3-4.6)^d
Race and ethnicity^f
Hispanic	22.5	23.9	24.8	24.3	24.1	28.3	31.8	33.2	37.1	47.2	57.4	8.8 (7.2-10.8)^d
Non-Hispanic American Indian or Alaska Native	99.8	100.2	103.3	102.2	99.2	105.4	106.3	118.2	121.2	166.7	249.6	9.8 (8.4-11.0)^d
Non-Hispanic Asian or Other Pacific Islander	6.5	5.9	6.3	6.8	6.5	7.2	7.9	9.1	9.7	13.0	14.7	8.9 (7.0-10.7)^d
Non-Hispanic Black	31.6	32.2	35.5	38.1	27.6	37.7	45.2	46.6	52.4	70.9	90.0	9.3 (6.0-13.2)^d
Non-Hispanic White	51.1	51.3	54.9	57.4	56.6	64.1	68.8	65.3	67.4	83.7	98.5	6.9 (5.1-7.9)^d
Non-Hispanic with >1 race	18.5	19.5	22.2	25.2	19.3	24.5	25.1	28.7	28.9	38.7	43.2	8.6 (6.3-10.2)^d

Open in a new tab

Abbreviation: AAPC, average annual percent change.

^{^a}

^{^b}

95% CIs of all estimated rates are presented in eTable 3 in Supplement 1.

^{^c}

AAPC was obtained from joinpoint regression. Empirical quantile 95% CIs are shown in parentheses.

^{^d}

Indicates the AAPC is significantly different from 0 at the α = .05 level.

^{^e}

AAPC and associated 95% CI obtained by generalized linear model are presented in eTable 4 in Supplement 1.

^{^f}

Discussion

In this cross-sectional study, we estimated that more than 320 000 US children lost a parent to drug overdose between 2011 and 2021, providing new insight into the multigenerational impacts of the ongoing overdose crisis in the US. These findings are particularly concerning given that children who experience parental loss are at increased risk of a range of health and social challenges, including future substance use and mental health challenges. Thus, the magnitude of our findings underscores the critical need for policy and programmatic efforts to incorporate the needs of people using substances as well as their children and other family members affected by their use.

Our findings highlight an additional dimension of the worsening overdose disparities seen among minoritized racial and ethnic groups, in particular among tribal populations.^26,27 Our results are consistent with previous research that shows significant increases in overdose among non-Hispanic American Indian or Alaska Native and Black persons in recent years.^26,27 Inequities in access to and use of evidence-based treatment and harm reduction services are also well documented.²⁶ These disparities are compounded and facilitated by structural and social determinants of health such as discrimination, neighborhood environment, access to care, unstable housing, and multigenerational poverty.^28,29 Continued programmatic and policy efforts to advance culturally responsive, trauma-informed prevention, treatment, and recovery support services combined with services such as housing, transportation, childcare, and education are critically needed.^29,30

One component of the strategy for reducing future harms of parental loss is to save lives by expanding prevention, harm reduction, treatment, and recovery services that are accessible and acceptable for parents and people of childbearing age. While expanding these services has been a priority of federal, state, and local efforts over the past decade,^31,32,33,34 a specific focus on parents has been lacking. Having a role as a parent can be a strong motivator to participate in substance use disorder treatment,³⁵ but disrupted neurobiological reward and stress systems in persons with substance use disorders may also cause difficulties with parenting.³⁶ Directly addressing parenting during treatment is a natural focus that has been examined by multiple studies that generally show positive outcomes.³⁷ However, specific parenting interventions, including peer-to-peer parenting training, are not often included in treatment.³⁸ It is also evident that being a parent may increase challenges with obtaining substance use disorder treatment or harm reduction services due to concerns about child protective services, internalized guilt and shame, and the practical demands of parenting.^35,39,40 For pregnant persons, these concerns may be amplified.⁴¹ At least 25 states and the District of Columbia consider substance use during pregnancy to be child abuse.⁴² If states take more harm reduction–centered approaches rather than punitive measures, the existing health care resources may help reduce pregnancy-associated drug overdose mortality⁴³ and impact on offspring.^44,45

A second component is ensuring ready access to services designed to support the full family unit. Living in a household with parental substance use is itself an adverse childhood experience, increasing risk of lasting negative impact on a child’s long-term health and well-being.⁴⁶ This existing vulnerability is subject to compounded trauma in cases of parental overdose death. Premature death of a parent has complex effects on a child’s mental and physical health, and increased risks of substance use disorder and suicide are associated with the anniversary of such deaths.^9,14 Support for children of parents who use drugs is essential at every stage of the drug use trajectory. From prevention interventions delivered to new parents who may use substances to interventions that enhance resilience and protective factors for children, services that support healthy development for children, especially for those whose parents use drugs, need to be readily available.^21,47,48 In the event of a parental overdose death, services to provide bereavement support to the child and treatments for subsequent depression, trauma, or substance use are essential.

