Research

JAMA Pediatrics | Original Investigation

Temporal Trends in Opioid Prescribing Practices in Children,

Adolescents, and Younger Adults in the US From 2006 to 2018
Madeline H. Renny, MD; H. Shonna Yin, MD, MS; Victoria Jent, MAS; Scott E. Hadland, MD, MPH, MS;
Magdalena Cerdá, DrPH, MPH

Supplemental content
IMPORTANCE Prescription opioids are involved in more than half of opioid overdoses among
younger persons. Understanding opioid prescribing practices is essential for developing
appropriate interventions for this population.

OBJECTIVE To examine temporal trends in opioid prescribing practices in children,

adolescents, and younger adults in the US from 2006 to 2018.

DESIGN, SETTING, AND PARTICIPANTS A population-based, cross-sectional analysis of opioid

prescription data was conducted from January 1, 2006, to December 31, 2018. Longitudinal
data on retail pharmacy–dispensed opioids for patients younger than 25 years were used in
the analysis. Data analysis was performed from December 26, 2019, to July 8, 2020.

MAIN OUTCOMES AND MEASURES Opioid dispensing rate, mean amount of opioid dispensed in
morphine milligram equivalents (MME) per day (individuals aged 15-24 years) or MME per
kilogram per day (age <15 years), duration of prescription (mean, short [ⱕ3 days], and long
[ⱖ30 days] duration), high-dosage prescriptions, and extended-release or long-acting
(ER/LA) formulation prescriptions. Outcomes were calculated for age groups: 0 to 5, 6 to 9,
10 to 14, 15 to 19, and 20 to 24 years. Joinpoint regression was used to examine opioid
prescribing trends.

RESULTS From 2006 to 2018, the opioid dispensing rate for patients younger than 25 years
decreased from 14.28 to 6.45, with an annual decrease of 15.15% (95% CI, −17.26% to
−12.99%) from 2013 to 2018. The mean amount of opioids dispensed and rates of
short-duration and high-dosage prescriptions decreased for all age groups older than 5 years,
with the largest decreases in individuals aged 15 to 24 years. Mean duration per prescription
increased initially for all ages, but then decreased for individuals aged 10 years or older. The
duration remained longer than 5 days across all ages. The rate of long-duration prescriptions
increased for all age groups younger than 15 years and initially increased, but then decreased
after 2014 for individuals aged 15 to 24 years. For children aged 0 to 5 years dispensed an
opioid, annual increases from 2011 to 2014 were noted for the mean amount of opioids
dispensed (annual percent change [APC], 10.58%; 95% CI, 1.77% to 20.16%) and rates of
long-duration (APC, 30.42%; 95% CI, 14.13% to 49.03%), high-dosage (APC, 31.27%; 95% CI,
16.81% to 47.53%), and ER/LA formulation (APC, 27.86%; 95% CI, 12.04% to 45.91%)
prescriptions, although the mean amount dispensed and rate of high-dosage prescriptions
decreased from 2014 to 2018.

CONCLUSIONS AND RELEVANCE These findings suggest that opioid dispensing rates decreased
for patients younger than 25 years, with decreasing rates of high-dosage and long-duration
prescriptions for adolescents and younger adults. However, opioids remain readily dispensed,
and possible high-risk prescribing practices appear to be common, especially in younger
children.

Author Affiliations: Author

affiliations are listed at the end of this
article.
Corresponding Author: Madeline H.
Renny, MD, Department of
Population Health, New York
University Grossman School of
Medicine, 227 E 30th St, New York,
JAMA Pediatr. doi:10.1001/jamapediatrics.2021.1832 NY 10016 (madeline.renny@
Published online June 28, 2021. nyulangone.org).

