Using a Multi-faceted Approach to Adolescent Opioid Misuse and Overdose

By Iris Smith, Ph.D

In 2022, there were 7,714,521 drug related emergency department (ED) visits in the U.S.  Rates of admission were highest among individuals who were: 26-44 years old (3,265/100,00) and 45-64 (2,738 per 100,000), male (2,635/100,000), Black or African American (3,409/100,000), not Hispanic or Latino (2,174/100,000). 


While the proportion of visits was highest for White individuals, Black or African Americans had significantly higher rates compared to Whites (3,409 vs.1,692/100,000).  Rates for American Indian/Pacific Islanders was comparable to that of White individuals.[1]


Overdose deaths increased 30% from 2019 to 2020 and an additional 15% in 2021.  Among high school age youth (14-18 years old) overdose rates increased 94% from 2019-2020 and 20% from 2020-21.  Many deaths recorded involved illicitly manufactured Fentanyl (IMFs), Fentanyl-laced counterfeit prescription pills and ease of purchasing pills through social media. Between July 2019 and December 2021, a total of 1,808 adolescent overdose deaths were documented in 32 jurisdictions.


Approximately 41% of those who died had a documented mental health history. This study[MM1]  highlights the importance of reducing the availability of IMFS and counterfeit pills, promoting awareness through evidence-based prevention programs, and ensuring access to evidence based mental health and substance misuse treatment for adolescents. [2] 


The association between mental illness and overdose is worth noting. Data from the Adolescent Behaviors and Experiences Survey found that between January and June of 2021, 31.6% of high school students reported current use of tobacco products, alcohol, marijuana, or misuse of prescription opioids.[3]   A CDC report summarizing data from 2013-2019,  obtained from nine federal surveillance systems in the U.S. that collect data on children’s mental health, found that 20.9% of  12–17-year-olds had experienced a major depressive episode at some point in their lives, 36.7% reported persistently feeling  sad or hopeless in the past year and 18.8% had seriously contemplated suicide.[4] 


A recently published cross-sectional study that examined opioid misuse from age 12 to 21, using data abstracted from the National Survey of Drug Use and Health (NSDUH).  The study found that rates of opioid misuse in adolescents decreased as students aged, with peak opioid misuse rates at age 19 among both males and females. These findings did not appear to be related to greater access to prevention messages or treatment access over time.  The findings are consistent with other studies that have documented similar decreases in other risky behaviors in individuals over time. The authors hypothesize that the observed decrease in misuse could be attributed to decrease in drug availability and increased awareness of the dangers associated with opioid use.


These studies highlight the importance of multi-level frameworks that address the availability of drugs (supply), access to culturally appropriate intervention and treatment specifically tailored to adolescents, and health promotion strategies that support resilience and promote mental health. Adolescents who are living in poverty, experience homelessness, adverse childhood experiences (ACEs), or grow up in families where there is substance misuse or mental illness are particularly vulnerable. 


Community violence is an often-overlooked cause of child trauma.  Data from the Youth Risk Behavior Survey (YRBS) found that from 2019-2021 firearm homicides of adolescents and young adults (10-24 years old) increased 39%.  20% of YRBS respondents had witnessed community violence and 3.5% carried guns.  African American/Black, Asian, American Indian, multiracial, and Hispanic males were most likely to be exposed to community violence and to report carrying a gun themselves.  Lesbian, gay or bisexual students were more likely to have witnessed violence compared to their heterosexual peers.[5]  Native Hawaiian/ Pacific Islander YRBS respondents were most likely to experience unstable housing, followed by American Indian, Alaskan Native and African American youth. Unstable housing was associated with risky sexual behaviors, substance use, suicide ideation, and attempts and exposure to violence.[6]


Studies that compared individuals who have had overdoses to those who have not experienced an overdose, have found that social and health inequities are often associated with overdose. Frameworks that address social health inequities and incorporate strategies to address how identity (social, cultural, racial), lived experience, and discrimination intersect to exacerbate heath disparities, may be needed to effectively reduce Opioid misuse and overdoses.  Equity-oriented frameworks address health inequities and seeks to reduce drug-related harms of stigma or overdose and include at least one of the following concepts:  cultural safety, trauma and violence-informed care, or harm reduction.[7]  Based on a scoping literature review of 148 studies (Wallace et al, 2021)  recommends that prevention and treatment professionals: include people with living & lived experience in planning;  employ a multi-faceted approach to reduce stigma and discrimination; recognize and address inequities; recognize the role played by drug policy and advocate for changes when appropriate; integrate harm reduction approaches; and balance targeted strategies to reach those at highest risk with universal strategies to reach the broader population.



