Abstract
Background
Illicit drug toxicity is an escalating public health emergency. Usually framed as an adult issue, adolescents are significantly impacted. Little is currently known about the interface between Canadian paediatric physicians and adolescents experiencing severe health events from illicit drug toxicity.
Objectives
(1) To determine the proportion of paediatricians in Canada who care for young people between 12 and 18 years who have managed cases of illicit drug toxicity; (2) to identify the characteristics of paediatricians that provide this care; and (3) to describe respondents’ awareness of substance use-oriented services for youth in their home communities.
Methods
A one-time descriptive cross-sectional study was conducted from May to June 2022. Clinicians self-reported cases of illicit drug toxicity from opioids, stimulants and sedatives for adolescents 12 to 18 years old over the preceding 24-month period. Respondents also self-reported their knowledge of substance use-focussed services for children and adolescents in their communities.
Results
A total of 1027/2791 (response rate 37%) physicians completed the survey. Most respondents (n = 934, 91%) reported providing medical care to children and youth 12 years of age and over. 128/934 (13.7%) reported caring for at least one case of illicit drug toxicity. The majority of case reporters were general paediatricians (43%). Overall awareness of substance-related services was limited.
Conclusion
A considerable proportion of respondents provided care for illicit drug toxicity over 24 months. This contrasts with a relatively low level of awareness of services for substance use in this population. Further research and education can support patients and physicians alike in the care of adolescent illicit drug toxicity.
Keywords: Substance use, Illicit drug toxicity, Adolescent health, Epidemiology
Introduction
Illicit drug toxicity is a public health emergency, with escalating mortality trends since the advent of synthetic opioids in the drug supply in 2016 (1). Most academic research and clinical programming to support people who use drugs is focused on adult populations (2). Despite this, overdose is now the leading cause of mortality in young people ages 12 to 18 years in some Canadian jurisdictions; specifically, unregulated drug deaths are now the most common cause of death among adolescents in British Columbia (BC) since 2022, with 36 cases reported that year in youth under 19 (3,4). Despite the significance of the issue, the epidemiology of adolescent substance use, especially emerging substances, such as synthetic opioids, sedatives and stimulants, remains poorly described (5). Recent articles have highlighted the importance of better understanding the epidemiology of paediatric drug overdose deaths to improve outcomes for this population (6). A recent population-based study in BC identified that 13% of participating youth had experienced an injury related to substance use, and 2% had experienced an overdose event (7). Understanding how Canadian paediatricians interact with young people experiencing drug-related harm is of paramount importance.
Though paediatric providers recognize the importance of substance use screening and intervention, education on substance use care including treatment and harm reduction for paediatricians is lacking (8). Paediatricians and paediatric subspecialists feel ill-equipped to deal with acute presentations related to illicit drug toxicity, even if many report treating youth with illicit drug toxicity as part of their practice (9). To our knowledge, the proportion of paediatric providers providing care to youth with illicit drug toxicity as well as the incidence of such presentations has not yet been reported in Canada. Understanding the locations and practice backgrounds of providers caring for youth who use substances can help identify the types of educational interventions that will be the most impactful in improving outcomes for this population.
The primary objective of this study was to determine the proportion of paediatricians and paediatric subspecialists in Canada who care for young people between 12 and 18 years who have been involved with cases of illicit drug toxicity from opioid, stimulant and sedative use over a 2-year recall period. The secondary objective was to identify the characteristics of paediatricians that provide this care, including practice location and speciality. The final objective was to understand respondents’ awareness of substance use-oriented services for youth ages 12 to 15 and 16 to 18 years in their home communities. We hypothesized that many paediatric providers across practice types and locations would report providing care to adolescents presenting with illicit drug toxicity and that important gaps in knowledge of treatment resources would be reported.
Methods
A one-time descriptive cross-sectional study of Canadian paediatricians and paediatric subspecialists was conducted from April to June 2022 through the established platform and methodology of the Canadian Paediatric Surveillance Program (CPSP) (10). Approximately 95% of practising paediatric physicians in Canada are members of the CPSP. Clinicians provided their postal code of employment, clinical environment (academic or community-based) and speciality background as demographic data.
Clinicians self-reported cases of illicit drug toxicity from opioids (illicit opioids or nonmedical use of prescription opioids requiring resuscitation), stimulants (severe methamphetamine or other stimulant toxicity) and sedatives (e.g., benzodiazepines or barbiturates) either in or out of the hospital in adolescents 12 to 18-years-old over the preceding 24-month period. Rather than specific cases, they provided a range of cases seen over the preceding 24 months: 1 to 2 cases, 3 to 5 cases, 6 to 10 cases, 10 to 19 cases and 20 or more cases.