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 Research Original Investigation
T
he rate of opioid overdose deaths continues to in-
crease in the US, with opioids implicated in the major-
ity of pediatric and younger adult drug overdose
deaths.1-3 Prescription opioids are involved in more than half
of opioid overdose deaths in the pediatric population.4-6 Pre-
scription opioid use in children and adolescents is associated
with a risk for future opioid misuse, opioid-related adverse
events, and emergency department visits or hospitalizations
for unintentional opioid exposures by younger children.7-13
There is an increased risk of opioid misuse and overdose
when adults are prescribed higher-dosage, longer-duration,
and extended-release and long-acting (ER/LA) formulation opi-
oid prescriptions.14-17 Two studies investigating opioid pre-
scribing patterns and the risk of overdose in adolescents and
younger adults revealed similar findings, emphasizing the need
for further research characterizing opioid prescribing prac-
tices in this population.18,19 Although temporal trends in these
high-risk opioid prescribing practices have been described in
the general population,20,21 to our knowledge, there are no
similar studies in youths. The limited research in children and
adolescents has focused on trends in opioid prescribing rates,
reporting decreases in prescribing rates similar to those in
adults.20-23 One study in adolescents assessed trends in pre-
scription duration, showing a decrease in short-duration
prescriptions.24 However, to our knowledge, no US population-
based studies have provided a comprehensive look at trends
in opioid prescribing practices, including amount prescribed,
duration, high-dosage, and ER/LA prescriptions, in the pedi-
atric, adolescent, and younger adult populations.
Although some states have enacted regulations on opioid
prescribing for children and postoperative guidelines for opi-
oid prescribing in children and adolescents were recently re-
leased, there remain no national guidelines regarding general
opioid prescribing for children and adolescents.25,26 To un-
derstand the current state of the opioid epidemic in youths, it
is necessary to not only describe the most recent trends in opi-
oid dispensing rates, but also examine trends in specific opi-
oid prescribing practices by age, including amount dis-
pensed, prescription duration, and high-dosage and ER/LA
prescriptions. Improved knowledge of these prescribing prac-
tices and possible high-risk prescribing will inform targeted
areas for future study and interventions to ensure safe and ap-
propriate opioid prescribing within this population. In this
study, we aimed to estimate temporal trends and the magni-
tude of change in several key opioid prescribing practices in
children, adolescents, and younger adults in the US from 2006
to 2018.
Methods
Data Sources
We abstracted data from January 1, 2006, to December 31, 2018,
from IQVIA Longitudinal Prescription Data (LRx), a nation-
wide database of all-payer opioid prescriptions dispensed from
US outpatient retail pharmacies.27 From 2006 to 2018, the da-
tabase captured 74% to 92% of US retail outpatient opioid pre-
scriptions. Data on prescriptions obtained by mail order, those
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Opioid Prescribing Practices in Children, Adolescents, and Younger Adults in the US
Key Points
Question Have specific opioid prescribing practices for children,
adolescents, and younger adults in the US changed from 2006 to
2018?
Findings In this cross-sectional analysis of US opioid prescription
data, opioid dispensing rates have decreased significantly for
children, adolescents, and younger adults since 2013. Overall,
rates of high-dosage and long-duration prescriptions decreased for
adolescents and young adults but increased in young children.
Meaning Findings of this study suggest that total opioid
prescriptions have decreased in patients younger than 25 years,
but opioids remain commonly dispensed; further investigation
into specific opioid prescribing practices may inform targeted
interventions to ensure appropriate opioid prescribing in this
subset of the US population.
dispensed in long-term care facilities, cough/cold formula-
tions, and methadone/buprenorphine used to treat opioid use
disorder were not included. Data were restricted to prescrip-
tions dispensed to patients aged 0 to 24 years. Data analysis
was conducted from December 26, 2019, to July 8, 2020.
According to the institutional policy of New York Univer-
sity Grossman School of Medicine, this study did not involve
human subjects and so did not require institutional review
board review. This study followed the Strengthening the Re-
porting of Observational Studies in Epidemiology (STROBE)
reporting guideline for cross-sectional studies.
We obtained annual population data from the US Census
Bureau American FactFinder 2006-2018 1-year estimates to cal-
culate age-adjusted prescribing rates.28 The IQVIA LRx data-
base does not include data on individuals’ weight, so we es-
timated weights using the median weight in kilograms from
age- and sex-specific growth charts from the Centers for Dis-
ease Control and Prevention.9,19,29 This estimated weight was
used to calculate morphine milligram equivalents (MME) (a
value assigned to each opioid formulation representing anal-
gesic potency relative to morphine) per kilogram per day in pa-
tients younger than 15 years.
Variables
Based on the age provided with each opioid prescription, we
created 5 groups: 0 to 5 years, 6 to 9 years, 10 to 14 years, 15 to
19 years, and 20 to 24 years. Prescribing practice variables were
calculated annually for each age group and included (1) opi-
oid dispensing rates (number of dispensed opioid prescrip-
tions per 100 persons); (2) mean amount of opioid dispensed
per prescription, calculated using MME and using prescrip-
tion duration,30 with weight-based dosing (morphine milli-
gram equivalents per kilogram per day) for patients younger
than 15 years; (3) duration of opioid prescription (days’ sup-
ply per prescription), including mean, short (≤3 days), and long
(≥30 days) duration21,31; (4) high-dosage opioid prescription
(≥90 MME/d for individuals aged 15-24 years 1 4 , 1 8 , 3 1 ;
>2 MME/kg/d for <15 years, defined using weight-based dos-
ing above the maximum recommended prescribed daily dose
from pharmaceutical formularies32-34); and (5) ER/LA formu-
lation prescriptions.35
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 Opioid Prescribing Practices in Children, Adolescents, and Younger Adults in the US
Rates for short-duration, long-duration, high-dosage, and
ER/LA prescriptions were calculated per 100 persons dis-
pensed an opioid in that year and age group. Because prescrib-
ing practice variables were analyzed at the prescription level,
we also calculated the number of patients dispensed 1 vs mul-
tiple prescriptions to determine the extent to which prescrib-
ing trends could have been related to a minority of patients.
Statistical Analysis
DescriptiveanalyseswerecompletedusingR,version3.6.3(RProj-
ect for Statistical Computing).36 Joinpoint regression program
analyses were used to identify the best-fitting points (years) with
a statistically significant increase or decrease in opioid prescrib-
ing trends from 2006 to 2018 for each variable and age group.37-39
Owing to the increase in retail outpatient pharmacy chan-
nel coverage in the IQVIA LRx database from 2013 to 2014, a
joinpoint jump model was used to avoid the bias associated
with a standard joinpoint model; 2014 was an added param-
eter to the model as a jump trend.38 We fit a weighted least-
squares regression model with constant variance and a log
transformation. A maximum of 2 joinpoints were searched for
using the grid search algorithm.
Final models were selected using a Monte Carlo permu-
tation test to determine the optimal number of joinpoints
(α = .05). We report the annual percent change (APC) with 95%
CIs for each trend line segment. The average annual percent
changes (AAPCs) with 95% CIs are reported for the complete
time period (2006-2018). Findings were statistically signifi-
cant at P < .05, using a 2-sided test based on the permutation
methods.
The IQVIA LRx database does not contain prescription di-
agnoses or indications but includes prescriber specialty infor-
mation. To identify patients who may be dispensed opioids
based on different practice guidelines than those for the gen-
eral population, we performed 2 sensitivity analyses. For the
first, we removed prescriptions from clinicians in oncology, he-
matology, and hospice subspecialties. For the second, we re-
moved prescriptions that were both high dosage and long du-
ration or patients dispensed both a high-dosage prescription
and a long-duration prescription.
Results
Overall Trends
From 2006 to 2018, total US annual opioid prescriptions dis-
pensed to patients younger than 25 years was highest in 2007
at 15 689 779 prescriptions, and since 2012 has steadily de-
creased to 6 705 478 in 2018 (eTable 1 in the Supplement). Most
opioid prescriptions (80.4%) were dispensed for patients aged
15 to 24 years. During each year, most patients (72%-82%) were
dispensed only 1 opioid prescription (eTable 2 in the Supple-
ment). The total opioid dispensing rate per 100 persons for pa-
tients younger than 25 years decreased from 14.28 in 2006 to
6.45 in 2018, with an annual decrease of 15.15% (95% CI,
−17.26% to −12.99%) from 2013 to 2018. There were signifi-
cant decreases in dispensing rates for every age group from
2014 to 2018 (Figure 1A, Table 1).
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Original Investigation Research
During the study period, the mean amount of opioids dis-
pensed decreased for all age groups, except for children aged
0 to 5 years, for whom amounts initially increased, followed
by a decrease toward the end of the study period (Figure 1B).
Rates of high-dosage prescriptions decreased for all age groups
older than 5 years, with the largest decreases in those aged 15
to 24 years (Figure 1C). Rates of ER/LA prescriptions had var-
ied trends by age group, with a marked increase for children
aged 0 to 5 years and an initial increase followed by a de-
crease for individuals aged 20 to 24 years (Figure 1D). Mean
prescription duration increased for all age groups initially, but
then decreased for those aged 10 years or older (Figure 2A).
Rates of short-duration prescriptions decreased in all age
groups, except for children aged 0 to 5 years (Figure 2B). Rates
of long-duration prescriptions increased during the study pe-
riod for children younger than 15 years; for those aged 15 to 24
years, rates initially increased, followed by a larger decrease
(Figure 2C).
Opioid Prescribing Practices by Age Group
Dispensing rates for children aged 0 to 5 years decreased from
4.64 in 2006 to 1.47 by 2018; the largest annual decrease (APC,
−25.60%; 95% CI, −34.19% to −15.90%) occurred in 2016-
2018 (Table 1). The mean amount dispensed (APC, 10.58%; 95%
CI, 1.77% to 20.16%) and rates of long-duration (APC, 30.42%;
95% CI, 14.13% to 49.03%), high-dosage (APC, 31.27%; 95% CI,
16.81% to 47.53%), and ER/LA (APC, 27.86%; 95% CI, 12.04%
to 45.91%) prescriptions increased from 2011 to 2014, al-
though the mean amount dispensed (APC, −10.14%; 95% CI,
−12.47% to −7.75%) and the rate of high-dosage prescriptions
(APC, −9.92%; 95% CI, −13.19% to −6.53%) then decreased from
2014 to 2018 (Table 1, Table 2, Table 3). The mean prescrip-
tion duration increased from 8.12 to 11.22 days. There was no
significant change in short-duration prescriptions. During the
study period, of all opioids dispensed, long-duration prescrip-
tions increased from 7.3% to 19.9%, high-dosage prescrip-
tions increased from 15.5% to 20.8%, and ER/LA prescrip-
tions increased from 1.8% to 5.3% (eTable 1 in the Supplement).
Dispensing rates for children aged 6 to 9 years decreased
from 4.30 in 2006 to 1.43 in 2018; the largest annual decrease
(APC, −20.15%; 95% CI, −24.99% to −14.99%) occurred in 2015-
2018 (Table 1). The mean amount dispensed (2006-2018: APC,
−2.38; 95% CI, −3.21 to −1.54) and rates of short-duration (2006-
2016: APC, −2.20%; 95% CI, −2.68% to −1.72%) and high-
dosage (2006-2011: APC, −11.78%; 95% CI, −16.58% to −6.71%)
prescriptions decreased, whereas rates of long-duration pre-
scriptions (2011-2018: APC, 7.77%; 95% CI, 4.04% to 11.64%)
increased (Table 2, Table 3). The mean prescription duration
increased from 7.27 to 9.19 days. During the study period, of
all opioids dispensed, short-duration prescriptions de-
creased from 34.7% to 31.3%, long-duration prescriptions in-
creased from 6.7% to 13.1%, high-dosage prescriptions de-
creased from 7.0% to 6.6%, and ER/LA prescriptions did not
change significantly (eTable 1 in the Supplement).
Dispensing rates for children aged 10 to 14 years de-
creased from 6.63 in 2006 to 2.64 in 2018; the largest annual
decrease (APC, −22.24%; 95% CI, −29.32% to −14.45%) oc-
curred in 2016-2018 (Table 1). The mean amount dispensed
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 Research Original Investigation Opioid Prescribing Practices in Children, Adolescents, and Younger Adults in the US