  • Tam CC, Smout SA, Wall SJ, Mason KL, Benotsch EG (2022).  Behavioral Intervention for Nonmedical Use of Prescription Drugs Among Adolescents and Young Adults:  A Narrative Review.  Pediatric Clinics of North America, 69 (4); pg. 807-818.
  • Kimmel SD, Gaeta JM, Hadland SE, Hallett E, Marshall BDL, (2021).  Principles of Harm Reduction for Young People Who Use Drugs. Pediatrics 147 (Suppl. 2): S240-S248.
  • Sharma G, Chakole S, Prasad R, Wanjari MB, Sharma R (2023).  A Review on Preventing Tragedy: Strategies to Combat the Devastating Effects of Adolescent Drug Overdoses. Cureus 15(5): e39132
  • Spoth R, Redmond C, Shin C, Trudeau L, Greenberg MT, Feinberg M, Welsh J (2022).  Applying the PROSPER Prevention Delivery System with Middle Schools: Emerging Adulthood Effects on Substance Misuse and Conduct Problem Behaviors Through 14 years past Baseline.  Child Development, 98 (4); pg. 925-940,
  • Wallace, B., MacKinnon, K., Strosher, H., Macevicius, C., Gordon, C., Raworth, R., Mesley, L., Shahram, S., Marcellus, L., Urbanoski, K. & Pauly, B. (2021). Equity-oriented Frameworks to Inform Responses to Opioid Overdoses: A Scoping Review. JBI Evidence Synthesis, 19 (8), 1760-1843.
  • Warren LK, Adams J, Georgiy Bobashev (2023).  Trends in Opioid Misuse Among Individuals Aged 12 to 21 Years in the US.  JAMA Network Open.2023;6(6): e2316276.


[1]SAMHSA Findings from Drug-Related Emergency Department Visits, 2022.

[2] Tanz LJ, Dinwiddie AT, Mattson CL, O’Donnell JO, Davis NL (2023).  Drug Overdose Deaths Among Persons Aged 1—19 years- United States, July 2019=December 2021.  Morbidity and Mortality Weekly Report (MMWR), 71 (50); pg. 1576-1582

[3] Brener ND, Bohm MK, Jones CM et al. (2022). Use of Tobacco Products, Alcohol and Other Substances Among High School Students During the COVID-19 Pandemic- Adolescent Behaviors and Experiences Survey, United States, January-June 2021.  Morbidity and Mortality Weekly Report (MMWR) 71(3); pg. 8-15.

[4] Bitsko RH, Claussen AH, Lichstein J et al. (2022). Mental Health Surveillance Among Children- United States, 2013-2019.  Morbidity and Mortality Weekly Report (MMWR) Suppl 2022; 71 (Suppl 2): pg. 1-42.

[5] Harper CR, Li J, Sheats K, Hertz MF, Merrill-Francis M, Friar NW, Ashley CI, Shanklin S, Barbero C, Gaylor EM, Hoots BE (2023) Witnessing Community Violence, Gun Carrying, and Associations with Substance Use and Suicide Risk Among High School Students – Youth Risk Behavior Survey, United States, 2021.  Morbidity Mortality Weekly Report (MMWR) 72(1); pg 22-28.

[6] McKinnon II, Krause KH, Robin L, King A, Leo-Nguyen, Zavala E, Suarez NA, Lim C, Smith-Grant J, Underwood JM (2023).  Experiences of Unstable Housing Among High School Students- Youth Risk Behavior Survey, United States, 2021.  Mortality Morbidity Weekly Report (MMWR) 72 (1); pg.29-36.

[7] Wallace, B., MacKinnon, K., Strosher, H., Macevicius, C., Gordon, C., Raworth, R., Mesley, L., Shahram, S. , Marcellus, L. , Urbanoski, K. & Pauly, B. (2021). Equity-oriented frameworks to inform responses to opioid overdoses: a scoping review. JBI Evidence Synthesis, 19 (8), 1760-1843. doi: 10.11124/JBIES-20-00304.


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