Psych meds and over-the-counter painkillers were the most common cause found in Medicaid claims for hospitalizations of low-income youth.
Foster youth are more than twice as likely as other young people to suffer a non-fatal drug overdose, a first-of-its-kind study based on a massive trove of health insurance claims has found.
And despite recent widespread attention to opioid misuse, among a broader study sample of low-income youth, common aspirin–like painkillers, antidepressants and other mental health drugs were the medications most frequently involved, according to a forthcoming article in the Journal of the American Academy of Child & Adolescent Psychiatry. More than 300,000 foster youth were among the millions of 12- to 18-year old patients whose records were examined for the study — and they were found to have a growing rate of intentional overdoses through 2020.
“This likely reflects medications adolescents more commonly have access to,” said lead author Greta Bushnell, assistant professor of epidemiology at Rutgers School of Public Health. She said these same drugs contribute to nonfatal overdoses in adults, “although they typically account for a smaller share than what we observed among adolescents.”
The study did not include the already well-documented fatal drug overdoses, which have become the third leading cause of death among youth in the United States. But nonfatal overdoses in this population are strongly associated with later dying of an overdose, Bushnell and her coauthors state in their study.
There were also limitations of the research, the results of which are described as estimates, and likely underestimates. Notably, some Medicaid claims lacked race and ethnicity information, and the study did not include fentanyl, which lacked the necessary records until late 2020.
Dr. Rachael Keefe, a pediatrician serving children in foster care at Texas Children’s Hospital in Houston, has treated foster youth after non-fatal overdoses involving both prescription psychotropic medications and over-the-counter medications.
She praised Bushnell’s study and added that such a case typically “isn’t about chronic substance misuse.”
“It’s about overwhelming feelings — hopelessness, anger, shame, grief — and a young person trying to make the pain stop at that moment,” she said. “When medications are widely available, they are often what gets used.”
The new study examined Medicaid claims for overdose-related hospitalizations and acute care visits over four years, 2016 to 2020. The number of youth whose claims were analyzed each year ranged from roughly 9 million to 11 million, including around 300,000 foster youth. Of the patients in foster care, an average of 3,160 required inpatient treatment each year for drug overdoses they had survived.
For all youth studied, just over .4% were treated for a non-fatal overdose each year, with a slightly higher rate for 15- to 18-year-olds. Among this larger publicly insured group, and among those in foster care, intentional overdoses took place nearly twice as often as unintentional ones.
“It’s about overwhelming feelings — hopelessness, anger, shame, grief — and a young person trying to make the pain stop at that moment. When medications are widely available, they are often what gets used.”
— Dr. Rachael Keefe, Baylor College of Medicine
The study authors also highlighted vast demographic differences: Girls suffered from overdoses at almost three times the rate of boys. The study broke down the overdose rate by race and ethnicity. American Indian or Alaskan Native youth had the highest non-fatal overdose rate, at .82% annually; multiracial or multiethnic youth were the next highest, at .6%, followed by white, non-Hispanic youth at .53%. Youth in other racial and ethnic groups overdosed at a rate well below the national average.
Foster youth had by far the highest rate of non-fatal overdose: 1.03%. Typically, they were intentional overdoses. The percentage grew between 2016 and 2020, an issue Bushnell said will be “important to monitor.” She did not speculate as to the possible cause.
Among intentional overdoses, the most common non-fatal overdose drugs were “non-opioid analgesics,” including over-the-counter pain medicine like aspirin, which comprised nearly 36%. Psychotropic medication overdoses were also frequent — including antidepressants, at nearly 22%, and antipsychotics at nearly 10% of drugs ingested.
Among unintentional overdoses, cannabis, benzodiazepines, opioids and stimulants were the most common. Unintentional cannabis and opioid overdoses also both increased in the years leading up to the pandemic in 2020.
The study authors describe its data on foster youth as unique.
“For adolescents in foster care, we are unaware of any other national overdose estimates,” they wrote, “however, there is evidence that youth in foster care have elevated substance use, and earlier age of use, compared to youth not involved in foster care.”
Keefe, who is also an associate professor at Baylor College of Medicine, has published research on the high rates of psychotropic prescriptions for foster youth using similar medical records. She added that while medication has a role to play in treating them, “we also have to be clear about its limits.”
In a multipart investigation published last spring, The Imprint documented that psychiatric drugs are often haphazardly prescribed to foster youth, with little state oversight in many parts of the country. The drugs, if overused and improperly monitored, can lead to severe, lifelong health problems including obesity, diabetes and irreversible tremors.
Bushnells’ new study also underscores a potential risk of youth intentionally overdosing on the drugs.
“There are very few psychotropic medications that are actually evidence-based treatments for trauma in children and adolescents,” Keefe said. “If trauma-related distress is managed primarily with medication, without consistent therapeutic support, we increase both reliance on medication and the physical presence of those medications in a teen’s daily life.”
To avoid misuse, Keefe recommends that caregivers safely store the drugs, and discuss medication safety with the children and youth in their homes. She emphasized that what happens after a non-fatal overdose “should be treated as a serious mental health crisis — and an opportunity to step in with stronger support, safety planning, and trauma-informed care.”