Figure 1. Annual Opioid Prescribing Practices in the US, 2006-2018

A Opioid dispensing rate B Mean amount of opioid dispensed

40 Age, y 3 50
Rate of opioid prescriptions per 100 persons

0-5
6-9 Age, y
10-14 0-5
15-19 6-9 40
30 20-24 10-14
2

Mean MME/kg/d

Mean MME/d
30

20

20
1
10
10 Age, y
15-19
20-24
0 0 0
2006 2008 2010 2012 2014 2016 2018 2006 2010 2014 2018 2006 2010 2014 2018
Year Year Year

C High-dosage opioid prescribinga D ER/LA opioid prescribingb

30 10.0
Age, y Age, y

Rate of ER/LA opioid prescriptions per

Rate of high-dosage prescriptions per

0-5 0-5

100 persons dispensed an opioid

100 persons dispensed an opioid

6-9 6-9
10-14 7.5 10-14
15-19 15-19
20
20-24 20-24

5.0

10
2.5

0 0
2006 2008 2010 2012 2014 2016 2018 2006 2008 2010 2012 2014 2016 2018
Year Year

Opioid prescribing practices shown by dispensing rate (A), mean amount (MME)/kg/d for individuals younger than 15 year and greater than 90 MME/d
dispensed (B), high-dosage prescribing (C), and ER/LA prescribing (D). for those aged 15 to 24 years.
a b
High dosage defined as greater than 2 morphine milligram equivalents Extended-release or long-acting opioid formulation.