Clinicians were also asked to self-report their knowledge of substance use-focused services for children and adolescents in their communities, for both 12 to 15-year-olds and 16 to 18-year-olds. These age categories were designed based on expert opinion from team members across Canada, in recognition that many jurisdictions have different service availability for older compared with younger youth. Clinicians were asked about nine types of services used to support youth who use drugs: inpatient consultations, phone consultations, inpatient hospital formulary access to medication for substance use, outpatient medication prescribers for substance use, outpatient medical health services, concurrent disorders (i.e., substance use and mental health) inpatient treatment, residential treatment programs, inpatient detoxification services and intensive outpatient programs. Clinicians were asked to rate their awareness of the above services as ʻyes’, ʻno’ or ʻunsure’.
Descriptive statistics were calculated using Stata v15. Per CPSP guidelines, cell counts < 5 were not reported. STROBE reporting guidelines for cross-sectional studies were followed (11). This study was reviewed by the British Columbia Children’s Hospital Research Ethics Board, and deemed exempt from needing review as a surveillance project.
Results
In total, 1027/2791 (response rate 37%) physicians completed the survey. All respondents were physicians practising in Canada. Most respondents (n = 934, 91%) reported providing care to children and youth 12 years of age and over. These 934 were used as the denominator for the primary analyses. 128/934 (13.7%) respondents who cared for children 12 and over reported caring for at least one young person with drug toxicity from illicit opioid, stimulant and sedative use over the 24-month recall period; 743/934 (79.5%) reported not seeing a case, and 63/934 (6.7%) did not respond to the question. Each respondent could report more than one type of substance. Sedative overdoses were most commonly reported (76/934, 8.1%), followed closely by stimulants (74/934, 7.9%), and opioids (65/934, 7.0%). Additional data is available in Table 1.
Table 1.
The number of respondents caring for youth 12 and over reporting cases of illicit opioid, stimulant and sedative toxicity (n = 934)a.
| Presentation | N (%) | Clinician reported case frequency in the preceding 24 months | ||||
|---|---|---|---|---|---|---|
| 1–2 n (%) |
3–5 n (%) |
6–9 n (%) |
10–19 n (%) |
≥20 n (%) |
||
| Any case | 128 (13.7) | |||||
| Opioid toxicity | 65 (7.0%) | 36 (3.9%) | 19 (2.0%) | 8 (0.9%) | <5 | <5 |
| Stimulant toxicity | 74 (7.9%) | 43 (4.6%) | 26 (2.8%) | <5 | <5 | <5 |
| Sedative toxicity |
76 (8.1%) | 46 (4.9%) | 18 (1.9%) | 10 (1.1%) | <5 | <5 |
aNote respondents could report cases of each opioid, stimulant and sedative toxicity; rows are not mutually exclusive.
Characteristics of respondents reporting cases
Of the 128 respondents who reported cases, 108/128 (84.4%) worked in urban settings and 93/128 (72.7%) at academic centres, and cases were also reported in rural and community practice settings (Table 2). General paediatricians made up the largest proportion of case reporters (43%), followed by paediatric emergency medicine (19.5%), paediatric critical care (13.3%) and adolescent medicine (7%) providers (Table 2).
Table 2.
Demographic characteristics of respondents that reported any illicit drug toxicity case (n = 128).
| Characteristic | n (%) |
|---|---|
| Practice type | |
| Adolescent and/or addiction medicine | 9 (7.0%) |
| Critical care | 17 (13.3%) |
| Emergency medicine | 25 (19.5%) |
| General paediatrician | 55 (43.0%) |
| Other subspecialist | 7 (5.5%) |
| Not reported/missing | 15 (11.7%) |
| Practice location | |
| Rural | 7 (5.5%) |
| Suburban | 12 (9.4%) |
| Urban | 108 (84.4%) |
| Not reported/missing | <5 |
| Practice type | |
| Academic | 93 (72.7%) |
| Non-academic | 33 (25.8%) |
| Not reported/missing | <5 |
Eleven municipalities had at least one respondent who reported more than five cases of illicit drug toxicity over the 2-year reporting period (Figure 1). These jurisdictions spanned seven provinces.
Figure 1.
Municipalities in Canada where at least one respondent reported >5 cases of illicit drug toxicity over the 2-year recall period.
