Impact of Fentanyl on Pediatrics

Peggy Zysk, RN, BSN, CPN, member of SPN Healthcare Policy and Advocacy Committee

The statistics of opioid overdoses and deaths are constantly news-worthy, yet our country has made negligible progress towards a solution to this problem. And, although much work has been put forth to combat the opioid epidemic, a newer, more insidious problem is emerging - accidental overdoses and deaths of infants, children and adolescents. As pediatric nurses, we need to not only be aware of this, but also be advocates in addressing this increasing problem.

The statistics are staggering. Fentanyl-related deaths among children increased more than 30-fold between 2013 and 2021. Nearly half of the deaths occurred at home, and most were deemed unintentional. Teens may not have known the drugs they were using were contaminated with fentanyl, while very young children may have ingested drugs used by their parents. Using death certificate data from the U.S. Centers for Disease Control and Prevention, fentanyl deaths were assessed over a period of two decades. In 1999, about 5% of the deaths from opioids were from fentanyl; by 2021, that had jumped to 94%, mirroring the pattern of adult fatalities.¹

A report from the CDC in May 2023, disclosed that fentanyl overdose deaths in the United States had soared 279% in just five years. A surge in fentanyl-related fatalities that began in 2018 has led to a nearly threefold increase in deaths among older teens and a nearly sixfold increase among children younger than 5. "There is a general consensus that the overdose deaths involving fentanyl, whether young kids or teens, are primarily unintentional”.²

Younger children are gaining access to pills or substances laced with fentanyl that are left within their reach. For adolescents, the culprit is more likely a lack of awareness that the pill they are intentionally taking contains fentanyl. The proliferation of counterfeit pills is particularly concerning for adolescents given marketing aimed toward this population and the availability of pills via social media. Whether adolescents intended to take legitimate pharmaceutical medications or were aware pills were counterfeit is unclear. Regardless, the statistics highlight the potential presence of illicit drugs in pills and emphasize that pills should only be used if they are prescribed. Another contributor to the ubiquity of Illicitly Manufactured Fentanyl (IMF) is that synthetic narcotics lead to overdose and subsequent death with just miniscule amounts of the drug. Detection of fentanyl in any form is only effective if fentanyl is in the actual test sample.³

From September 2023 through December 2023, the following are just a few examples of how this problem is affecting our pediatric population:

• In September 2023, a 1-year-old boy died after he and three other children were apparently exposed through contact with a fentanyl packaging device at a Bronx day care center.
• In October 2023, nine students at Park View High School in Virginia overdosed on suspected fentanyl in less than one month, four of those were on campus.
• In December 2023, seven students in Virginia in the 4th grade became ill after eating gummy bears from a baggie that tested positive for fentanyl (the gummy bears did not test positive; only residue inside the bag).

The cited examples are only what was reported during a 4-month period of time and as nurses we must ask ourselves what are the implications for public health practice? There is no clear answer. A multi-pronged approach is most likely the best answer. From educating adolescents about the dangers of IMFs and counterfeit pills, to working with public safety to reduce availability of illicit drugs, to ensuring access to evidence-based substance use and mental health treatment could help save lives. In December of 2023, the American Medical Association called for school staff to have naloxone available and issued a statement encouraging states, schools and local communities to allow students of all grade levels to carry naloxone in schools. State and federal legislators have introduced legislation that would require schools to carry naloxone, and the Biden administration recently encouraged schools to keep it “on-hand and teach staff how to use it”.4 Since approximately 40% of overdose deaths reported to the CDC State Unintentional Drug Overdose Reporting System (SUDORS) between January–June 2019 occurred in the presence of a bystander, Good Samaritan laws protect someone from assisting in the event of an overdose (whether this is the administration of naloxone or the call for emergency medical care).⁶

1. Center for Disease Control and Prevention; https://www.cdc.gov/opioids/basics/epidemic.html
2. US News and World Report U.S. Child Deaths From Fentanyl Jumped 30-Fold in Just 8 Years. By HealthDay; May 8, 2023
3. CDC Morbidity and Mortality Weekly Report Drug Overdose Deaths Among Persons Aged 10–19 Years - United States, July 2019–December 2021. Weekly / December 16, 2022 / 71(50);1576–1582
4. Gaither,J PhD, MPH, RN; Richter, L.PhD. Prevention Research and Analysis, Partnership to End Addiction; JAMA Pediatrics, online, May 8, 2023
5. Ernst,J and Kaine,T; Opinion: Fentanyl is killing a shocking number of young Americans. What the US can do to respond; Published online 10:00 AM EDT, Sat May 20, 2023
6. Real-world study of multiple naloxone administration for opioid overdose reversal among bystanders; Published online 2022 May. Randa Abdelal, 1 A. Raja Banerjee,2 Suzanne Carlberg-Racich,3 Neyla Darwaza,4 Diane Ito,5 Jessica Shoaff,6 and Josh Epstein