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Substance Use Disorder Visits Among Adolescents at Children’s Hospitals During COVID-19

Purpose To assess changes in adolescent visits with substance use disorders (SUDs) at children’s hospitals during COVID-19. Methods We conducted a retrospective cohort study of adolescents (11–18 years) with SUD diagnoses during a hospital visit in the Pediatric Health Information System. Study periods were defined as spring (03/15–05/31), summer (06/01–08/31), and fall (09/01–12/31), pre-COVID-19 (2017–2019), or during COVID-19 (2020). We summarized the change in weekly median visits and interquartile range (IQR) by characteristics and compared between the two periods (e.g., spring pre-COVID-19 [3/15–05/31/2017–2019] versus spring COVID-19 [3/15–05/31/2020]) using median regression. Results There were 42,979 SUD visits (10,697 COVID-19; 32,282 pre-COVID-19) and 256 annual weekly median adolescent SUD visits [IQR 235, 280] pre-COVID-19 and 268 [IQR 245, 278] during COVID-19. The median number of weekly SUD visits increased by 14.3% during summer COVID-19 (median visits, [IQR]: 272 [268, 278]) compared to pre-COVID-19 (median visits: 237, IQR [216, 249]; p < .001) but did not significantly differ in spring (p = .091) or fall (p = .65) COVID-19. Discussion Our findings suggest increased problematic adolescent substance use during summer COVID-19. Efforts to increase the identification and treatment of adolescent SUDs remain critical.


A B S T R A C T
Purpose: To assess changes in adolescent visits with substance use disorders (SUDs) at children's hospitals during COVID-19. Methods: We conducted a retrospective cohort study of adolescents (11e18 years) with SUD diagnoses during a hospital visit in the Pediatric Health Information System. Study periods were defined as spring (03/15e05/31), summer (06/01e08/31), and fall (09/01e12/31), pre-COVID-19 (2017e2019), or during COVID-19 (2020). We summarized the change in weekly median visits and interquartile range (IQR) by characteristics and compared between the two periods (e.g., spring pre-COVID-19 [ [216,249]; p < .001) but did not significantly differ in spring (p ¼ .091) or fall (p ¼ .65) COVID-19. Discussion: Our findings suggest increased problematic adolescent substance use during summer COVID-19. Efforts to increase the identification and treatment of adolescent SUDs remain critical.
Ó 2021 Society for Adolescent Health and Medicine. All rights reserved.

IMPLICATIONS AND CONTRIBUTION
COVID-19 mitigation strategies have increased unstructured time, social isolation, and thus, the potential for increased risk for adolescent substance use disorders. This retrospective cohort study found increased median adolescent visits for substance use disorders at children's hospitals during summer COVID-19 compared to presummer-COVID-19, which may suggest increased problematic adolescent substance use.
Coronavirus 2019 (COVID-19) pandemic mitigation strategies in the United States have led to increased unstructured time, less parental monitoring, social isolation, and adverse mental health for adolescents [1,2]. Together, these may increase the risk for adolescent substance use during COVID-19 [3]. Self-reported substance use among adolescents during COVID-19 has shown conflicting results, with some studies finding increased problematic use of alcohol and cannabis, others finding decreased ecigarette use, and others finding no significant change in marijuana use or binge drinking [4e6].
Hospital-based care for SUDs may indicate greater acuity or concerning substance use compared to self-reported substance use, and to date, little is known regarding adolescent hospital visits for SUDs during COVID-19. In addition, hospital reliance for healthcare, already high for those with underlying mental health and SUDs [7], may have been even greater during the COVID-19 pandemic while primary care clinics were operating at reduced capacity. To understand the impact of the COVID-19 pandemic on hospital-based care for SUDs, we aimed to describe changes in adolescent visits with a SUD diagnosis at children's hospitals' emergency department (ED) and inpatient (IP) settings during COVID-19.

