Adolescent Opioid Harms Double Despite Reduced Emergency Department Prescribing

A decade-long study of 1.2 million visits shows that cutting pediatric opioid prescriptions did not prevent a rise in clinical harms.

For Doctors in a Hurry

Clinicians lack clarity on whether reducing emergency department opioid prescriptions effectively mitigates subsequent opioid-related harms among adolescent patients.
The researchers analyzed 1,197,829 emergency department visits for patients aged 12 to 17 in Alberta between 2010 and 2020.
While opioid prescribing dropped from 3.3% to 1.2% of visits, opioid-related harms increased from 0.15% to 0.28% over the decade.
The authors concluded that broad deprescribing efforts in emergency settings did not prevent the rise of opioid-related harms in adolescents.
Physicians should prioritize risk assessment for patients with mental health comorbidities, frequent emergency visits, or prolonged opioid prescription durations.

The Divergent Trends of Pediatric Opioid Prescribing and Patient Safety

Adolescent opioid exposure carries significant risks for systemic physiological consequences, including impaired cognitive development and respiratory depression [1]. To mitigate these dangers, recent clinical practice guidelines advocate for a multimodal approach to acute pain that prioritizes non-opioid analgesics and limits the duration of any necessary opioid therapy [2]. Despite these efforts to standardize prescribing, adolescents with underlying mental health conditions or previous substance use remain uniquely vulnerable to developing opioid use disorder [3, 4]. Furthermore, significant barriers persist in connecting at-risk youth to essential medications for opioid use disorder, complicating the trajectory from initial treatment to recovery [5]. A longitudinal study now evaluates whether the widespread reduction of opioid prescriptions in the emergency department has successfully lowered the rate of subsequent clinical harms in this population.

A Decade of Shifting Prescribing Patterns

The researchers conducted a large scale cohort analysis using linked administrative data from Alberta, Canada, to track longitudinal trends in pediatric care. The study population included patients aged 12 to 17 years who were discharged from any emergency department in the province between April 1, 2010, and June 30, 2020. By utilizing a total sample size of 1,197,829 emergency department visits, the authors provided a high resolution view of how prescribing behaviors and patient outcomes evolved over a ten year period. To analyze these trends, the team employed joinpoint regression (a statistical method that identifies specific points in time where the direction or magnitude of a trend significantly changes), allowing them to pinpoint exactly when shifts in clinical practice occurred. The findings indicate a substantial change in physician behavior, as overall emergency department opioid prescribing rates decreased from 3.3% of visits in 2010 to 1.2% in 2020. While the total volume of prescriptions fell, the specific agents selected by clinicians also changed significantly. The data show that the prescribing of codeine and oxycodone decreased during the study period, likely reflecting increased clinical awareness of the safety profiles and metabolic variability associated with these drugs in younger patients. Conversely, the prescribing of tramadol and other opioids increased between 2010 and 2020. This transition suggests that while physicians successfully reduced the frequency of opioid initiation, the pharmacological landscape of adolescent pain management became increasingly reliant on alternative opioid formulations that may carry their own distinct metabolic risks.

Institutional Disparities in Analgesic Stewardship

The analysis revealed that the type of facility where an adolescent seeks care significantly influences their likelihood of receiving an opioid prescription. The data showed that general emergency departments prescribed opioids at a higher rate than pediatric emergency departments, with prescribing frequencies of 2.5% versus 1.5%, respectively. This gap suggests that specialized pediatric centers may be more closely aligned with restrictive prescribing guidelines tailored to younger populations, whereas general facilities may apply adult oriented prescribing patterns to adolescent patients. The study further demonstrated that the adoption of more conservative pain management strategies was not uniform across institutions. While both types of facilities saw reductions in opioid use, general emergency departments exhibited slower decreases in opioid prescribing rates over time compared to pediatric emergency departments. This slower rate of change in general settings, which often manage a broader demographic of patients, highlights a potential delay in the translation of pediatric specific safety evidence into routine clinical practice. For the practicing physician, these findings emphasize that institutional setting remains a key determinant of analgesic choice; they suggest that targeted stewardship efforts in general emergency departments may be necessary to bridge the gap in care standards between specialized and non-specialized centers.

To evaluate the longitudinal impact of emergency department care on adolescent safety, the researchers defined opioid exposure as prescription fills occurring within 3 days following an emergency department visit. The study utilized a primary outcome consisting of a 1-year composite measure of opioid-related harms (a combined endpoint that captures multiple types of adverse events to provide a broader picture of patient risk). This composite measure specifically included opioid-related emergency department visits, opioid-related hospitalizations, and the initiation of opioid agonist therapy (the use of medications such as methadone or buprenorphine to treat opioid use disorder). By tracking these three indicators over a 12 month period, the authors sought to identify the total burden of opioid-related morbidity in this vulnerable population. The longitudinal analysis revealed a stark divergence between prescribing trends and patient outcomes. While the frequency of prescriptions declined, the incidence of opioid-related harms increased from 0.15% in 2010 to 0.28% in 2020. This data demonstrates that opioid-related harms nearly doubled over the decade despite the substantial decrease in emergency department prescribing observed during the same period. For the practicing physician, these findings suggest that simply reducing the volume of opioids dispensed in acute care settings is insufficient to curb the rising tide of adolescent opioid morbidity. The disconnect between lower prescribing rates and higher rates of hospitalization and therapy suggests that the broader community environment and illicit drug landscape may be outpacing clinical deprescribing efforts.

Clinical Implications for Risk Stratification

The researchers suggest that broad deprescribing measures in the emergency department may not effectively combat the opioid epidemic in Alberta. While the reduction in prescriptions from 3.3% of visits in 2010 to 1.2% in 2020 represents a significant shift in clinical practice, the concurrent rise in harms suggests that a universal reduction strategy does not address the underlying drivers of adolescent opioid morbidity. For the practicing physician, these findings indicate that simply limiting the number of prescriptions written during an acute care encounter is insufficient to protect patients from long-term adverse outcomes. To improve patient safety, the study identifies specific clinical markers that require higher vigilance. The authors note that caution should remain for patients with longer prescription durations and frequent emergency department use, as these factors were associated with a higher risk of developing opioid-related harms. Rather than focusing solely on the initial decision to provide an analgesic, clinicians should evaluate the total duration of the supply and the patient's history of acute care utilization, which may serve as a proxy for chronic pain or healthcare-seeking behaviors that precede opioid-related complications. Furthermore, the findings highlight that mental health or substance use comorbidities are significant patient-level risk factors for subsequent harms. This underscores the necessity of integrated screening within the emergency department setting. Because the incidence of harms nearly doubled over the study period, the researchers emphasize that further studies are needed to better delineate patient-level risk. For the clinician, these results suggest that a history of psychiatric illness or prior substance use should trigger more intensive monitoring and more nuanced analgesic strategies than those applied to the general adolescent population.

Study Info

Emergency Department Prescribing and Opioid-Related Harms Among Adolescents in Alberta: 2010-2020

Henry Li, Samina Ali, Jessalyn K. Holodinsky, Grant Innes, et al.

Journal PEDIATRICS

Published April 24, 2026