Fentanyl-Involved Deaths Drive Increase

If you read or follow national news at all, you know that for the past decade, the nation has been in the grip of what’s called the opioid crisis. The opioid crisis – or the opioid epidemic, as it is also called – actually began over twenty years ago, around 1999, with an increase in opioid prescriptions driving upward trends in opioid addiction and opioid-related overdose death.

However, as the opioid crisis spread across the U.S. from 1999-2015, affecting adults from inner cities to small rural towns to everywhere in between, experts did not witness the same effect in adolescents. In fact, overall drug use among adolescents during this period decreased. Increases in adolescent drug use, for the most part, were related to the new phenomenon of vaping. Tobacco vaping increased first, then vaping cannabis and other products containing THC – the psychoactive ingredient in marijuana – increased for teens around the country shortly thereafter.

Here’s the data on the vaping increases among teens from the 2020 Monitoring the Future Survey:

MTF: Past 30-Day Marijuana Vaping

• 2017:
  • 12^th grade: 4.9%
  • 10^th grade: 4.3%
  • 8^th grade: 1.6%
• 2018:
  • 12^th grade: 7.5%
  • 10^th grade: 7.0%
  • 8^th grade: 2.6%
• 2019:
  • 12^th grade: 14%
  • 10^th grade: 7.2%
  • 8^th grade: 2.7%

That data is important for parents to understand. Vaping among teens is on the rise, but prevalence rates levelled off for 8^th and 10^th graders in 2019 after a sharp increase from 2017 to 2018. Experts explain this in two ways. First, in 2017, vaping marijuana was new, and a novelty effect drove initial experimentation. This effect is visible in the prevalence stability among 8^th and 10^th graders from 2018-2019: it became popular in the beginning, but interest waned. Second, the steady increase in vaping among 12^th graders is related to the cannabis legalization movement: it’s legal to purchase cannabis in 18 states, which resulted in increased access for 12^th graders.

While the legal age for recreational cannabis purchase is 21 in most of the 18 states in which cannabis is legal, most adults understand that, like alcohol, an 18-year-old high school senior can gain access to marijuana vaping product without much difficulty.

For teens, then, we see that – until 2019 – the biggest substance use issue was vaping marijuana. Over the same period of time, adults in the U.S. experienced the opioid crisis.

Next, we’ll offer a quick overview on the opioid crisis, then address the primary topic of this article: the increase in overdose death among teens from 2019-2021.

The Opioid Crisis: What Happened Among Adults Between 1999 and Now

In case you don’t know how we got where we are now, with regards to the nationwide opioid crisis, we should tell you that it didn’t happen overnight. It began decades ago. The Centers for Disease Control (CDC) identifies three phases of the opioid crisis:

Phase 1

This phase was driven by an increase in prescribing opioid painkillers that began in the early 1990s and resulted in an increase in overdose death by 1999.

Phase 2

This phase started around 2010. Lawmakers established new, stricter rules around opioid prescriptions. An unintended consequence of these restrictions was the beginning of an upward trend in overdose associated with illicit opioids such as heroin.

Phase 3

This phase started in 2013, driven by fentanyl and various other black-market/illicit opioid-type drugs. This phase continued until 2017, when we began to see a decrease in opioid involved overdose deaths around the country.

We are now in what’s unofficially known as Phase 4, which began when the federal government declared the opioid crisis a national emergency in 2017. At that point, states around the country had already begun to turn the tide. We saw progress – not without hiccups – but we did see progress:

• Overdose deaths stabilized between 2017 and 2019
• Overdose deaths began to increase before the pandemic
  • Fentanyl caused this increase

Then, the pandemic happened.

• From 2019-2020, the Centers for Disease Control (CDC) reported 78,056 overdose deaths
• Overdose deaths increased dramatically in April 2020
• Between April 2020 and April 2021, the CDC reported 100,306 drug overdose deaths. At that time, that was the largest number of overdose deaths recorded since we began keeping records on drug overdose.

The final data from 2021 is now in. There were 101,954 drug overdose deaths in the U.S., with 73,453 involving opioids.

And now, a new study shows the overdose crisis in the U.S. has reached adolescents. The numbers, as we indicate in the title of this article, are alarming.

Actually – and we’re not exaggerating at all – the numbers are more than alarming.

They’re scary.