(2006-2018: APC, −1.26; 95% CI, −1.43 to −1.08) and rates of (2016-2018: APC, −3.83%; 95% CI, −5.05% to −2.61%) and rate
high-dosage prescriptions (2014-2018: APC, −9.67%; 95% CI, of high-dosage prescriptions (2016-2018: APC, −24.06%; 95%
−13.88% to −5.26%) decreased, whereas rates of long- CI, −31.81% to −15.42%) decreased, although the rates of ER/LA
duration (2006-2013: APC, 8.01%; 95% CI, 4.05% to 12.13%) prescriptions did not change significantly (Table 3). The mean
and ER/LA (2006-2014: APC, 6.35%; 95% CI, 3.27% to 9.30%) prescription duration was stable (5.11 days in 2006; 5.09 days
prescriptions increased (Tables 1-3). The rate of short- in 2018), with an initial increase (2006-2016: APC, 1.16%; 95%
duration prescriptions decreased during the study period over- CI, 0.94% to 1.38%), followed by a decrease in 2016-2018 (APC,
all (2006-2016: APC, −2.51%; 95% CI, −2.79% to −2.24%) but −6.72%; 95% CI, −9.29% to −4.07%) (Table 2). During the study
increased annually in 2016-2018 (APC, 4.32%; 95% CI, 0.56% period, of all opioids dispensed, short-duration prescriptions
to 8.22%). The mean prescription duration increased from 5.91 decreased from 51.5% to 50.6% (eTable 1 in the Supplement),
to 7.38 days, with an initial increase in duration, followed by although the rate increased annually in 2016-2018 (APC, 4.64%;
a decrease in 2014-2018 (APC, −1.97%; 95% CI, −3.64% to 95% CI, 0.99 to 8.42). Long-duration prescriptions increased
−0.26%). During the study period, of all opioids dispensed, slightly from 3.0% to 3.4% of prescriptions, although the rates
short-duration prescriptions decreased from 47.3% to 41.3%, decreased overall, with an initial increase followed by a greater
long-duration prescriptions increased from 4.7% to 9.2%, high- decrease in 2014-2018.
dosage prescriptions decreased from 2.7% to 2.0%, and ER/LA Dispensing rates for individuals aged 20 to 24 years de-
prescriptions increased from 1.2% to 2.5% (eTable 1 in the creased from 34.81 in 2006 to 15.24 in 2018, with an annual
Supplement). decrease in 2013-2018 (APC, −15.67%; 95% CI, −17.78% to
Dispensing rates for adolescents aged 15 to 19 years de- −13.50%) (Table 1). During the study period, the mean amount
creased from 19.87 in 2006 to 10.54 in 2018; the largest an- dispensed (2010-2018: APC, −3.14%; 95% CI, −3.50% to −2.77%)
nual decrease (APC, −13.67%; 95% CI, −18.97% to −8.03%) was and rates of short-duration (2009-2018: APC, −2.57%; 95% CI,
in 2015-2018 (Table 1). The mean amount dispensed −3.25% to −1.88%) and high-dosage (2016-2018: APC, −20.83%;

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 Opioid Prescribing Practices in Children, Adolescents, and Younger Adults in the US Original Investigation Research

Table 1. Trends in Opioid Dispensing Rates per 100 Persons and Mean Amount of Opioid Dispensed, 2006-2018

Mean or rate AAPC (95% CI)a APC and joinpoint segmentsa

Dispensing rate 2006 2018 2006-2013 2014-2018 Trend years APC (95% CI)
Opioid dispensing rate, per 100 persons
Age, y
Total <25 14.28 6.45 −1.03 (−2.51 to 0.46) −15.15 (−17.26 to −12.99)b 2006-2013 −1.03 (−2.51 to 0.46)
NA NA NA NA 2013-2018 −15.15 (−17.26 to −12.99)b
b b
0-5 4.64 1.47 −2.42 (−4.01 to −0.81) −21.14 (−26.18 to −15.74) 2006-2013 −2.42 (−4.01 to −0.81)b
NA NA NA NA 2013-2016 −16.40 (−26.05 to −5.49)b
NA NA NA NA 2016-2018 −25.60 (−34.19 to −15.90)b
b b
6-9 4.30 1.43 −3.75 (−4.84 to −2.64) −16.33 (−19.61 to −12.91) 2006-2015 −3.75 (−4.84 to −2.64)b
NA NA NA NA 2015-2018 −20.15 (−24.99 to −14.99)b
b
10-14 6.63 2.64 −1.24 (−2.49 to 0.03) −17.09 (−21.25 to −12.71) 2006-2013 −1.24 (−2.49 to 0.03)
NA NA NA NA 2013-2016 −11.60 (−19.65 to −2.74)b
NA NA NA NA 2016-2018 −22.24 (−29.32 to −14.45)b
b b
15-19 19.87 10.54 −1.47 (−2.60 to −0.32) −10.77 (−14.30 to −7.09) 2006-2015 −1.47 (−2.60 to −0.32)b
NA NA NA NA 2015-2018 −13.67 (−18.97 to −8.03)b
b
20-24 34.81 15.24 −0.94 (−2.43 to 0.57) −15.67 (−17.78 to −13.50) 2006-2013 −0.94 (−2.43 to 0.57)
NA NA NA NA 2013-2018 −15.67 (−17.78 to −13.50)b
c
Mean amount opioid dispensed, MME/kg/d or MME/d
Age, y
0-5 1.39 1.54 1.79 (−0.30 to 3.92) −10.14 (−12.47 to −7.75)b 2006-2011 −1.53 (−3.34 to 0.32)
NA NA NA NA 2011-2014 10.58 (1.77 to 20.16)b
NA NA NA NA 2014-2018 −10.14 (−12.47 to −7.75)b
b b d
6-9 0.95 0.89 −2.38 (−3.21 to −1.54) −2.38 (−3.21 to −1.54) NA NAd

