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Opioid Substitution Treatment and risks to children

Improving child safety during the provision of drug treatment medications to parents and carers

Over the past decade, a number of children have been killed or seriously harmed through ingesting drug treatment medication prescribed to their parents and carers.

In light of these incidents, in 2014 Adfam published a research report, Medications in drug treatment: Tackling the risks to children (pdf). This analysed learning from Serious Case Reviews, explored current literature and guidance on the issue, canvassed the views of frontline practitioners and experts, and recommended ways of improving safety.

The report was launched in the House of Commons and covered in the national media, with the key messages of:

  • Medicines used to treat adults’ drug addiction can be lethal to children in their care
  • Child ingestions occur too often and ‘lessons learned’ from local investigations are not transferred into national learning
  • There is a ‘rare but real’ phenomenon of parents deliberately administering methadone to young children in misguided attempts to pacify them, with tragic consequences.

Following publication, we received a high level of interest from practitioners across the country.

A year after the publication of the report, Adfam produced a new research report, Medications in drug treatment: Tackling the risks to children – one year on (pdf) to build on the original work by looking at progress made in the last year, providing updated statistics and information, and giving recommendations to practitioners and policymakers on how to reduce risk and the incidence of these tragic occurrences.

The new research, launched in the House of Lords, found that lessons had not been heeded, and children are still dying – many more than previously identified.


We are now working alongside local areas to improve safety on the front line and implement the recommendations of the report. By the end of 2015, Adfam will have delivered multi-agency training to 19 local councils to reduce the risks to children posed by these medications, and hope to continue this crucial work in 2016.

If you have any other queries about Adfam's work in this area, please get in touch with Vivienne Evans for further information.