Rising Stimulant Overdoses among Young People in the United States

Although commonly described as an ‘opioid crisis’, the drug overdose epidemic in the US is complex and evolving, and increasingly involves use of substances other than opioids.^1,2 In this issue of Pediatrics, Roehler and colleagues describe a concerning rise in deaths among children, adolescents, and young adults related to stimulants such as cocaine, methamphetamine, and prescription drugs (including those commonly used to treat attention deficient/hyperactivity disorder).³

Drawing on 2016-2019 surveillance data from a plurality of US emergency departments across 47 states, the authors found that whereas visits for drug overdoses rose only slightly among children <15 and remained unchanged in adolescents and young adults 15-24, visits for stimulant overdoses increased across all ages. Specifically, over each quarter between April 2016 and September 2019, stimulant overdose visits among young people aged 0-10 years, 11-14 years, and 15-24 years increased by 3%, 4%, and 2%, respectively.

These findings mirror other recent national drug overdose trends. Although the overall US overdose mortality rate plateaued in 2018 after climbing for two decades,⁴ preliminary 2019 data suggest a return to increasing year-over-year rates.¹ Nationally, deaths involving cocaine and other stimulants increased sharply after 2016, including among youth 15-24.^1,5

Public health experts have described the overdose crisis as having occurred in ‘waves’.^5,6 The first wave, beginning in the early 2000s, was largely driven by increases in prescription opioid-related overdoses, likely fueled by aggressive industry marketing of opioid products.⁷ Concomitant with a decrease in opioid prescribing, heroin began to supplant prescription opioids during the second wave of the early 2010s. From late 2013 onwards, highly potent fentanyl flooded drug markets and contributed to unprecedented mortality during the third wave. Now, in the crisis’ fourth wave, clinicians, public health experts, and policymakers are grappling with rising overdose fatalities involving stimulants, particularly cocaine and methamphetamine.

Pediatricians and other clinicians caring for youth should be concerned. Approximately 1 in 25 high school students has used cocaine, and 1 in 50 has used methamphetamine.⁸ Racial inequities are pernicious; prior work has shown that Black and Latinx youth are significantly less likely to receive timely receipt of evidence-based addiction treatment.⁹ These inequities are critical not only because of the excess risk for overdose without recommended care, but also because youth of color are significantly more likely than white youth to be incarcerated for drug-related charges and experience resulting lifelong adverse health consequences stemming from criminal justice involvement.

What should also concern clinicians is the exceptional difficulty of treating stimulant use disorder. Whereas opioid use disorder is effectively treated with FDA-approved medications,¹⁰ there are no approved pharmacotherapies for stimulant use disorder, and most behavioral therapies are disappointingly ineffective.¹¹ Similarly, whereas widespread distribution of the opioid overdose reversal agent naloxone in the US has averted innumerable deaths,¹² no comparable antidote exists for stimulants. Preventing stimulant use disorder from developing in the first place remains our best hope for averting its downstream harms.

Roehler et al. draw much-needed early attention to this worsening public health problem. Further studies are needed. The authors examine fatalities among 15-24 year-olds collectively; more granular age data would shed light on the precise times during adolescence and young adulthood that mortality is rising. Data on how stimulant overdose deaths are related to rising fentanyl overdose deaths in youth⁶—and to polysubstance use more broadly, including use of benzodiazepines and alcohol^13,14—are also needed. Finally, researchers should take care to identify differences by race/ethnicity to ensure that our clinical and public health responses reduce inequities, rather than exacerbate them.¹⁵

Researchers should also pursue a greater understanding of which stimulants are involved in the pathway to misuse, addiction, and overdose, and whether they are illicit drugs like cocaine and methamphetamine, prescription pills, or both. Treating attention deficient/hyperactivity disorder is not associated with risk for substance use disorder; clinicians should continue to prescribe stimulants when appropriate.¹⁶ Nonetheless, there has been a simultaneous rise in stimulant prescribing,¹⁷ misuse among young adults (particularly college students),¹⁸ and pharmaceutical industry marketing to pediatricians.¹⁹ Understanding whether the widespread availability of prescription stimulants is related to rising overdose rates—or simply coincidental—could inform prescribing guidelines.

In the meantime, pediatricians and other clinicians can take immediate action. They can routinely screen for substance use using a validated tool (e.g., S2BI, https://www.drugabuse.gov/ast/s2bi/; BSTAD, https://www.drugabuse.gov/ast/bstad/; CRAFFT, https://crafft.org/), counsel on substance use, and refer to addiction treatment when needed.^20,21 As respected citizens in their communities, clinicians can advocate for evidence-based prevention programming in schools and other settings. When clinicians prescribe stimulants, they can counsel parents that they should ensure safe, locked storage of medications, which is especially critical given the rising rates of presumably unintentional stimulant overdoses observed in younger ages in Roehler’s study. Given that preliminary national 2019 data suggest that overdose rates have once again resumed their climb,¹ addressing stimulant misuse and overdose early in the life course is urgent.

Abbreviations:

BSTAD

Brief Screener for Tobacco, Alcohol, and other Drugs

CRAFFT

Car, Relax, Alone, Forget, Family/Friends, Trouble

S2BI

Screening to Brief Intervention

US

United States