10-14 0.74 0.66 −1.26 (−1.43 to −1.08)b −1.26 (−1.43 to −1.08)b NAd NAd

15-19 41.21 33.90 −1.16 (−1.25 to −1.06)b −2.51 (−3.03 to −1.98)b 2006-2016 −1.16 (−1.25 to −1.06)b
NA NA NA NA 2016-2018 −3.83 (−5.05 to −2.61)b
b b
20-24 44.30 34.02 −1.20 (−1.74 to −0.65) −3.14 (−3.50 to −2.77) 2006-2010 0.28 (−0.81 to 1.39)
NA NA NA NA 2010-2018 −3.14 (−3.50 to −2.77)b
Abbreviations: AAPC, average annual percent change; APC, annual percent for persons younger than 15 years and mean morphine milligram equivalents
change; MME, morphine milligram equivalents; NA, not applicable. per day per prescription for persons aged 15 to 24 years. Trends not reported
a
Joinpoint allowed up to 2 joinpoints. Owing to retail channel data coverage, for total strata (<25 years) because mean morphine milligram equivalent
2014 was added as a jump point. amounts are not comparable throughout all age groups.
d
b
Annual percent change and AAPC were statistically significant (P < .05) using a No joinpoint detected for these strata and outcomes; APC was constant and
2-sided test based on the permutation methods. equal to AAPC.
c
Mean morphine milligram equivalents per kilogram per day per prescription

95% CI, −29.65% to −10.89%) prescriptions decreased
(Tables 1-3). The mean prescription duration decreased from
6.28 to 6.15 days, with an annual increase (2006-2010: APC,
4.35%; 95% CI, 3.36% to 5.34%) followed by a larger decrease
in 2016-2018 (APC, −6.54%; 95% CI, −9.30% to −3.70%). Dur-
ing the study period, of all opioids dispensed, short-duration
prescriptions were stable at approximately 47% and high-
dosage prescriptions decreased from 6.9% to 3.1% (eTable 1 in
the Supplement). The proportion of long-duration and ER/LA
prescriptions increased, although the rates decreased over-
all, with an initial increase, followed by a decrease toward the
end of the study period.
Similar temporal and age-specific patterns of opioid pre-
scribing were found when prescriptions from certain subspe-
cialty prescribers were removed from the analysis (eTable 3 in
the Supplement) and when patients dispensed both a high-
dosage and a long-duration prescription were removed from
the analysis (eTable 4 in the Supplement).
Discussion
This cross-sectional study describes national trends in sev-
eral important opioid prescribing practices in children, ado-
lescents, and younger adults. Dispensed opioid prescriptions
for this population have decreased by 15% annually since 2013.
The overall decrease in total opioid prescriptions and rates of
dispensing are consistent with prior studies in the pediatric and
adult literature and suggest that opioid prescribing practices
may be improving.20-23 Despite this decrease, opioid prescrip-
tions continue to be readily dispensed in all age groups, but
most notably to adolescents and younger adults.

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 Research Original Investigation Opioid Prescribing Practices in Children, Adolescents, and Younger Adults in the US

the context of research in adults, which has shown associa-

Figure 2. Annual Duration of Opioid Prescriptions in the US, 2006-2018
tions between high-dosage, long-duration, and ER/LA pre-
A Mean duration per opioid prescription scriptions and opioid use disorder and opioid overdose, and
15 studies showing similar findings among adolescents and
Age, y younger adults.14-19,40 Earlier studies of trends in opioid pre-
0-5
6-9 scribing among adolescents and younger adults have found
10-14 stable or decreasing opioid prescribing rates within the past
15-19
10 20-24 several years and decreases in long-duration prescriptions, al-
though, to our knowledge, no studies have examined trends
Days

in high-risk opioid prescribing practices.22-24,41 Our findings

might reflect changing norms about opioid prescribing, re-
5
lated to policy changes for adults, such as the publication of
the Centers for Disease Control and Prevention guideline for
prescribing opioids for chronic pain published in 2016,31 which
0 states that clinicians should prescribe the lowest effective dose
2006 2008 2010 2012 2014 2016 2018
and duration of opioids, as well as state legislation limiting du-
Year
ration and amount of opioid prescribed.25 Opioid prescribing
B
guidelines and efforts focused on deprescribing for adoles-
Opioid prescription duration ≤3 d
cents and younger adults at risk for opioid dependence are im-
100
portant strategies to reduce unnecessary prescription opioid
Rate per 100 persons dispensed an opioid

use.
75 In contrast, rates of long-duration prescriptions in-
creased for children and younger adolescents. In particular,
children younger than 10 years were dispensed opioids for a
50 longer average duration than were older age groups. Across age
groups, the mean prescription duration was always longer than
5 days, which is a risk factor for continuing opioid use long-
25
term in adults.17 In addition, there was a decrease in the rates
of short-duration prescriptions for all age groups older than 5
0
years. These findings are similar to earlier studies in adoles-
2006 2008 2010 2012 2014 2016 2018 cents and the broader population.21,24 Inappropriately long-
Year
duration prescriptions could lead to leftover medication in the
home and subsequent poisoning in younger children and might
C Opioid prescription duration ≥30 d
increase the risk for nonmedical use of opioids.8,10,11,42
30
Although dispensing rates decreased significantly for chil-
Rate per 100 persons dispensed an opioid