Fatal Adolescent Drug Overdose in 2021

In a research letter published in April 2022 – “Trends in Drug Overdose Deaths Among US Adolescents, January 2010 to June 2021” – researchers examined data collected from the Centers for Disease Control (CDC) WONDER database to determine the cause of a increase in drug-related overdose death among teens that occurred between 2010 and 2021, and the sudden increase that occurred between 2019 and 2021. The increase in overdose deaths needed analysis, because, as we mention above, drug use among adolescents did not increase, overall, between 2010 and 2021, with the exception of vaping marijuana. As the opioid crisis got worse and opioid use and opioid-related overdose death increased among adults, opioid use among adolescents decreased.

Then, something happened.

That something was fentanyl.

In September 2021, the Drug Enforcement Agency (DEA) released a public safety alert warning about a “sharp increase” in illicit prescription pills containing fentanyl. This alert appeared after the DEA issued a similar alert in March 2021 about the presence of fentanyl in various drugs of misuse, including methamphetamine and benzodiazepines.

Here’s an excerpt from the September safety alert. DEA Administrator Anne Milgram writes:

“The United States is facing an unprecedented crisis of overdose deaths fueled by illegally manufactured fentanyl and methamphetamine. Counterfeit pills that contain these dangerous and extremely addictive drugs are more lethal and more accessible than ever before. In fact, DEA lab analyses reveal that two out of every five fake pills with fentanyl contain a potentially lethal dose. Today, we are alerting the public to this danger so that people have the information they need to protect themselves and their children.”

Now we’ll present the data from the research letter on adolescent overdose trends. We encourage parents to review this data with the words of DEA Administrator Milgram in mind.

Here’s the data:

Adolescent Drug Overdose Deaths 2010-2021

• 2010:
  • Total Deaths: 38,329
  • Adolescents: 518
    • Prescription Opioids: 159
    • Benzodiazepines: 83
    • Heroin: 52
    • Methamphetamine: 38
    • Illicit fentanyl/synthetic opioids: 38
• 2019:
  • Total Deaths: 70,630
  • Adolescents: 492
    • Prescription Opioids: 52
    • Benzodiazepines: 71
    • Heroin: 37
    • Methamphetamine: 80
    • Illicit fentanyl/synthetic opioids: 253
• 2020:
  • • Total Deaths: 91,799
    • Adolescents: 954
      • Prescription Opioids: 74
      • Benzodiazepines: 142
      • Heroin: 40
      • Methamphetamine: 104
      • Illicit fentanyl/synthetic opioids: 680
• 2021:
  • • • Total Deaths: 101,954
      • Adolescents: 1,146
        • Prescription Opioids: 66
        • Benzodiazepines: 153
        • Heroin: 26
        • Methamphetamine: 112
        • Illicit fentanyl/synthetic opioids: 884

Now let’s look at the data another way.

Adolescent Drug Overdose Deaths 2010-2021 By Race/Ethnicity

• American Indian/Alaska Natives:
  • 2010: 11 overdose fatalities
  • 2019: 14
  • 2020: 16
  • 2021: 24
• Among Black/African Americans:
  • 2010: 24
  • 2019: 46
  • 2020: 114
  • 2021: 96
• Among Latinos:
  • 2010: 62
  • 2019: 136
  • 2020: 276
  • 2021: 354
• Among White/Caucasian:
  • 2010: 412
  • 2019: 281
  • 2020: 521
  • 2021: 604

We’ll take a moment for all that information to settle before we talk about what we want parents to take away from this report. We know – this information is alarming, shocking, and scary, as we’ve said – all at once. To be honest, we don’t have any more adjectives to describe the data itself. Speaking for ourselves, we’re stunned.

How to Interpret This Data

We’ll start by identifying our primary takeaways.

Between 2010 and 2019, overall fatal adolescent drug overdose rates decreased among adolescents, including for prescription opioids and heroin. As a reminder, that was during the time when opioid overdose addiction and overdose rates for adults increased dramatically. This data appears to indicate that public health efforts to address the opioid crisis were successful in protecting our adolescents from the worst effects, while adults experience the lion’s share of the negative consequences.

However, during the same time – from 2010 to 2019 – deaths among adolescents from illicit fentanyl increased by 565 percent. This should have been the canary in the coalmine that warned public health experts to be prepared for what happened next.

What happened next was unexpected.

Between 2019 and 2020, overall overdose deaths among adolescents increased by 94 percent. Then, between 2020 and 2021, they increased further, bringing the total percent change in overdose deaths among adolescents between 2010 and 2021 to 121 percent.

The increase in overdose deaths is clearly related to the influx of illegal fentanyl in the U.S. Here’s a breakdown of the overdose data from 2021, with the drugs involved in overdose listed in order from highest to lowest:

• Fentanyl: 77%
• Benzodiazepines: 13%
• Methamphetamine: 9,7%
• Cocaine: 7.3%
• Prescription opioids: 5.8%
• Heroin: 2.8%

Fentanyl involved overdose deaths increased by a staggering 2,226 percent. You read that correctly: an increase of over two thousand percent. We understand that many parents may have heard of fentanyl, and written it off as something they don’t have to worry about.