The provinces with the highest number of respondents reporting at least one case were Ontario (38/128, 29.7%), British Columbia (26/128, 20.3%) and Quebec (22/128, 17.2%). Sedative use was reported most commonly by respondents in Ontario (27/76, 35.5%) and Quebec (17/76, 22.4%), followed by Alberta (10/76, 13.2%) and British Columbia (7/76, 9.2%). For stimulants, of the 74 respondents that reported any case of toxicity 22 (29.8%) were from Ontario, followed by 15 from Alberta (20.3%), 14 from Quebec (19.0%) and 12 from British Columbia (16.2%). Of the 65 respondents who reported at least one case of illicit opioid toxicity, 21 (32.3%) were from British Columbia, 19 (29.2%) from Ontario and 14 (21.6%) from Alberta. Details are provided in Table 3.
Table 3.
Respondents reporting cases of illicit opioid, simulant and sedative toxicity, by province or region (n = 128)a.
| Province | Any opioid case (n = 65) n (%) | Any stimulant case (n = 74) n (%) | Any sedative case (n = 76) n (%) | Any case (n = 128) n (%) |
|---|---|---|---|---|
| British Columbia | 21 (32.3) | 12 (16.2) | 7 (9.2) | 26 (20.3) |
| Alberta | 14 (21.5) | 15 (20.3) | 10 (13.2) | 22 (17.2) |
| Saskatchewan and Manitoba | <5 | 6 (8.1) | 6 (7.9) | 10 (7.8) |
| Ontario | 19 (29.2) | 22 (29.7) | 27 (35.5) | 28 (29.7) |
| Quebec | <5 | 14 (18.9 | 17 (22.4) | 22 (17.2) |
| Atlantic Canadab | <5 | <5 | 8 (10.5) | 8 (6.3) |
| Province not reported | <5 | <5 | <5 | <5 |
aNo respondents from Yukon, Northwest Territories or Nunavut reported a case.
bAtlantic Canada includes respondents from New Brunswick, Nova Scotia, Newfoundland and Prince Edward Island.
Service awareness
Nearly one-third (297/934, 31.8%) of clinicians provided any response about service awareness (Table 4). Clinicians who reported cases were more likely to report their service awareness. For patients aged 12 to 15 years, the majority of respondents (251/297, 84.5%) had an awareness of outpatient mental health services for this population. For every other service included in the survey, less than 50% of respondents were aware of a related service in their community; details are provided in Table 4. There was notably low awareness (<30%) for residential treatment programs (87/297, 29.3%), outpatient medication treatment for substance use prescribers (84/297, 28.3%), intensive outpatient programs (78/297, 26.3%) and inpatient detoxification centres (75/297, 24.9%).
Table 4.
Respondents’ self-reported awareness of substance-use-oriented services (n = 297).
| Service | Awareness of service for 12-15-year-olds | Awareness of service for 16-18-year-olds | ||||||
|---|---|---|---|---|---|---|---|---|
| Yes n (%) | No n (%) | Unsure n (%) | No response n (%) | Yes n (%) | No n (%) | Unsure n (%) | No response n (%) | |
| Inpatient consultation | 135 (45.5) | 66 (22.2) | 95 (32.0) | 1 (0.3) | 153 (51.5) | 45 (15.2) | 90 (30.3) | 9 (3.0) |
| Phone consultation | 97 (32.7) | 58 (19.5) | 133 (44.8) | 9 (3.0) | 111 (37.4) | 45 (15.2) | 128 (43.1) | 13 (4.4) |
| Medication treatment on formulary | 111 (37.8) | 33 (11.1) | 149 (50.2) | 4 (1.3) | 117 (39.4) | 28 (9.4) | 142 (47.8) | 10 (3.4) |
| Outpatient medication prescribers | 84 (28.3) | 42 (14.1) | 169 (56.9) | 2 (0.7) | 117 (39.4) | 29 (9.8) | 144 (48.5) | 7 (2.4) |
| Outpatient mental health services | 251 (84.5) | 12 (4.0) | 31 (10.4) | 3 (1.0) | 248 (83.5) | 10 (3.4) | 30 (10.1) | 9 (3.0) |
| Concurrent disorders inpatient services | 127 (42.8) | 78 (26.3) | 88 (29.6) | 4 (1.3) | 139 (46.8) | 66 (22.2) | 82 (27.6) | 10 (3.4) |
| Residential treatment services | 87 (29.3) | 65 (21.9) | 142 (47.8) | 3 (1.0) | 102 (34.3) | 57 (19.2) | 127 (42.7) | 11 (3.7) |
| Inpatient detox services | 74 (24.9) | 92 (31.0) | 127 (42.8) | 4 (1.3) | 85 (28.6) | 75 (25.3) | 129 (43.4) | 8 (2.7) |
| Intensive outpatient services | 78 (26.3) | 71 (23.9) | 146 (49.2) | 2 (0.7) | 82 (27.6) | 63 (20.9) | 144 (48.5) | 9 (3.0) |
Patterns for service awareness for 16 to 18-year-old youth were similar. A majority of respondents were aware of outpatient mental health services for this population (248/297, 83.5%). The next service with the highest level of respondent awareness was inpatient consultation for substance use support, at 51.5% (153/297). Fewer than 50% of respondents were aware of all other substance-use-related services for 16 to 18-year-olds. The services with the lowest responses for awareness were inpatient detoxification (85/297, 28.6%) and intensive outpatient programs (82/297, 27.6%).
