Study of direct costs of children hospitalized with opium poisoning: a case study of Iran

Abstract

Introduction

Opioid poisoning in children under 12 years of age is a serious health problem in Iran that can lead to mortality and increase the economic burden on the health system. Given the increasing access of children to opioids, a more accurate understanding of the economic dimensions of these poisonings is necessary to develop effective strategies to prevent the costs imposed on families and the health sector.

Methods

This cross-sectional descriptive study was conducted on 45 children hospitalized with opioid poisoning in Motahari Hospital, Urmia during 2022. Demographic information of children and parents, type of substance consumed, type of health insurance, length of hospitalization, and direct medical costs were collected and analyzed using SPSS version 27 software.

Results

The mean age of the children was 5.08 ± 1.96 years, and 57.8% of them were boys. The most commonly used substance was methadone (40%). A total of 62.2% of the parents had less than a diploma, 17.8% had a history of addiction, and 6.7% of the children died due to poisoning. The estimated economic burden of pediatric opioid poisoning in Iran was $318,306 in 2022.

Conclusion

Opioid poisonings in young children occurred more frequently in boys, with methadone identified as the most common cause of poisoning. Low parental education levels and a history of addiction in the family were the main risk factors. Increasing parental awareness, controlling access to opioids, and strengthening support services can be effective in reducing poisoning cases and preventing unnecessary costs.

Introduction

Opioids, including morphine, codeine, and fentanyl, are primarily used in medicine for pain management. However, their misuse can lead to addiction and significant health issues. Globally, over 180 million individuals have engaged in illicit drug use, with 13.5 million people dependent on opioids [1]. Iran has the highest reported rate of opioid addiction, with approximately 4 million people regularly or intermittently using opium [2, 3].

Opium poisoning, particularly in children, poses significant risks, including loss of consciousness, respiratory depression, and death. In cases involving methadone, QT prolongation can further exacerbate these risks [4]. The widespread availability of opioids in many regions has increased the incidence of intentional or accidental poisoning in children. The classic triad of opioid poisoning—miosis, decreased consciousness, and respiratory depression—requires immediate intervention with naloxone and supportive care. In severe cases, admission to the ICU and continuous naloxone infusion may be necessary [5–8].

Economically, the opioid crisis in the United States cost an estimated $696 billion in 2018, encompassing healthcare costs, treatment for abuse, justice system expenses, and lost productivity [9]. Pediatric hospitalizations for opioid poisoning in the U.S. nearly doubled between 1997 and 2012, with a sharp increase in cases requiring intensive care [10, 11]. These findings highlight the global nature of the problem, particularly in households with easy access to opioids [12]. In Iran, opioid poisoning is one of the most common and deadly poisonings in children, with some reports indicating that about 50% of pediatric poisonings are opioid-related [11].

An accurate understanding of the extent and severity of diseases is crucial for effective resource planning. The Global Burden of Disease studies began in 1998, and the World Health Organization underscores the importance of assessing the burden of diseases accurately [13]. In Iran, the first estimate of the disease burden was published in 2007 [14]. Given the limited studies on pediatric opioid poisoning, a study was conducted at Motahari Hospital in Urmia in 2022 to evaluate the direct costs of hospitalization and help in improving health planning [15–17].

Methods

This cross-sectional descriptive study aimed to investigate the direct costs associated with hospitalization for children diagnosed with opioid poisoning at Motahari Hospital in Urmia during 2022. Ethical approval was obtained from the Ethics and Research Committee of Urmia University of Medical Sciences (IR.UMSU.REC.1402.297). Data were collected on all children under the age of 12 who were hospitalized with a diagnosis of opioid poisoning between March 2021 and February 2022. Basic demographic information, including age, gender, and place of residence (urban or rural), as well as data related to the parents’ characteristics -such as age, gender, education level, and history of substance addiction- were extracted from patient records and documented in a checklist.

To calculate the economic burden of opioid poisoning, a prevalence-based approach was employed for a one-year period. The analysis included direct medical costs such as doctor visits, medical services, diagnostic tests, medications, hospitalization, and hoteling expenses. These costs were estimated using both insurance payments and out-of-pocket payments incurred by patients.

The target population for this study comprised all children with opioid poisoning who were hospitalized at Motahari Hospital in Urmia. A census sampling method was employed, including all children under the age of 12 whose opioid poisoning was confirmed through toxicological results and clinical evidence. Patients with incomplete information in their medical records were excluded from the study.

Data collection was conducted using a checklist designed based on the study variables. Following data collection, analysis was performed in accordance with the research objectives using SPSS version 27 software. Quantitative variables were reported as mean ± standard deviation, while qualitative variables were presented as numbers and percentages. All the costs were presented in US Dollars using the exchange rate ($US 1 = 264,604 Rials) in 2022.

Results

In this study, the mean age of 45 children hospitalized for opioid poisoning was 5.08 years, with a standard deviation of 1.96 years. The youngest child was 4 months old, and the oldest was 9 years old. Among these children, 26 (57.8%) were boys, and 19 (42.2%) were girls.