dren aged 0 to 5 years, the mean amount of opioids dis-

20
10
0 scribed opioids as outpatients found an increased rate of ad-
2006 2008
Duration of opioid therapy shown as mean (A), short term (ⱕ3 days) (B), and
long term (ⱖ30 days) (C).
The amount dispensed and rates of short-duration and
high-dosage prescriptions decreased across all age groups older
than 5 years. The greatest decrease in these prescribing prac-
tices, as well as a decrease in rates of long-duration prescrip-
tions, was found in adolescents and younger adults. For ex-
ample, rates of high-dosage prescriptions showed a greater than
20% annual decrease in adolescents and younger adults from
2016 to 2018. Furthermore, rates of ER/LA prescriptions de-
creased for younger adults. These findings are encouraging in
pensed and rate of high-dosage prescriptions increased. De-
creasing trends from 2014 to 2018 suggest a potential change
in prescribing practices toward the end of the study period.
However, in 2018, 1 in 5 opioid prescriptions for children aged
0 to 5 years was categorized as a high-dosage prescription, in-
dicating that younger children continue to receive large
amounts of opioids. A study of children and adolescents pre-
2010 2012 2014 2016 2018 verse events with higher opioid doses prescribed.9 However,
Year
to our knowledge, no studies have examined national trends
in the amount of opioids dispensed to children. Younger chil-
dren are a unique population in which acute and chronic pain
management may be challenging owing to difficulties in com-
munication and assessment of pain, which could lead to in-
appropriate over- or underprescribing.43 In addition, high-
dosage and long-duration prescriptions may represent
prescriptions for children with chronic illness, for whom these
opioid prescribing practices may be appropriate, but our sen-
sitivity analyses found no significant difference in patterns.
These findings indicate that trends may not be influenced by
this subset of children. However, given the limitations of our
database and our findings of differences in prescribing trends

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 Opioid Prescribing Practices in Children, Adolescents, and Younger Adults in the US Original Investigation Research

Table 2. Trends in Duration of Opioid Prescriptions per 100 Persons Dispensed an Opioid 2006-2018

Mean or rate AAPC (95% CI)a APC and joinpoint segmentsa

Prescribing
characteristic 2006 2018 2006-2013 2014-2018 Trend Years APC (95% CI)
Mean duration per prescription, d
Age, y
Total <25 6.08 6.24 1.97 (1.60 to 2.35)b −3.02 (−4.26 to −1.76)b 2006-2015 1.97 (1.60 to 2.35)b
2015-2018 −4.63 (−6.54 to −2.68)b
b
0-5 8.12 11.22 2.51 (1.65 to 3.39) 0.39 (−1.16 to 1.98) 2006-2011 1.13 (−0.03 to 2.31)
NA NA NA NA 2011-2015 6.05 (3.34 to 8.84)b
2015-2018 −1.42 (−3.95 to 1.17)
6-9 7.27 9.19 0.86 (0.28 to 1.44)b 0.86 (0.28 to 1.44)b NAc NAc

10-14 5.91 7.38 3.38 (2.18 to 4.59)b −1.97 (−3.64 to −0.26)b 2006-2009 1.20 (−1.52 to 4.00)
NA NA NA NA 2009-2014 5.04 (3.24 to 6.87)b
NA NA NA NA 2014-2018 −1.97 (−3.64 to −0.26)b
15-19 5.11 5.09 1.16 (0.94 to 1.38)b −2.86 (−4.01 to −1.69)b 2006-2016 1.16 (0.94 to 1.38)b
NA NA NA NA 2016-2018 −6.72 (−9.29 to −4.07)b
b b
20-24 6.28 6.15 2.03 (1.56 to 2.51) −3.80 (−4.92 to −2.67) 2006-2010 4.35 (3.36 to 5.34)b
NA NA NA NA 2010-2016 −0.98 (−1.64 to −0.31)b
NA NA NA NA 2016-2018 −6.54 (−9.30 to −3.70)b
Short duration (≤3 d)
Age, y
Total <25 76.34 63.83 −1.38 (−1.88 to −0.88)b −1.04 (−3.05 to 1.02) 2006-2013 −1.38 (−1.88 to −0.88)b
NA NA NA NA 2013-2016 −5.06 (−8.62 to −1.37)b
NA NA NA NA 2016-2018 3.16 (−0.70 to 7.77)
0-5 36.78 45.05 −1.20 (−2.65 to 0.27) 4.50 (−3.62 to 13.30) 2006-2016 −1.20 (−2.65 to 0.27)
NA NA NA NA 2016-2018 10.53 (−8.57 to 33.61)
6-9 47.36 42.70 −2.20 (−2.68 to −1.72)b 1.33 (−1.35 to 4.07) 2006-2016 −2.20 (−2.68 to −1.72)b
NA NA NA NA 2016-2018 4.98 (−1.41 to 11.78)
10-14 65.06 54.41 −2.51 (−2.79 to −2.24)b 0.84 (−0.72 to 2.43) 2006-2016 −2.51 (−2.79 to −2.24)b
NA NA NA NA 2016-2018 4.32 (0.56 to 8.22)b
b
15-19 78.52 63.47 −2.08 (−2.51 to −1.65) −0.51 (−2.00 to 1.01) 2006-2012 −1.51 (−2.10 to −0.92)b
NA NA NA NA 2012-2016 −5.40 (−7.07 to −3.71)b
NA NA NA NA 2016-2018 4.64 (0.99 to 8.42)b
20-24 89.69 69.37 −1.28 (−2.70 to 0.15) −2.57 (−3.25 to −1.88)b 2006-2009 0.45 (−3.35 to 4.40)
NA NA NA NA 2009-2018 −2.57 (−3.25 to −1.88)b
Long duration (≥30 d)
Age, y
Total <25 8.15 8.78 5.75 (3.78 to 7.76)b −9.50 (−11.98 to −6.94)b 2006-2009 10.43 (5.68 to 15.40)b
NA NA NA NA 2009-2014 2.37 (−0.44 to 5.26)
NA NA NA NA 2014-2018 −9.50 (−11.98 to −6.94)b
b
0-5 9.66 30.55 8.03 (4.50 to 11.69) 1.75 (−2.46 to 6.13) 2006-2011 0.20 (−2.75 to 3.23)
NA NA NA NA 2011-2014 30.42 (14.13 to 49.03)b
NA NA NA NA 2014-2018 1.75 (−2.46 to 6.13)
6-9 9.08 17.84 0.01 (−3.61 to 3.76) 7.77 (4.04 to 11.64)b 2006-2011 −2.94 (−8.50 to 2.96)
NA NA NA NA 2011-2018 7.77 (4.04 to 11.64)b
b
10-14 6.51 12.07 8.01 (4.05 to 12.13) −3.25 (−9.11 to 3.00) 2006-2013 8.01 (4.05 to 12.13)b
NA NA NA NA 2013-2018 −3.25 (−9.11 to 3.00)
15-19 4.53 4.26 2.95 (1.58 to 4.35)b −9.20 (−12.67 to −5.58)b 2006-2014 2.95 (1.58 to 4.35)b
NA NA NA NA 2014-2018 −9.20 (−12.67 to −5.58)b
b b
20-24 10.80 9.11 5.60 (1.10 to 10.30) −12.50 (−14.87 to −10.06) 2006-2010 13.64 (9.31 to 18.14)b
NA NA NA NA 2010-2013 −4.25 (−15.31 to 8.27)
NA NA NA NA 2013-2018 −12.50 (−14.87 to −10.06)b
b
Abbreviations: AAPC, average annual percent change; APC, annual percent Annual percent change and AAPC were statistically significant (P < .05) using a
change; MME, morphine milligram equivalents; NA, not applicable. 2-sided test based on the permutation methods.
a c
Joinpoint allowed up to 2 joinpoints. Owing to retail channel data coverage, No joinpoint detected for this strata and outcome. APC was constant and
2014 was added as a jump point. equal to AAPC.

