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The illicit drug supply has increasingly become contaminated with illicitly manufactured fentanyls and other synthetic opioid and benzodiazepine analogues.¹ Adolescent drug use rates remained generally stable between 2010 and 2020, with 30.2% and 30.4%, respectively, of 10th-graders reporting any illicit drug use in the past 12 months, which declined to 18.7% of 10th-graders in 2021.² However, given the increase in illicit fentanyls and potential associated risks, we assessed shifts in overdose deaths among adolescents.

We calculated drug overdose deaths per 100 000 population for adolescents (aged 14-18 years), compared with the overall population, from January 2010 to June 2021, using data from the Centers for Disease Control and Prevention WONDER (Wide-Ranging Online Data for Epidemiologic Research) database,³ containing records on all US deaths for which drug overdose was listed as the underlying cause of death. Values for January to June 2021 were provisional and annualized by proportional scaling. Descriptive trends by specific substance involvement were assessed using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision multiple cause of death codes (eAppendix in the Supplement) and by ethnicity (Latinx) and race (American Indian or Alaska Native, Black or African American, White) as categorized in the underlying records. Rationale for assessment of race and ethnicity is described in footnote c of the Table. Analyses were conducted using R version 4.0.3. This study was deemed exempt from review and informed consent by the University of California, Los Angeles institutional review board.

There were 518 deaths among adolescents (2.40 per 100 000 population) in 2010, with rates remaining stable through 2019 with 492 deaths (2.36 per 100 000). Deaths increased to 954 (4.57 per 100 000) in 2020 and to 1146 (5.49 per 100 000) in 2021. Between 2019 and 2020, overdose mortality increased by 94.03% and from 2020 to 2021 by 20.05%.

In the overall population, numbers of overdose deaths were higher and rates increased steadily from 2010 (n = 38 329; 12.4 per 100 000) to 2020 (n = 91 799; 27.86 per 100 000) and 2021 (n = 101 954; 31.06 per 100 000). The percent change was 29.48% from 2019 to 2020 and 11.48% from 2020 to 2021 (Table).

Among adolescents, fentanyl-involved fatalities increased from 253 (1.21 per 100 000) in 2019 to 680 (3.26 per 100 000) in 2020 and to 884 (4.23 per 100 000) in 2021 (Figure, A). In 2021, fentanyls were identified in 77.14% of adolescent overdose deaths, compared with 13.26% for benzodiazepines, 9.77% for methamphetamine, 7.33% for cocaine, 5.76% for prescription opioids, and 2.27% for heroin.

American Indian and Alaska Native adolescents experienced the highest overdose rate in 2021 (n = 24; 11.79 per 100 000), followed by Latinx adolescents (n = 354; 6.98 per 100 000) (Figure, B).

Beginning in 2020, adolescents experienced a greater relative increase in overdose mortality than the overall population, attributable in large part to fatalities involving fentanyls. In the context of decreasing adolescent drug use rates nationally,² these shifts suggest heightened risk from illicit fentanyls, which have variable and high potency.¹ Since 2015, fentanyls have been increasingly added to counterfeit pills resembling prescription opioids, benzodiazepines, and other drugs, which adolescents may not identify as dangerous and which may be playing a key role in these shifts.^1,4

The highest rates of overdose deaths were among American Indian and Alaska Native adolescents, which have also been reported among adults in this population in 2020.⁵ High rates among Latinx adolescents contrast with relatively lower rates among Latinx adults.⁵ These adolescent trends fit a wider pattern of increasing racial and ethnic inequalities in overdose that deserve further investigation and intervention efforts.⁵

Study limitations include the observational design that cannot establish causality, that race and ethnicity may be incorrectly assigned in some death investigations, that results from 2021 were provisional and include proportionally scaled values from January to June, and small numbers in some subgroups. In addition, the contribution of factors unique to the COVID-19 pandemic, such as suicidal ideation, mental illness, social isolation, and disruptions to illicit drug markets, cannot be discerned.⁶

Increasing adolescent overdose deaths, in the context of increasing availability of illicit fentanyls, highlight the need for accurate harm-reduction education for adolescents and greater access to naloxone and services for mental health and substance use behaviors.

Accepted for Publication: February 14, 2022.

Corresponding Author: Joseph Friedman, MPH, UCLA Semel Institute, 760 Westwood Plaza, B7-435, Los Angeles, CA 90024 (joseph.robert.friedman@gmail.com).

Author Contributions: Mr Friedman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Friedman, Godvin, Shover, Hansen, Schriger.

Acquisition, analysis, or interpretation of data: Friedman, Shover, Gone, Schriger.

Drafting of the manuscript: Friedman, Godvin, Schriger.

Critical revision of the manuscript for important intellectual content: Friedman, Shover, Gone, Hansen, Schriger.

Statistical analysis: Friedman, Schriger.

Administrative, technical, or material support: Friedman, Godvin.

Supervision: Friedman, Hansen, Schriger.

Conflict of Interest Disclosures: None reported.

Funding/Support: Mr Friedman received support from the UCLA Medical Scientist Training Program (National Institute of General Medical Sciences training grant GM008042). Dr Shover was supported by a grant from the National Institute on Drug Abuse (K01-DA050771). Dr Schriger’s time on this project was supported in part by an unrestricted educational grant from the Korein Foundation.

Role of the Funder/Sponsor: The study funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Disclaimer: Dr Schriger is Associate Editor of JAMA but was not involved in any of the decisions regarding review of the manuscript or its acceptance.