The children in the study came from three counties: Urmia, Poldasht, and Salmas. The largest number of cases, 20 children (44.4%), were from Urmia, including 11 boys and 9 girls. Poldasht followed with 12 children (26.7%), and Salmas had 13 children (28.9%) (Table 1).

Table 1.

Distribution of children’s gender based on place of residence

Residence City	Gender	Number (percent)	Place of residence (%)
Urmia	Male	11 (42.3)	55
	Female	9 (47.4)	45
Poldasht	Male	6 (23.1)	50
	Female	6 (31.6)	50
Salmas	Male	9 (34.6)	69.2
	Female	4 (21.1)	30.8

The educational level of the parents was also assessed. Of the 45 children, 28 (62.2%) had parents with less than a high school diploma, while 17 (37.8%) had parents with a high school diploma or higher education.

Regarding the type of substance involved, methadone was the most common, accounting for 18 cases (40%). Tramadol followed with 10 cases (22.2%), and buprenorphine was involved in 9 cases (20%) (Table 2).

Table 2.

Distribution of types of consumed substances based on gender

Type of substance used	Gender	Number (percent)
Buprenorphine	Male	6 (23.1)
	Female	3 (15.8)
Tramadol	Male	4 (15.4)
	Female	6 (31.6)
Methadone	Male	11 (42.3)
	Female	7 (36.8)
Morphine	Male	4 (15.4)
	Female	3 (15.8)

Urine toxicology results revealed that, among a total of 45 children, 18 (40%) tested positive for methadone. Additionally, tramadol was detected in 10 children (22.2%), and buprenorphine was identified in 9 (20%).

Regarding how the children were brought to the hospital, 24 (53.3%) arrived in person, accompanied by parents, relatives, or friends, while 19 (42.2%) were transported by ambulance.

The type of health insurance coverage for the children was also assessed. Of the participants, 22 (48.9%) were covered by public health insurance, 14 (31.1%) had social security insurance, and 9 (20%) were insured through rural insurance programs.

The average length of hospitalization for the children was 4.87 days. The shortest hospital stay was 2 days, while the longest was 10 days. Generally, most children were hospitalized for approximately 5 days (Table 3).

Table 3.

Distribution of hospitalization status based on ward

Ward	Minimum length of stay (Days)	Maximum length of stay (Days)	Average length of stay (Days)	Standard deviation
ICU	2	10	5.02	1.604
General	2	4	3.25	0.957
Total	2	10	4.87	1.632

In terms of outcomes, 42 children were released after recovering, but tragically, 3 boys died due to the severity of their poisoning (Table 4).

Table 4.

Distribution of hospital outcomes based on gender

Outcome	Gender	Number
Alive	Male	23
	Female	19
Deceased	Male	3
	Female	0

The direct medical costs associated with opioid poisoning were estimated to average $199, with reported costs ranging from a minimum of $51 to a maximum of $2155 (Table 5).

Table 5.

Distribution of direct medical costs based on urine toxicology and gender

Substance	Gender	Number	Minimum cost ($)	Maximum cost ($)	Average cost ($)
Buprenorphine	Male	6	135	232	159
	Female	3	152	166	158
Tramadol	Male	4	139	177	154
	Female	6	137	184	162
Methadone	Male	11	96	212	151
	Female	7	71	282	163
Morphine	Male	5	51	2,155	541
	Female	3	126	160	144

A breakdown of expenses by service showed that the highest cost, averaging $69, was attributed to special hotel accommodations for patients, while the lowest cost, an average of $6, was related to medical consultations.

Discussion

In this study, the mean age of 45 children hospitalized due to opioid poisoning was 5.08 years (standard deviation: 1.96), ranging from a minimum of 4 months to a maximum of 9 years. Among them, 57.8% (n = 26) were boys and 42.2% (n = 19) were girls. These findings suggest that opioid poisoning is more prevalent among young and preschool-aged children, with boys being at a higher risk than girls.

The results align with those of a 2016 study by Hosseini-Nasab et al [4]. conducted in Kerman, which reported a mean age of 3.9 years, with 59% of cases involving boys [4]. Similarly, a 2021 study by Foroughian et al [18]. in Sabzevar found a mean age of 2.74 years, with 60.05% of poisoned children being boys [18]. This convergence of findings highlights a consistent pattern in domestic studies, indicating that young boys are particularly vulnerable to opioid poisoning.

In contrast, studies conducted in the United States, such as Kane et al. [19], have reported a much higher mean age for pediatric opioid poisoning (11.3 years) with most incidents occurring among adolescents [19]. This discrepancy may be attributed to differences in substance use patterns and accessibility across various communities.

Recent research in Iran has pointed to the unsafe storage of opioids at home as a key contributor to pediatric poisonings, especially in households where substance use is a known issue [20]. Educating high-risk families on safer storage practices could go a long way in preventing accidental overdoses in children.