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 Research Original Investigation Opioid Prescribing Practices in Children, Adolescents, and Younger Adults in the US

Table 3. Trends in Rate of High-Dosage Opioid Prescriptions and Rate of ER/LA Formulation Prescriptions
per 100 Persons Dispensed an Opioid, 2006-2018

Mean or rate AAPC (95% CI)a APC and joinpoint segmentsa

Prescription
type 2006 2018 2006-2013 2014-2018 Trend years APC (95% CI)
High-dosage prescription, rate per 100 persons dispensed an opioidb
Age, y
Total <25 10.80 5.03 −2.24 (−3.53 to −0.93)c −14.85 (−18.68 to −10.48)c 2006-2012 −0.94 (−2.73 to 0.88)
NA NA NA NA 2012-2016 −9.68 (−14.43 to −4.67)c
NA NA NA NA 2016-2018 −19.72 (−27.94 to −10.57)c
c c
0-5 20.51 31.92 3.68 (0.70 to 6.75) −9.92 (−13.19 to −6.53) 2006-2011 −5.66 (−8.09 to −3.16)c
NA NA NA NA 2011-2014 31.27 (16.81 to 47.53)c
NA NA NA NA 2014-2018 −9.92 (−13.19 to −6.53)c
6-9 9.60 9.01 −5.52 (−11.24 to 0.57) −0.89 (−8.42 to 7.27) 2006-2011 −11.78 (−16.58 to −6.71)c
NA NA NA NA 2011-2014 12.14 (−12.67 to 44.00)
NA NA NA NA 2014-2018 −0.89 (−8.42 to 7.27)
10-14 3.70 2.61 −1.31 (−4.44 to 1.93) −9.67 (−13.88 to −5.26)c 2006-2009 −5.23 (−12.11 to 2.20)
NA NA 2009-2014 1.73 (−3.01 to 6.71)
NA NA 2014-2018 −9.67 (−13.88 to −5.26)c
c c
15-19 8.11 2.94 −3.45 (−4.26 to −2.64) −14.37 (−18.22 to −10.35) 2006-2016 −3.45 (−4.26 to −2.64)c
NA NA NA NA 2016-2018 −24.06 (−31.81 to −15.42)c
c
20-24 13.02 4.56 −1.80 (−3.60 to 0.02) −15.39 (−19.20 to −11.39) 2006-2010 4.45 (0.62 to 8.43)c
NA NA NA NA 2010-2016 −9.57 (−11.93 to −7.15)c
NA NA NA NA 2016-2018 −20.83 (−29.65 to −10.89)c
d
ER/LA prescription, rate per 100 persons dispensed an opioid
Age, y
Total <25 2.43 2.89 4.45 (0.08 to 9.01)c −6.55 (−11.29 to −1.56)c 2006-2008 21.89 (1.72 to 46.05)c
NA NA NA NA 2008-2015 −1.81 (−4.76 to 1.24)
NA NA NA NA 2015-2018 −8.08 (−16.03 to 0.62)
0-5 2.37 8.16 8.04 (4.54 to 11.66)c −0.97 (−5.02 to 3.25) 2006-2011 1.00 (−1.94 to 4.03)
NA NA NA NA 2011-2014 27.86 (12.04 to 45.91)c
NA NA NA NA 2014-2018 −0.97 (−5.02 to 3.25)
6-9 2.16 4.44 0.35 (−2.40 to 3.18) 0.35 (−2.40 to 3.18) NAe NAe

10-14 1.68 2.24 6.35 (3.47 to 9.30)c −3.74 (−11.09 to 4.22) 2006-2014 6.35 (3.27 to 9.30)c
NA NA NA NA 2014-2018 −3.74 (−11.09 to 4.22)
15-19 1.55 1.84 3.71 (−1.24 to 8.92) −6.09 (−13.49 to 1.94) 2006-2008 17.80 (−4.83 to 45.81)
NA NA NA NA 2008-2016 −1.44 (−4.21 to 1.41)
NA NA NA NA 2016-2018 −10.53 (−27.72 to 10.74)
20-24 3.33 3.08 2.82 (0.23 to 5.48)c −7.48 (−8.62 to −6.32)c 2006-2009 18.36 (10.57 to 26.71)c
NA NA NA NA 2009-2018 −7.48 (−8.62 to −6.32)c
c
Abbreviations: AAPC, average annual percent change; APC, annual percent Annual percent change and AAPC were statistically significant (P < .05) using a
change; ER/LA, extended-release, long-acting; MME, morphine milligram 2-sided test based on the permutation methods.
equivalents; NA, not applicable. d
Prescriptions for ER or LA opioid formulations.
a
Joinpoint allowed up to 2 joinpoints. Owing to retail channel data coverage, e
No joinpoint detected for these strata and outcomes. APC was constant and
2014 was added as a jump point. equal to AAPC.
b
Prescription for more than 2 MME/kg/d for persons younger than 15 years and
prescription for 90 MME/d or more for persons aged 15 to 24 years.