Unfortunately, parents around the country now need to pay attention to fentanyl: we don’t say worry because that implies powerlessness. We want parents to be aware and actively concerned about fentanyl.

Fentanyl: A Potent Opioid Pain Reliever

Fentanyl is a synthetic opioid that was developed to relieve pain. Initially, pharmaceutical companies created fentanyl for two groups of people: those with severe post-surgical pain, and those with chronic pain who developed a tolerance for typical opioids. Fentanyl is similar to both heroin and morphine with one critical difference: it’s 50 to 100 more times more powerful than either one. That’s why illicit drug trafficker began producing fentanyl. It allowed them to increase the potency, and thus the value, of other opioid street drugs. It also allowed them to produce illicit pills that look exactly like the legal, prescription version.

Drug dealers also began adding fentanyl to non-opioid drugs, like cocaine and methamphetamine. This is the practice that most experts believe is responsible for the drastic increase in fentanyl overdose. Its presence in non-opioid drugs is a recipe for disaster, because when an individual takes a stimulant like cocaine methamphetamine, they’re not expecting – and their friends, or people they may use drugs with – do not anticipate anything resembling an opioid-like overdose.

This is important. Parents should warn their teens – again, if they haven’t already – about the dangers of illicit drugs, including black market prescription medication. Here’s a list of drugs the DEA says may contain illicit fentanyl:

• Methamphetamine
• Heroin
• Illicit prescription opioids such as Oxycontin
• Cocaine
• Illicit prescription sedatives such Xanax or Alprazolam
• MDMA (ecstasy)

In addition, all parents and teens should know the signs of fentanyl overdose, because, in the words of Dr. Glenn Wagner, the San Diego Medical Examiner:

“These pills are deadly, and even just part of one pill kills.”

Here are the signs of fentanyl overdose every parent and teen should know and watch for:

• Passing out/unconsciousness
• Unresponsive: no reaction to talking, shaking, or attempts to wake
• Limp body/limbs
• Clammy, cold, pale skin
• Small pupils
• Blue lips
• Blue fingertips
• Slow, irregular, or no breathing
• Loud snoring, gurgling, and/or choking sounds
• Slow/irregular heartbeat
• Vomiting

We do our best not to be alarmist in our articles, but fentanyl has us legitimately alarmed. No one expected overdose numbers like these – and the fact that one mistake can kill makes the presence of fentanyl on the streets of the U.S. a significant threat to the health and safety of our teens.

What Parents Can Do to Lower the Risk of Adolescent Drug Overdose

First, we advise parents to read about fentanyl and talk to their kids about it. There’s not an ounce of hyperbole in the statement “just one dose is enough to kill you.” Next, we advise parents to redouble their warnings about experimenting with prescription medication. In some peer groups, teens take pills from parents and use them. Within those groups, when teens run out of the drugs they take from parents, they may seek the same drug on the black market: with the increased presence of fentanyl in illicit drugs in the U.S., this can be a fatal mistake.

We also advise anyone – parents, teens, teachers, coaches – involved in the life of a teen to download and memorize – yes, memorize – this document, created and published by the CDC: Preventing an Opioid Overdose.

For those who can’t download, open, or read that document, here are the steps to take when the signs of fentanyl overdose are present. These steps are exactly as they appear on the CDC pdf:

1. Call 911 immediately.
2. If Naloxone is available, administer it immediately.
3. Keep the individual awake and breathing.
4. Turn them on their side to prevent choking.
5. Stay with them until help arrives.

We’ll close this article with the words of study author Dr. Joseph Friedman, interviewed in the online publication Science Daily:

“Teens urgently need to be informed about this rising danger. [They] need to know that pills and powders are the highest risk for overdose, as they are most likely to contain illicit fentanyl…drug use is becoming more dangerous, not more common. These counterfeit pills are spreading across the nation, and teens may not realize they are dangerous.”

With the help of parents, teachers, friends, and others, teens can learn about the very real dangers of fentanyl. It’s our hope that with awareness, advocacy, teen learn that experimenting with illicit drugs – especially black-market pills designed to look like prescription medication – is not only risky, but also deadly.

Finding Help: Resources

If you’re worried about adolescent drug overdose and seeking substance abuse treatment for your teen, please navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.

In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors in your area. Both the National Institute of Mental Health (NIMH) and the National Alliance on Mental Illness also provide and high-quality online resources, ready and waiting for you right now.