Hayden Panettiere was 16 when drugs first arrived in her life in Hollywood.

Ahead of a red carpet event for the hit series Heroes, she has said someone on her team handed her a pill to help amp up her energy. The hit sci-fi NBC series had catapulted the teen into a household name – and that brought with it intense pressure and exhaustion she says felt overwhelming.

“Within minutes, a wave of energy washed over me, like I’d just woken up from the most refreshing night’s sleep of my life,” Panettiere wrote about that pill in her memoir, which was released just months before her death.

She called it “the gateway drug that ushered me toward the good of pharmaceuticals and the downfall of addiction”.

The star’s sudden death at the age of 36 has placed a renewed focus on her struggles with mental health and substance abuse, and re-ignited a discussion about the pressures of Hollywood on child stars.

The coroner’s office in Greenville, South Carolina said crews treated a woman in “cardiac arrest” and her autopsy showed “no signs of trauma”.

No cause of death has been released, though additional tests are yet to be completed.

Audio from police dispatchers and crews who responded to the address said they were responding to a “cardiac arrest” and detailed their efforts to resuscitate the woman after a possible “overdose”. Panettiere’s ex boyfriend, Brian Hickerson – who has admitted to abusing her – and his brother Zack, were with Panettiere when emergency services came, according to a police report.

There is no suggestion of wrongdoing on their part, according to police.

It is not known if drugs or alcohol played a factor in her death, but the US Drug Enforcement Agency is joining an investigation into her death, according to US media reports.

Panettiere is one of many actors who has openly struggled with addiction after exposure to fame at an early age, which addiction experts told the BBC can put people at risk for mental health and substance abuse issues.

It can sometimes seem to the rest of the world that child actors have “everything” at their fingertips – like fame and money, said Lucas Trautman, the medical director of Oxford Treatment Center, an addiction treatment centre in Mississippi.

“But it’s important to remember that they were also exposed during a developmental time to many adult aspects of life that the rest of us weren’t – including traumatic experiences – and so that gives them unique risk factors for addiction,” Trautman said.

Panettiere’s death comes after she published a memoir where she discussed at length her issues with addiction, her postpartum depression and the loss of her 28-year-old brother.

Panettiere’s decision to publicly share her struggles is worthy of respect, said William Moyers, the vice-president of public affairs for Hazelden Betty Ford, the largest nonprofit addiction treatment provider in the US. But he said the constant public scrutiny she faced may not have allowed her room to address her mental health in private.

“Her entire life from the beginning was centred in the intense public spotlight, and this didn’t give Hayden much in the way of a respite,” said Moyers, who has been in recovery from an addiction since 1989.

Trautman – who has treated child stars – said they often have “adult access” to drugs and alcohol without adult protection.

“We aren’t equipped at a young age to be able to say no to it, to manage it, to correctly stay away from it altogether,” he said.

Other child stars have talked about being exposed to drugs at an early age, including Drew Barrymore, who went to rehab at 12, and Demi Lovato, a Disney Channel star.

“I got into a car accident and they prescribed me opiates. My mum didn’t think she would have to lock up the opiates from her 13-year-old daughter, but I was already drinking at that point,” the singer told podcast Call Her Daddy in 2022.

Actress Michelle Rodriguez, who once hosted the World Music Awards with Panettiere, said this week that the number of child actors who had passed away at a young age was strange.

“I just can’t stand how many young people are leaving us lately. It’s disheartening, and it’s making me think, ‘What’s going on?’ It’s not normal,” she told Variety.

Panettiere’s death comes just a year after the death of Michelle Trachtenberg and months after Daveigh Chase, two child stars who both struggled with drugs and alcohol.

In an essay she wrote after Panettiere’s death, former Disney star Christy Carlson Romano compared early fame to a traumatic brain disease.

“[W]e have almost no language for what happens when stress, scrutiny, rejection, adult pressure, and the collapse of privacy become the architecture of a childhood,” she wrote.

And when a child actor’s career changes or comes to an end, they are left without the dopamine of fame and money that came with their identity as an actor, cautioned Trautman.

“At the same time many of them self medicated… so their brain is still reliant on that, and it’s really really hard to to stop using,” he said.

Many child stars also have professional relationships with their parents, which can blur boundaries and leave them vulnerable, Trautman said.

In her book and in the media, Panettiere has discussed the pressure her mother placed on her to excel as an actress from an early age. She appeared in her first commercial when she was just 11-months-old.

“You always want to think the best of your parents and see them in the brightest light,” the actress told the New York Times in May. “But there were a lot of things done with an approach that was not about my mental health or what was emotionally or mentally safe for me to do.”

Substance abuse also puts people at risk for a host of medical conditions, including heart disease and liver and other organ damage.

Panettiere’s brother, Jansen, died aged 28 from a heart condition, and Panettiere revealed in her book that her brother was using heroin and cocaine leading up to his death.

But after he died, the actress told People Magazine in 2024 she was committed to staying sober, telling the outlet her addiction was “in the rear view mirror”.

She said in her book that at one point a doctor told her that if she did not stop drinking, she would be “dead within five years”.

For Moyers and other substance abuse experts, addiction is a chronic illness, meaning that relapses still happen even while treatment saves lives.

“Living in recovery means doing the best we can, but doing it imperfectly,” he said.