by age, future investigation using a database that includes clini-
cal information is warranted to better understand prescrib-
ing practices in younger children.
The rates of ER/LA prescriptions have increased for youths
younger than 20 years since 2006, with no marked changes
toward the end of the study period. In our sensitivity analy-
ses, we found overall lower rates of these prescriptions, but
similar trends, which suggests that ER/LA prescriptions may
be readily prescribed for patients without chronic pain or ill-
ness. When initiating opioid therapy in adults, the Centers for
Disease Control and Prevention guidelines recommend im-
mediate-release opioids for both acute and chronic pain.31 To
our knowledge, there have been no studies in children and ado-
lescents examining trends of ER/LA opioid prescriptions; how-
ever, one study found an association between ER/LA opioid
use and an increased risk of overdose in adolescents and

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 Opioid Prescribing Practices in Children, Adolescents, and Younger Adults in the US Original Investigation Research

younger adults.18 Therefore, our findings emphasize the need
for pediatric guidelines on prescribing and interventions tar-
geted on opioid selection strategies in children. In addition,
although we examined ER/LA prescriptions, understanding
trends in the type of opioid dispensed is another important area
of future study.
Limitations
There are several limitations to this study. First, the IQVIA LRx
database does not contain detailed patient or clinical infor-
mation, including weights, diagnoses, or indications for pre-
scriptions. We used weight estimates, which have been used
in other studies but could lead to inaccuracies in opioid amount
and high-dosage opioid calculations.9,19 Without clinical di-
agnoses, we were limited in our ability to identify patients who
may be appropriately prescribed high-dosage or long-
duration opioid treatment. However, we performed 2 sensi-
tivity analyses attempting to identify a subset of patients with
chronic illness, both of which showed no significant changes
in trends. Second, opioids are commonly prescribed to be taken
as needed, but the IQVIA LRx database does not contain this
information. The database estimates the days’ supply for these
prescriptions based on the quantity of opioid dispensed, which
could lead to inaccuracies in determining daily dosage and pre-
scription duration. Third, the IQVIA LRx database is a pre-
scription-level database, so we were unable to determine
whether a prescription was a refill vs new prescription for a
patient. However, we analyzed the number of patients dis-
pensed 1 vs multiple prescriptions each year, with most pa-
tients receiving only 1 prescription. Fourth, there is no estab-
lished definition for high-dosage opioid prescription for
children. We created a definition based on maximum dosing
by prescribing formularies, but the clinical significance of this
value remains unknown. We used 90 MME/d as the level for a
high-dosage prescription for adolescents based on the adult
studies, although the clinical significance of this dosing in ado-
lescents is not well studied.
Conclusions
From 2006 to 2018, there have been significant decreases in
opioid dispensing rates in patients younger than 25 years, with
decreased rates of high-dosage and long-duration prescrip-
tions in adolescents and younger adults. However, opioids re-
main readily dispensed and potential high-risk prescribing
practices were common. Given the differences between pedi-
atric and adult pain and indications for opioid prescribing, there
is a need for pediatric-specific and adolescent-specific guide-
lines and focused research in this unique population. Exam-
ining trends in opioid prescribing practices is a necessary first
step in understanding the scope and direction of the opioid epi-
demic in this subset of patients. This information may be used
to develop national and local targeted interventions.

ARTICLE INFORMATION
Accepted for Publication: May 5, 2021.
Published Online: June 28, 2021.
doi:10.1001/jamapediatrics.2021.1832
Author Affiliations: Center for Opioid
Epidemiology and Policy, Department of Population
Health, New York University Grossman School of
Medicine, New York (Renny, Jent, Cerdá);
Department of Population Health, New York
University Grossman School of Medicine, New York
(Renny, Yin); Department of Emergency Medicine,
New York University Grossman School of Medicine,
New York (Renny); Department of Pediatrics, New
York University Grossman School of Medicine, New
York (Renny, Yin); Grayken Center for Addiction,
Boston Medical Center, Boston, Massachusetts
(Hadland); Department of Pediatrics, Boston
Medical Center, Boston, Massachusetts (Hadland);
Division of General Pediatrics, Department of
Pediatrics, Boston University School of Medicine,
Boston, Massachusetts (Hadland).
Author Contributions: Ms Jent 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: Renny, Yin, Hadland, Cerdá.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Renny, Jent, Cerdá.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Jent.
Obtained funding: Cerdá.
Administrative, technical, or material support:
Cerdá.
Supervision: Yin, Cerdá.
Conflict of Interest Disclosures: None reported.
Funding/Support: Dr Renny was supported by the
T32HS026120 grant from the Agency for
Healthcare Research and Quality and by the New
York University Clinical and Translational Science
Institute 2UL1 TR001445-06A1 grant. Dr Hadland
was supported by grants K23DA045085 and
L40DA042434 from the National Institute on Drug
Abuse, National Institutes of Health. The IQVIA LRx
database was supported by the Center for Opioid
Epidemiology and Policy, New York University
Grossman School of Medicine. Ms Jent was
supported by the Center for Opioid Epidemiology
and Policy, New York University Grossman School of
Medicine.
Role of the Funder/Sponsor: The funding
organizations 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; and decision to submit
the manuscript for publication.
Disclaimer: The content is solely the responsibility
of the authors and does not necessarily represent
the official views of the Agency for Healthcare
Research and Quality.
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