Our findings revealed that a higher socioeconomic status (SES), male gender, and White race were strongly associated with HOD, and these findings are consistent with a study using the National Violent Death Reporting System (2016) on opioid overdose [12]. Caucasian HOD inpatients were reportedly (81%) consistent with our findings, and the race difference in HOD has also been reported by several studies [9,13]. Furthermore, adolescents (aged 12–18 years) were more affected compared to the younger age group.

Using the NIS data, we found that HOD inpatients not only abuse heroin but that there is also a comorbid abuse or dependence of other substances like cocaine, tobacco, cannabis, and amphetamine. However, a study by Rodríguez-Llera et al. [14] found cocaine to be most abused substance, whereas in our study tobacco was more abused than cocaine. These findings are consistent with a study demonstrating that the combination of drug types in drug overdose deaths is a common occurrence across the US [15,16]. Psychiatric comorbidities were also observed amongst the HOD inpatient population; they included mood disorders, anxiety disorders, suicide, and psychotic disorders. The Rodriguez et al. [14] study findings were consistent with our data and further revealed that, amongst heroin abusers, women were at a high risk of comorbid mood disturbances when compared to men. Furthermore, a lower percentage of their study suffered major depressive and borderline personality disorders [14].

Furthermore, our study shows that substance abuse is related to the family SES. We found that a good number of HOD inpatients (40%) are from a higher SES. According to a study by Trim et al. [17], adolescents who are more likely to abuse substances are ones who live in an affluent neighborhood. This contributes to a high substance abuse likely because there is less supervision of children in these areas. Additionally, there is more exposure to peers who abuse substances [17]. Affluent children are also at an increased risk for other substances, such as alcohol, during their transition to adulthood [17]. Non-Hispanic males were at a relatively higher risk compared to other races [18,19] for substance use; however, non-Hispanic Black patients account for a greater number of casualties [18].

Our study provides a unique picture of the trends in the US hospitals from 2010 to 2014 of HOD-related hospitalizations in the child and adolescent population. Our findings revealed that comorbid cocaine and tobacco use disorders had significantly increased over the past five years in HOD inpatients. This may be due to an increase in the accessibility to these substances [3]. We found that the suicide rate in HOD inpatients had increased significantly over the past years from 1.7% in 2010 to 5.7% to 2014. This increased rate could be the result of a combination of other illicit drugs, as most heroin addicts may abuse other substances [20]; it is therefore of the utmost importance to develop de-addiction programs to reduce this increasing poly-substance abuse in the HOD child and adolescent population. According to a study by Dragisic et al. [21], intravenous heroin abuse is a significant risk factor for suicidality among addicts. However, as per a study by Gaither et al., the majority of the deaths among drug addicts were unintentional [18], comorbid psychotic disorders declined over the years from 3.5% in 2010 to 0% in 2014, and, conversely, HOD inpatients with comorbid mood disorders increased from 40.5% to 45.3%, though this was not statistically significant.

According to the Centers for Disease Control and Prevention, people addicted to prescription opioids are 40 times more likely to abuse heroin [22]. This can be mitigated by reducing the access of prescription opioids, as most studies revealed that most heroin abusers transitioned from prescribed opioids. Therefore, improving physicians’ prescription practices is a critical way to reduce the heroin addiction problem. Furthermore, pediatric providers should discuss the importance of safe medication storage with guardians, as this is another essential way of reducing this problem [23]. Parents or guardians who are on prescribed opioid should be advised to keep these medications away from their children’s reach [23]. Additionally, another way to reduce the overdose prevalence is by medication-assisted treatment (MAT), i.e., a combined use of methadone, buprenorphine, or naltrexone for heroin addicts [20]. Nevertheless, buprenorphine is associated with misuse [24], leading to cardiovascular and dermatological complications [25,26]. Furthermore, counseling and cognitive behavioral therapies and counseling are also recommended as strategies for harm reduction amongst this population [22].

Younger children are more vulnerable to the accidental ingestion of opioids [27]. Certain strategies should be developed and also implemented to curb heroin overdoses in the pediatric population. Child-serving agencies, i.e., child welfare or child protection services, should provide services and treatments to impacted children and their families, which can reduce long-term catastrophe and prevent fatal outcomes [28]. Children whose guardians or parents abuse heroin, treatment programs such as social rehabilitation, parental coaching and mentoring, and cognitive behavior parental skills should be explored; furthermore, physicians should work closely to oversee parents and their child’s progress [28].

There were several limitations to our study. First, these findings may be underreported, thereby making them unrepresentative of the real burden of HOD across the US due to the nature of the administrative database based on ICD-9 codes that was used in this study. Second, we examined pooled data and year-by-year trend data, though we cannot rule out the possibility that outpatients, and re-hospitalizations across different healthcare settings, may not be represented. We used the NIS, which enabled us to get a national representative sample of HOD inpatients, and the large sample size also increased the power of our study. We compared the trends over five years, which gave us a broader picture and increased the external validity. Furthermore, the findings in this study are useful for understanding the burden of HOD, which can help to adequately and strategically devise specific intervention plans to curb the problem.