Given the magnitude and lifelong impacts of parental loss, future research could explore how such loss varies by other factors such as socioeconomic status and geography. Future research also could examine the effectiveness of strategies designed to address the economic, social, educational, and health care needs of children who have lost parents to overdose.

Limitations

This study has several limitations. First, the lack of direct information about overdose decedent family and household structure necessitated use of family structures among people using drugs; future research may provide direct data on decedent family structure. Due to small sample sizes, we pooled multiple years of NSDUH data to estimate mean annual number of children of parents with past-year drug use by parental sex, age, and race and ethnicity. In addition, we applied the family structures from the 2015 to 2019 NSDUH to the 2020 and 2021 mortality data due to COVID-19–related NSDUH survey changes. However, household composition of such parental characteristics should be relatively consistent within the pooled years of data.⁴⁹ Second, NSDUH only includes the noninstitutionalized population; thus, NSDUH estimates on the mean number of children of coresident parents with past-year drug use only represent the community-dwelling population. They do not capture populations such as individuals who are incarcerated, in institutional settings, or those experiencing homelessness and not living in shelters. However, the NVSS does not contain information on whether the decedent is community dwelling or not. Thus, our estimates may overestimate or underestimate the total number of children who lost a parent to overdose. Third, the NSDUH relies on self-report of race and ethnicity and NVSS relies on race and ethnicity classification by death certifiers, which may result in misclassification. Fourth, we assumed the mean number of children whose parents died from a drug overdose is the same as the national mean number of children of coresident parents with past-year drug use (excluding those with cannabis-only use). Fifth, since we estimated numbers of children who lost a parent to drug overdose by parental sex annually, we assumed our estimates did not count a child twice either within a specific year or in different years.

Conclusions

In this study, an estimated 321 566 children lost a parent to drug overdose from 2011 to 2021, with significant disparities evident across racial and ethnic groups, in particular among non-Hispanic American Indian or Alaska Native people. Given the potential impacts of parental loss, program and policy planning should ensure that responses to the overdose crisis integrate the full burden of drug overdose on families and children, including the economic, social, educational, and physical and behavioral health care needs of children who have lost parents to overdose.

Supplement 1.

eTable 1. Weighted mean numbers of children aged <18 residing with parent(s) by time period and parental drug use status, sex, age, and race/ethnicity

eTable 2. Estimates and 95% confidence intervals of community-dwelling children who lost a parent to a drug overdose, by parental age, sex, race/ethnicity, and year in U.S., 2011-2021

eTable 3. 95% CIs of rate of community-dwelling children aged 0-17 who lost a parent to a drug overdose per 100,000 children, by parental age, sex, and race/ethnicity, 2011-2021

eTable 4. Rate of community-dwelling children aged <18 who lost a parent to a drug overdose per 100,000 children, by parental age, sex, and race/ethnicity, 2011-2021

eTable 5. Drug overdose death rate among men, 2011-2021

eTable 6. Drug overdose death rate among women, 2011-2021

jamapsychiatry-e240810-s001.pdf^{(227.1KB, pdf)}

Supplement 2.

Data sharing statement

jamapsychiatry-e240810-s002.pdf^{(14.7KB, pdf)}

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

eTable 1. Weighted mean numbers of children aged <18 residing with parent(s) by time period and parental drug use status, sex, age, and race/ethnicity

eTable 2. Estimates and 95% confidence intervals of community-dwelling children who lost a parent to a drug overdose, by parental age, sex, race/ethnicity, and year in U.S., 2011-2021

eTable 3. 95% CIs of rate of community-dwelling children aged 0-17 who lost a parent to a drug overdose per 100,000 children, by parental age, sex, and race/ethnicity, 2011-2021

eTable 4. Rate of community-dwelling children aged <18 who lost a parent to a drug overdose per 100,000 children, by parental age, sex, and race/ethnicity, 2011-2021

eTable 5. Drug overdose death rate among men, 2011-2021

eTable 6. Drug overdose death rate among women, 2011-2021

jamapsychiatry-e240810-s001.pdf^{(227.1KB, pdf)}

Supplement 2.

