News Flash: Increased Numbers of Children Poisoned by Fentanyl

Adult deaths and drug poisonings have captured most media attention, and there has been a lack of data on fatal overdoses in pediatric populations and nonfatal fentanyl overdose in general. However, new research published in the American Journal of Drug and Alcohol Abuse discovered more than 3,000 nonfatal fentanyl poisoning cases in children from 2015 to 2023, with over one-third accidental (or unintentional). The number of recorded exposures increased by 1,194 percent from 2015 to 2023. Nonfatal pediatric exposures not only increased but also are becoming more severe. In 2023, for example, nearly half (44.6 percent) of incidents were life-threatening, up from 15.9 percent in 2015.

This new research also found that most younger patients aged 0 to 12 were exposed unintentionally (81.7 percent). In contrast, among those ages 13 to 19 years, nearly two-thirds (65.7 percent) were exposed intentionally, but for nonmedical purposes.

The fentanyl misuse landscape is shifting, with counterfeit prescription pills (pills made to resemble other drugs like Xanax but which contain illicit fentanyl) comprising almost half (49 percent) of seized fentanyl in the U.S. in 2023. This is alarming because younger individuals are particularly more likely to experience fatal overdoses linked to pills or even patches.

There is a paucity of information, however, regarding the extent to which fatal pediatric poisonings have resulted from illicitly manufactured fentanyl vs. prescribed fentanyl (e.g., prescribed to a child’s caregiver) and whether the use was intentional or unintentional.

Counterfeit Pills

The Drug Enforcement Administration (DEA) reports that 5 of every 10 of the counterfeit pills they seize contain a potentially deadly amount of fentanyl. Counterfeit pills can be pressed to resemble common drugs like alprazolam or Adderall, and “M30” pills (pressed to represent oxycodone) are particularly prevalent. In addition, various drugs not directly purchased from a pharmacy can be adulterated with fentanyl. Fentanyl, with the co-use of psychostimulants, has come to define the "fourth wave" of the opioid crisis, and smoking has increased as a preferred route of fentanyl abuse.

For children aged 0 to 12 years of age, most fentanyl exposures (81 percent) were unintentional. In contrast, adolescents aged 13 to 19 comprised the majority (58.9 percent) of child and young adult cases. About two-thirds of these cases were intentional and by individuals who had abused or used the drugs nonmedically.

Researcher and lead author Joseph Palamar, MPH, Ph.D., from the Department of Population Health at NYU Grossman School of Medicine in New York, who is also deputy director of the National Drug Early Warning Network (NDEWS), says these results demonstrate the need for increased prevention, treatment, and harm reduction. Palomar says, "We can't forget kids are also at risk during this opioid crisis. Parents need to be aware teens can purchase pills via apps that are sold as Adderall or Xanax but contain fentanyl. Even secondhand exposure to paraphernalia or baggies can contain small amounts of fentanyl and be lethal to youngsters.”

Children may touch or ingest such items out of curiosity, through a lack of a sense of danger, or even imitation of a parent who uses them. While ingestion was most prevalent across age groups, a third (33.8 percent) of adolescents in this study inhaled the drug.

Even used, smoked, and discarded fentanyl patches can lead to accidental or intentional poisonings among pediatric populations. Parents and others need to be careful not to leave fentanyl, whether prescribed or not, in the open around unsupervised children. Reports indicate that even minimal amounts can be fatal to children.

Fellow co-author Linda Cottler, Ph.D., MPH, director of NDEWS, from the Department of Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, further recommends parents and health care providers "be aware of the importance of receiving training about these drugs and what they do and what they look like, and how to caution teens about the dangers of friends and siblings sharing diverted drugs."

Nonfatal fentanyl exposures reported to poison centers have increased among pediatric populations, especially among adolescents, and many characteristics of exposures shifted between 2015 and 2023. Not only has naloxone (Narcan) administration to children increased, but naloxone administration has also saved children as young as 15 months. Cottler says, "We encourage people to contact a poison center if they suspect a poisoning (1-800-222-1222) or call 911 if someone collapses, has a seizure, has trouble breathing, or can't be awakened following drug use.”

She adds, “We also strongly recommend people using opioids have Narcan at home or in the car, to reverse the effects of an overdose. Narcan can be obtained from most local Departments of Health for free, or the DOH can tell people where to get it for free.”

Pediatric Opioid Crisis

Fentanyl is now the primary agent noted in the pediatric opioid crisis. Mirroring trends seen among adults, pediatric deaths from fentanyl began to increase substantially, resulting in a more than 30-fold increase in mortality between 2013 and 2021. A surge that began in 2018 led to a nearly threefold increase in deaths among older adolescents and a nearly sixfold increase among children younger than 5 years. Fentanyl was implicated in more than a third (37.5 percent) of fatal pediatric opioid poisonings between 1999 and 2021.

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Experts report that most deaths were among adolescents aged 15 to 19 years (89.6 percent) and children aged 0 to 4 years (6.6 percent). For all ages, 43.8 percent of deaths occurred at home, and 87.5 percent were unintentional.

A dose as small as 2 milligrams of fentanyl, equivalent to 10 to 15 grains of table salt, can be fatal. In Oregon, unintentional overdose deaths related to illicitly manufactured fentanyl nearly quadrupled between 2020 and 2022, increasing from 223 to 843 fatalities.

Summary: Education and Prevention Needed

Any pill not prescribed by a medical professional and dispensed by a licensed pharmacist can be deadly. The DEA's “One Pill Can Kill” prevention campaign is a critical initiative aimed at educating the public about the dangers of counterfeit prescription pills laced with lethal substances like fentanyl. By educating the public, especially vulnerable populations like adolescents and their caregivers, the campaign aims to prevent further tragedies and combat the escalating overdose crisis.

CADCA, which represents over 5,000 community coalitions involving schools, law enforcement, youth, parents, healthcare, and media, has been working since 1992 to drive community-level substance abuse solutions, education, and prevention.