Methods
We conducted a retrospective cohort study of adolescents (11e18 years old) with a hospital encounter (IP, including observation; ED), in the Pediatric Health Information System (Children's Hospital Association, Lenexa, KS) database, which contains up to 41 diagnoses on each encounter using the International Classification of Diseases Tenth Revision [8]. Hospitals that provided data throughout the study period were included (42 out of 49). The primary outcome was the median number and interquartile range (IQR) of adolescent visits with diagnosis (primary or secondary) of a SUD, including alcohol, cannabis, nicotine, opioid, and other psychoactive substance use, during COVID-19 compared to pre-COVID-19. Given the changes in healthcare utilization during COVID-19 impacting the overall number of visits, we chose to compare the percent change in median weekly adolescent SUD visits to ensure consistent comparison. Covariates included age, sex, clinical setting (ED/IP), payer type, median household income quartile, disposition, underlying mental health disorder, hospital region, and setting (rural/urban). We investigated race/ethnicity because adolescent substance use patterns and treatment differ between racial/ethnic groups [9,10]. Due to different mitigation strategies over time during COVID-19, as well as seasonal variations in substance use, we defined our study periods as spring COVID-19 (03/15e05/31/ 2020), summer COVID-19 (06/01e08/31/2020), and fall COVID-19 (09/01/2020e12/31/2020) [11]. We defined our comparison periods as spring pre-COVID-19 (03/15e05/31, 2017e2019), summer pre-COVID-19 (06/01e08/31, 2017e2019), and fall pre-COVID-19 (09/01e12/31, 2017e2019).
We summarized the percent change in the median number of visits and IQR by categorical characteristics and compared between the two study periods (e.g., spring pre-COVID-19 [3/15e 05/31/2017e2019] versus spring COVID-19 [3/15e05/31/2020]) using median regression, based on methods similar to a recent study [11]. We were unable to adjust for a hospital effect due to low weekly volumes at individual hospitals; p-values <.05 were considered statistically significant. The Institutional Review Board deemed the research of this nonhuman subject.

Discussion
We found the median number of adolescent visits for SUD at children's hospitals increased during summer COVID-19 compared to summer pre-COVID-19. Recent literature describes mixed findings regarding adolescent substance use during COVID-19 [5,6], with some studies finding increased alcohol and cannabis use among adolescents with current substance use and solitary substance use [4]. Our findings may be driven in part by differences in adolescent substance use patterns due to variation in mitigation strategies across the study periods, e.g., strict measures nationwide in spring, decreased measures but not yet back in school in summer, and return to remote or in-person school in fall.
Our findings also suggest increased problematic substance use among certain adolescents. Further study is needed to better understand the underlying drivers of these findings, with particular focus on younger adolescents, those of non-Hispanic Black and Hispanic race/ethnicity, and those with underlying mental health disorders. A recent study in younger adolescents (10e14-year-olds) found that while there was no substantial change in overall substance use during COVID-19, there was an increase in nicotine and misuse of prescription drugs. Importantly, this study found a correlation with underlying mental health as youth reporting "extreme" stress related to the pandemic were 2.4 times more likely to report any substance use [12]. Recent evidence shows the adverse impact of COVID-19 on adolescent mental health, including increased symptoms of depression, anxiety, and psychological distress [13,14]. Given our finding that adolescent SUD visits increased during summer COVID-19 among those with underlying mental health disorders, further study is needed to understand underlying drivers that can inform SUD interventions in this atrisk population.
Due to the use of administrative data, our findings are subject to misclassification bias and likely underestimate true SUD prevalence. Due to low weekly volumes at individual hospitals, we were unable to adjust for differences between hospitals. Given the ongoing COVID-19 pandemic and continued mitigation strategies, there is great concern that adolescents engaging in problematic substance use are at heightened risk for numerous adverse outcomes. Efforts to increase identification and treatment of adolescent SUDs at children's hospitals are critical to offsetting heightened risk for poor health outcomes.

Supplementary Data
Supplementary data related to this article can be found at http://doi.org/10.1016/j.jadohealth.2021.12.024. Overall percent difference in weekly adolescent visits for substance use disorders during COVID-19. This figure depicts the percent difference in median weekly adolescent visits in the inpatient (blue), emergency department (red; ED), and combined (black; ED and inpatient) for substance use disorders during spring, summer and fall COVID-19 (2020) compared to spring, summer, and fall pre-COVID-19 (2017e2019).