Data sharing statement

jamapsychiatry-e240810-s002.pdf^{(14.7KB, pdf)}

[yoi240018r1] 1.US Centers for Disease Control and Prevention’s National Center for Health Statistics . Provisional mortality dashboard. Accessed September 20, 2023. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm

[yoi240018r2] 2.Loch SF, Stein BD, Ghertner R, et al. Neonatal opioid withdrawal syndrome is associated with infant foster care entry at the county level. Health Aff (Millwood). 2021;40(11):1776-1783. doi: 10.1377/hlthaff.2021.00460 [DOI] [PMC free article] [PubMed] [Google Scholar]

[yoi240018r3] 3.Hirai AH, Ko JY, Owens PL, Stocks C, Patrick SW. Neonatal abstinence syndrome and maternal opioid-related diagnoses in the US, 2010-2017. JAMA. 2021;325(2):146-155. doi: 10.1001/jama.2020.24991 [DOI] [PMC free article] [PubMed] [Google Scholar]

[yoi240018r4] 4.Ghertner R, Baldwin M, Crouse G, Radel L, Waters A. The relationship between substance use indicators and child welfare caseloads. 2018. Accessed September 18, 2023. https://aspe.hhs.gov/sites/default/files/migrated_legacy_files/179971/SubstanceUseCWCaseloads.pdf

[yoi240018r5] 5.Madras BK, Han B, Compton WM, Jones CM, Lopez EI, McCance-Katz EF. Associations of parental marijuana use with offspring marijuana, tobacco, and alcohol use and opioid misuse. JAMA Netw Open. 2019;2(11):e1916015. doi: 10.1001/jamanetworkopen.2019.16015 [DOI] [PMC free article] [PubMed] [Google Scholar]

[yoi240018r6] 6.Meulewaeter F, De Schauwer E, De Pauw SSW, Vanderplasschen W. “I grew up amidst alcohol and drugs:” a qualitative study on the lived experiences of parental substance use among adults who developed substance use disorders themselves. Front Psychiatry. 2022;13:768802. doi: 10.3389/fpsyt.2022.768802 [DOI] [PMC free article] [PubMed] [Google Scholar]

[yoi240018r7] 7.Nash SG, McQueen A, Bray JH. Pathways to adolescent alcohol use: family environment, peer influence, and parental expectations. J Adolesc Health. 2005;37(1):19-28. doi: 10.1016/j.jadohealth.2004.06.004 [DOI] [PubMed] [Google Scholar]

[yoi240018r8] 8.Li C, Pentz MA, Chou CP. Parental substance use as a modifier of adolescent substance use risk. Addiction. 2002;97(12):1537-1550. doi: 10.1046/j.1360-0443.2002.00238.x [DOI] [PubMed] [Google Scholar]

[yoi240018r9] 9.Burrell LV, Mehlum L, Qin P. Parental death by external causes during childhood and risk of psychiatric disorders in bereaved offspring. Child Adolesc Ment Health. 2022;27(2):122-130. doi: 10.1111/camh.12470 [DOI] [PubMed] [Google Scholar]

[yoi240018r10] 10.US Centers for Disease Control and Prevention’s National Center for Health Statistics . Wide-ranging online data for epidemiologic research (WONDER). 2023. Accessed August 23, 2023. https://wonder.cdc.gov

[yoi240018r11] 11.Beatty KE, Mathis SM, McCurry AR, Francisco MM, Meit M, Wahlquist AE. The association between grandparents as caregivers and overdose mortality in Appalachia and non-Appalachia counties. Front Public Health. 2023;11:1035564. doi: 10.3389/fpubh.2023.1035564 [DOI] [PMC free article] [PubMed] [Google Scholar]

[yoi240018r12] 12.Caudillo ML, Villarreal A, Cohen PN. The opioid epidemic and children’s living arrangements in the United States, 2000-2018. Ann Am Acad Pol Soc Sci. 2023;703(1). doi: 10.1177/00027162221142648 [DOI] [PMC free article] [PubMed] [Google Scholar]

[yoi240018r13] 13.Lancet Public Health . A last taboo in public health. Lancet Public Health. 2022;7(8):e647. doi: 10.1016/S2468-2667(22)00175-X [DOI] [PubMed] [Google Scholar]