In the present study, parental education levels were also examined. It was found that 62.2% of parents had less than a high school diploma, while only 37.8% had a high school diploma or higher. These results suggest a possible association between low parental education and an increased risk of childhood poisoning. A similar trend was observed in the study by Hosseini-Nasab et al. [4], where most parents had a high school education or lower [4]. Additionally, Foroughian et al. [18] reported that 90.7% of fathers and 95.3% of mothers had a diploma or below high school level [18]. Lower levels of education may reduce parental awareness of the risks associated with opioids and the importance of safe storage practices. Therefore, targeted educational and awareness programs are essential.

A history of addiction among parents was reported in 17.8% of cases, which is relatively lower compared to other studies. For instance, in the study by Hosseini-Nasb et al. [4], all cases involved at least one addicted family member or relative [4]. Likewise, Foroughian et al. [18] found that 93% of families had a history of drug dependence [18]. The presence of familial addiction is considered a significant risk factor for child poisoning, as it may increase children’s access to opioids. Variations in these findings could be due to differences in data collection methods or socio-cultural contexts.

Methadone was identified as the most commonly used substance in this study (40%), followed by tramadol (22.2%) and buprenorphine (20%). These findings are consistent with those of Hosseini-Nasab et al. [4], who also identified methadone as the leading cause of poisoning [4]. However, Foroughian et al. [18] reported opium as the most common agent, accounting for 68.45% of cases [18]. In contrast, international studies, such as Kane et al. [19] and Patel et al. [16], have shown that prescription opioids like oxycodone and hydrocodone are more prevalent in the U.S [16, 19]. These variations likely reflect differences in drug availability, cultural norms, and patterns of substance use across societies.

The average length of hospitalization was 4.87 days, with 93.3% (n = 42) of children released after complete recovery, while 6.7% (n = 3) unfortunately died. The mortality rate in this study was higher compared to some international reports - for example, Kane et al. [19] reported a mortality rate of 1.6% [19]. This difference may be related to the severity of poisoning, type of substance used, time of referral, and quality of medical care received. Notably, Kane et al. [19] also found that 42.9% of poisoned children required admission to the Pediatric Intensive Care Unit (PICU), indicating a high severity of poisoning in their cohort [19].

The average direct medical costs in this study amounted to $199, with the largest portion attributed to special hospitalization, averaging $69. This finding highlights the significant economic burden of opioid poisoning in children. Similarly, Kane et al. [19] reported that 42.9% of poisoned children required intensive care unit (ICU) admission, which imposes a high economic burden on the health system [19].

A recent U.S. study found that opioid poisonings in children led to more than $400 million in direct medical costs each year from 2019 to 2021, highlighting just how heavy the financial burden of these incidents can be on the healthcare system [16].

Among all medical expenses, consultation costs were the lowest, averaging $6, likely due to the limited number of consultations performed and lower medical tariffs. Additionally, imaging costs were relatively low ($4), as imaging was generally unnecessary in cases without severe complications.

Overall, the findings of this study align with previous domestic research, particularly regarding the high prevalence of methadone poisoning and its correlation with low parental education levels. In contrast to foreign studies, differences in the types of substances involved and affected age groups are evident, likely stemming from cultural, social, and economic factors.

Based on the average direct medical cost of $199 per patient reported in this study and an estimated annual incidence of 8 cases per 100,000 children, the estimated economic burden of pediatric opioid poisoning in Iran was $318,306 in 2022. This figure emphasizes the substantial financial impact of such poisonings on the national healthcare system. Notably, this estimate only includes direct medical costs and does not account for indirect costs such as lost parental workdays, long-term disability, or psychological consequences, suggesting that the true economic burden may be considerably higher. These findings highlight the urgent need for preventive interventions, particularly in high-risk populations, to reduce both human and economic losses associated with pediatric opioid exposure.

Conclusion

This study demonstrates that opioid poisoning is a significant health issue among young children, especially boys. Methadone emerged as the primary causative agent of poisoning. Low parental education and a family history of addiction were identified as key risk factors. The associated medical costs impose a considerable financial burden on families and the healthcare system. These findings underscore the need for targeted educational and preventive interventions, particularly among families of low socioeconomic status.

Research limitations

This study has several limitations. The relatively small sample size and focus on West Azerbaijan Province may limit the generalizability of the findings to the wider Iranian population. Furthermore, hospital records lacked data on important variables such as parental marital status, prior emergency visits, duration of parental substance use, and the specific circumstances of poisoning (e.g., whether the child was unsupervised or intentionally administered opioids). Socioeconomic information, including household income and living conditions, was also unavailable, restricting a more comprehensive assessment of risk factors. Future studies with larger and more diverse populations, along with more detailed data collection, are recommended to address these limitations and strengthen understanding of pediatric opioid exposure in Iran.

Author contributions

All authors contributed to the conception and design of the study. MR, NR and HY performed the data analysis. MR and NR collected the data and drafted the manuscript. HY critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript.

Funding

This work was supported by the Urmia University of Medical Sciences.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of the Urmia University of Medical Sciences (IR.UMSU.REC.1402.297).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.