Discussion
Results of our study indicate that Canadian paediatricians and paediatric subspecialists interface relatively frequently with older children and adolescents experiencing illicit drug toxicity, with 14% of respondents caring for children and youth aged 12 and above reporting at least one case in their clinical practice over 24 months. This finding, in combination with increasing mortality trends, builds an argument for illicit drug toxicity being a major concern for the Canadian paediatric community. Our findings challenge the conceptualization of substance use as a purely adult issue and suggest that paediatricians across Canada need to be prepared to manage youth with severe substance-use-related presentations. These findings match emerging literature from the United States, which also demonstrated an increase in overdose events and substance-used related harms (12). Establishing the capacity for paediatric providers to support adolescents who use drugs is particularly important given the literature surrounding the development of substance use patterns in the adolescent period, the potential benefit of intervention during this period and the youth-identified need for specific services (13,14).
At present, there is minimal focus on the management of substance use disorders in accredited Canadian paediatric training; only adolescent medicine fellowships cover this topic with any specificity, and there is no accredited paediatric-focused addiction medicine fellowship in Canada. A recent US study demonstrated similar educational gaps in American paediatric training (15). Some education on toxidromes exists in medical school as well as paediatric, family medicine and emergency medicine residency programs, but treatment typically only covers immediate resuscitation/antidotes, and not ongoing management (16). In our study, general paediatricians accounted for the highest proportion of cases. This suggests that a breadth of paediatric providers will encounter and be expected to manage cases of illicit drug toxicity. To our knowledge, there is no published data from Canada regarding paediatric practitioners’ attitudes toward the management of substance use-related presentations; however, a recently published American study demonstrated that while a majority of paediatric emergency medicine providers encountered youth with substance use-related issues, most did not feel comfortable treating youth with these presentations, specifically when the needs were related to substance withdrawal and prescription of medications for opioid use disorder (9). Our study team strongly advocates for increased education and training in managing substance use for all paediatricians.
Our results show a trend of more reported opioid-related toxicity events in the western provinces, most notably British Columbia, compared with higher rates of sedative and stimulant toxicity in central and eastern Canada. This trend is congruent with reporting from Health Canada, where western Canada tends to be the epicentre for opioid-related poisoning hospitalizations with more similar rates of stimulant-related poisoning hospitalizations across western, central and eastern Canada (17). Spatiotemporal mapping has also been used to identify regions that may represent epicentres; the clusters reported by Health Canada are similar to the municipalities in our study where at least one clinician reported more than 5 cases of drug toxicity over the 24-month study period (18). Understanding these trends is important to empower providers in different communities to be prepared to meet the needs of the youth they serve. It is also important to note that many presentations may feature polysubstance exposure, which could not be accounted for in our study. A recent US study showed that a large proportion of opioid-related overdose deaths in adolescents and young adults were complicated by other substances, specifically stimulants or sedatives (19).
Awareness of substance use-related services for adolescents in this study was overall low. A majority of respondents were aware of general mental health-focused services for youth, but the majority answered ʻno’ or ʻunsure’ for all other services. Determining whether services exist at a jurisdictional level was beyond the scope of this project. However, our findings suggest that a range of services either do not exist or are not well known to paediatric providers across the country. This finding mirrors reports in the published literature, that have generally demonstrated a paucity of services for adolescents that use drugs (20,21). Furthermore, it is well described that many services that do exist have not been created in concert with youth and/or do not utilize care models that centre the perspectives of young people (22). This can lead to ambivalence about treatment, increasing overdose risk (23). It is important to better understand these gaps and address them through both provider-level education and systemic advocacy.