[yoi240018r14] 14.Hiyoshi A, Berg L, Saarela J, et al. Substance use disorder and suicide-related behaviour around dates of parental death and its anniversaries: a register-based cohort study. Lancet Public Health. 2022;7(8):e683-e693. doi: 10.1016/S2468-2667(22)00158-X [DOI] [PubMed] [Google Scholar]

[yoi240018r15] 15.Barenbaum E, Smith T. Social support as a protective factor for children impacted by HIV/AIDS across varying living environments in southern Africa. AIDS Care. 2016;28(suppl 2):92-99. doi: 10.1080/09540121.2016.1176683 [DOI] [PMC free article] [PubMed] [Google Scholar]

[yoi240018r16] 16.Carr MJ, Mok PLH, Antonsen S, Pedersen CB, Webb RT. Self-harm and violent criminality linked with parental death during childhood. Psychol Med. 2020;50(7):1224-1232. doi: 10.1017/S0033291719001193 [DOI] [PMC free article] [PubMed] [Google Scholar]

[yoi240018r17] 17.Bergman AS, Axberg U, Hanson E. When a parent dies—a systematic review of the effects of support programs for parentally bereaved children and their caregivers. BMC Palliat Care. 2017;16(1):39. doi: 10.1186/s12904-017-0223-y [DOI] [PMC free article] [PubMed] [Google Scholar]

[yoi240018r18] 18.Hulsey EG, Li Y, Hacker K, Williams K, Collins K, Dalton E. Potential emerging risks among children following parental opioid-related overdose death. JAMA Pediatr. 2020;174(5):503-504. doi: 10.1001/jamapediatrics.2020.0613 [DOI] [PMC free article] [PubMed] [Google Scholar]

[yoi240018r19] 19.Luecken LJ, Roubinov DS. Pathways to lifespan health following childhood parental death. Soc Personal Psychol Compass. 2012;6(3):243-257. doi: 10.1111/j.1751-9004.2011.00422.x [DOI] [PMC free article] [PubMed] [Google Scholar]

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PERMALINK

Estimated Number of Children Who Lost a Parent to Drug Overdose in the US From 2011 to 2021

Christopher M Jones, PharmD, DrPH, MPH

Kun Zhang, PhD

Beth Han, MD, PhD, MPH

Gery P Guy, PhD, MPH

Jan Losby, PhD

Emily B Einstein, PhD

Miriam Delphin-Rittmon, PhD

Nora D Volkow, MD

Wilson M Compton, MD, MPE

Key Points

Question

Findings

Meaning

Abstract

Importance

Objective

Design, Setting, and Participants

Exposure

Main Outcomes and Measures

Results

Conclusions and Relevance

Introduction

Methods

Data Sources

National Survey on Drug Use and Health

National Vital Statistics System

Measures

Household Composition

Parental Past-Year Drug Use

Drug Overdose Deaths

Statistical Analyses

Number of Children Who Lost a Parent to Drug Overdose

Rates of Children Who Lost a Parent to Drug Overdose

Results

Table 1. Estimates of Community-Dwelling Children Who Lost a Parent to Drug Overdose in the US, 2011-2021, by Parental Age, Sex, Race, and Ethnicitya.

Figure 1. Estimated Rate of Community-Dwelling Children Who Lost a Parent to Drug Overdose per 100 000 Children in the US, 2011-2021, by Parental Race and Ethnicity.

Figure 2. Estimated Rate of Community-Dwelling Children Who Lost a Parent to Drug Overdose per 100 000 Children in the US, 2011-2021, by Parental Age Group.

Figure 3. Estimated Rate of Community-Dwelling Children Who Lost a Parent to Drug Overdose per 100 000 Children in the US, 2011-2021 by Parental Sex.

Table 2. Rate of Community-Dwelling Children Younger Than 18 Years Who Lost a Parent to Drug Overdose per 100 000 Children in the US, 2011-2021, by Parental Age Group and Sex, Race, and Ethnicitya,b.

Discussion

Limitations

Conclusions

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases

Table 1. Estimates of Community-Dwelling Children Who Lost a Parent to Drug Overdose in the US, 2011-2021, by Parental Age, Sex, Race, and Ethnicity^a.

Table 2. Rate of Community-Dwelling Children Younger Than 18 Years Who Lost a Parent to Drug Overdose per 100 000 Children in the US, 2011-2021, by Parental Age Group and Sex, Race, and Ethnicity^a^,^b.