Current Canadian and international guidelines emphasize that adolescents with opioid use disorder should have access to the full spectrum of treatment options available for adults (24–26). However, data from both BC and Ontario suggest that adolescents and young adults with opioid use disorder are less likely to initiate or be maintained on medications for opioid use disorder than their adult counterparts (27,28). These findings highlight well-known and worrisome facts: illicit drug toxicity and overdose-related mortality in adolescents are on the rise and access to and availability of treatment resources are suboptimal, specifically for adolescents (29). There is a need for concerted efforts at local, provincial and national levels to better understand current adolescent illicit substance use trends and provide timely treatment and support for adolescents and their families.
This study had limitations, mainly that results cannot be used to determine population-level estimated minimum incidence due to the possibility of more than one paediatrician reporting the same case, and missed cases presenting to non-CPSP respondents, such as non-paediatricians. Additionally, though response rates were higher than average for one-time CPSP surveys, participation rates were under 50%, leading to the possibility of nonresponse bias and overestimation of the prevalence of illicit drug toxicity in paediatric practice. Conversely, more than two-thirds of respondents did not answer questions on awareness of treatment resources, which may have led to an overestimation of participant knowledge of available services. It is also important to note the inherent risk of recall bias in cross-sectional studies (30).
In conclusion, a considerable proportion of paediatricians and paediatric subspecialists provided care to young people aged 12 to 18 with illicit drug toxicity from opioids, stimulants and sedatives over 24 months. This contrasts with a relatively low level of awareness of services for substance use in this population. This data highlights illicit drug toxicity and substance use are substantial paediatric issues and that paediatricians need to be prepared to provide medical care for youth presenting with these issues. Paediatric substance use should be prioritized as a field of education and further study.
Acknowledgements
M.C., E.M., N.C., H.S., and H.S. participated in protocol and survey development. M.C. had full access to all the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. M.C. drafted the initial manuscript, with input from E.M. and N.C. All authors reviewed and confirmed the final version.
The study team would like to thank the staff at the Canadian Paediatric Surveillance Program (CPSP), particularly Ms Melanie Laffin, Ms Melanie King, Dr Charlotte Moore-Hepburn, and Dr Sam Wong for their support.
The authors would also like to thank their collaborators for their support for this project: Dr Richard Belanger (Laval University, QC), Dr Sara Citron (Whitehorse, YT), and Dr Christina Grant (McMaster University, ON).
Glossary
Abbreviations:
- BC
British Columbia
- CPSP
Canadian Paediatric Surveillance Program.
Contributor Information
Matthew Carwana, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; BC Children’s Hospital Research Institute, Vancouver, BC, Canada; Human Early Learning Partnership, University of British Columbia, Vancouver, BC, Canada.
Eva Moore, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada; BC Children’s Hospital Research Institute, Vancouver, BC, Canada.
Helia Shariati, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.
Hasina Samji, Human Early Learning Partnership, University of British Columbia, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.
Nicholas Chadi, Department of Pediatrics, University of Montreal, Montreal, QC, Canada; CHU Sainte-Justine, Montreal, QC, Canada.
Funding
M.C. and E.M. were supported by a BC Children’s Hospital Research Institute, Clinical Research Support Unit Grant. M.C. receives support from the BC Children's Hospital Research Institute.
N.C. is supported by a Fonds de Recherche du Quebec—Sante clinician-investigator award.
The Canadian Pediatric Surveillance Program and Public Health Agency of Canada provided in-kind support for survey development and distribution as well as data collation.
Potential conflict of interest
All authors: No reported conflicts of interest. All authors have submitted the ICMJE form for disclosure of potential conflicts of interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Data sharing statement
De-identified data that underlie the results reported in this article (text, tables, figures and appendixes) and that abide by the privacy rules of the Canadian Paediatric Surveillance Program and the Public Health Agency of Canada can be made available to investigators whose secondary data analysis study protocol has been approved by an independent research ethics board.
Contributors statement page
Dr Matthew Carwana conceptualized the study, developed the protocol and survey, had full access to all the data, completed statistical analyses and drafted the initial report.
Dr Eva Moore and Dr Nicholas Chadi co-conceptualized the study, developed the protocol and survey, reviewed the results and critically reviewed and revised the initial report.
Dr Helia Shariati developed the protocol and survey, and critically reviewed and revised the report.
Dr Hasina Samji provided guidance on survey development, reviewed the results, suggested analyses and critically reviewed and revised the manuscript.
All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.
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